Digital video capture and synchronous consultation in open surgery

Advancements in Telemedicine for Surgical Practices: A Comprehensive Bibliometric Analysis

Purposes: This study aims to use bibliometric analysis to explore the development, research hotspots, and trends in the field of telemedicine for surgical practices (TSPs). Methods: A bibliometric analysis of 3,235 documents from the Web of Science Core Collection was conducted, spanning from 2004 to 2022. Citespace (6.2.R5) was used to perform a bibliometric analysis. Results: The findings highlight a marked escalation in researches of TSPs, particularly between 2019 and 2022, aligning with the COVID-19 pandemic. The Telemedicine and e-Health Journal was the most productive journal with 118 publications, and Journal of Telemedicine and Telecare had the most citations (n = 700). Howard S. An and Mohammad El-sharkawi had the most papers (n = 8). Harvard University was the most prolific institution (n = 103). The United States, England, and Canada were identified as the predominant contributing countries with a total of 1,521 publications. There was a notable shift in research focus areas over time, with recent emphasis being placed on pediatric surgery, COVID-19-related studies, and orthopedics. Future trends may involve teleconsulting, ameliorating the quality and safety of telemedicine, and improving satisfaction levels of patients and caregivers when they are using telemedicine. Conclusions: The study reveals that the rapid and sustained advancement in TSPs, significantly driven by the COVID-19 pandemic, and huge gaps between developed countries and developing countries. This study also reflects the current hotspots and future directions for TSPs.

Dynamic Augmented Reality Cues for Telementoring in Minimally Invasive Surgeries: Scoping Review

BACKGROUND

Remote surgeons use telementoring technologies to provide real-time guidance during minimally invasive surgeries (MIS). Such technologies are continuously improving with the integration of dynamic augmented reality (AR) cues. This includes virtual overlays of hand gestures, pointers, and surgical tools onto the operating surgeon's view. The operating surgeon comprehends this augmented information to operate on the patient. Thus, understanding these dynamic AR cues (either during surgical training or live surgery) is crucial.

OBJECTIVE

In this paper, we aimed to review the existing telementoring technologies that use dynamic AR cues during MIS. This review describes the MIS (including surgery type, specialty, procedure, and clinical trial), the telementoring system, the dynamic AR cues generated by these systems, and evaluation of the technology in terms of technical aspects, user perceptions, skills gained, and patient outcomes.

METHODS

A scoping review was conducted using PubMed, Web of Science, Scopus, IEEE Xplore, and ACM Digital Library databases. The search terms included "telementoring," "minimally invasive surgery," and "augmented reality" without restrictions imposed on the publication year. Articles covering telementoring using dynamic AR cues during MIS, including laparoscopic and robot-assisted, were identified.

RESULTS

A total of 21 articles were included and categorized based on type of surgery, the telementoring technology used, and evaluation of the technology. Most of the articles reported on laparoscopic suturing performed using synthetic phantoms. Hand gestures and surgical tools were the most frequently used dynamic AR cues (10 articles on each cue), while the mentors and mentees primarily consisted of experienced surgeons and medical students. The studies assessing the telementoring technologies were either descriptive (7 articles) or analytical (14 articles) where it was compared against no cue, prerecorded visual cue, in-person guidance, audio cue, or static AR cue. Outcomes were measured mostly using skills gained (13 articles) and user perception about the telementoring system.

CONCLUSIONS

In general, telementoring using dynamic AR cues resulted in positive outcomes during MIS. In some cases, they were considered on par with conventional methods such as audio cues and in-person guidance. Further randomized controlled trials are required to objectively assess its clinical benefits.

Virtual Supervision in Graduate Medical Education: A Systematic Review

Background Despite the increased use of telemedicine, the evidence base on virtual supervision in graduate medical education (GME) is not well described. Objective To systematically review the impact of virtual supervision on trainee education, patient care, and patient satisfaction in Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties. Methods Two databases (PubMed, EMBASE) were searched from database inception to December 2022. Inclusion criteria were peer-reviewed, full-text, English-language articles reporting the use of virtual supervision in GME in ACGME-accredited specialties. Exclusion criteria were studies involving direct supervision, supervisors who were not credentialed physicians, or non-GME trainees. Two investigators independently extracted data and appraised the methodological quality of each study using the Mixed Methods Appraisal Tool (MMAT). The reporting of this systematic review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Results Of 5278 records identified, 26 studies met the eligibility criteria. Virtual supervision was predominantly utilized in operating rooms and inpatient settings, facilitating clinical examinations or surgical procedures through videoconferencing software in specialties such as dermatology, neurosurgery, and orthopedics. However, some studies reported technical challenges that hindered effective teaching and communication. Based on self-reported surveys, supervisor and trainee satisfaction with virtual supervision was mixed, while patient satisfaction with the care was generally high. The MMAT ratings suggested limitations in sampling strategy, outcome measurement, and confounding factors. Conclusions Virtual supervision was applicable to various specialties and settings, facilitating communication between supervisors and trainees, although there were some technological challenges.

Overcoming the Impact of COVID-19 on Surgical Mentorship: A Scoping Review of Long-distance Mentorship in Surgery

BACKGROUND

Mentorship in the surgical field has been increasingly recognized as a crucial component of career success. Distance mentorship models may be utilized to overcome geographic limitations, increase mentorship access, and strengthen mentoring relationships in surgery.

OBJECTIVE

This review aimed to identify the scope of literature on distance mentoring in surgery, the range of its application, its effectiveness, and any gaps in the literature that should be addressed in order to enhance mentorship in the surgical field.

DESIGN

A comprehensive PubMed review was performed in January 2021 on distance mentorship of students, trainees, and surgeons in the surgical field. Reviews, replies, and non-English articles were excluded. Data was extracted regarding publication year, author's country, specialty, subjects, aim of mentorship model, and efficacy.

RESULTS

134 total studies met inclusion and exclusion criteria. Most studies were published in 2020, written by authors in the United States, from general surgery, and featured an expert surgeon paired with a more junior fully trained surgeon. In all, 93.3% of studies utilized distance mentorship to enhance surgical skill through telementoring and only 4.5% were focused on mentorship to enhance careers through professional development. The remaining studies utilized distance mentorship models to increase surgical research (0.7%) and clinical knowledge (1.5%).

CONCLUSION

The results of this review suggest successful implementation of distance mentoring in surgery through telementoring, but a lack of professionally aimed distance mentorship programs. Amidst COVID-19, distance mentorship is particularly important because of decreased face-to-face opportunity. Future studies in the surgical field should investigate distance mentoring as a means of increasing mentorship for professional development.

Overcoming the Impact of COVID-19 on Surgical Mentorship: A Scoping Review of Long-distance Mentorship in Surgery

BACKGROUND

Mentorship in the surgical field has been increasingly recognized as a crucial component of career success. Distance mentorship models may be utilized to overcome geographic limitations, increase mentorship access, and strengthen mentoring relationships in surgery.

OBJECTIVE

This review aimed to identify the scope of literature on distance mentoring in surgery, the range of its application, its effectiveness, and any gaps in the literature that should be addressed in order to enhance mentorship in the surgical field.

DESIGN

A comprehensive PubMed review was performed in January 2021 on distance mentorship of students, trainees, and surgeons in the surgical field. Reviews, replies, and non-English articles were excluded. Data was extracted regarding publication year, author's country, specialty, subjects, aim of mentorship model, and efficacy.

RESULTS

134 total studies met inclusion and exclusion criteria. Most studies were published in 2020, written by authors in the United States, from general surgery, and featured an expert surgeon paired with a more junior fully trained surgeon. In all, 93.3% of studies utilized distance mentorship to enhance surgical skill through telementoring and only 4.5% were focused on mentorship to enhance careers through professional development. The remaining studies utilized distance mentorship models to increase surgical research (0.7%) and clinical knowledge (1.5%).

CONCLUSION

The results of this review suggest successful implementation of distance mentoring in surgery through telementoring, but a lack of professionally aimed distance mentorship programs. Amidst COVID-19, distance mentorship is particularly important because of decreased face-to-face opportunity. Future studies in the surgical field should investigate distance mentoring as a means of increasing mentorship for professional development.

Team training and surgical crisis management

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

Telementoring in Leg Fasciotomies via Mixed-Reality: Clinical Evaluation of the STAR Platform

Introduction

Point-of-injury (POI) care requires immediate specialized assistance but delays and expertise lapses can lead to complications. In such scenarios, telementoring can benefit health practitioners by transmitting guidance from remote specialists. However, current telementoring systems are not appropriate for POI care. This article clinically evaluates our System for Telementoring with Augmented Reality (STAR), a novel telementoring system based on an augmented reality head-mounted display. The system is portable, self-contained, and displays virtual surgical guidance onto the operating field. These capabilities can facilitate telementoring in POI scenarios while mitigating limitations of conventional telementoring systems.

Methods

Twenty participants performed leg fasciotomies on cadaveric specimens under either one of two experimental conditions: telementoring using STAR; or without telementoring but reviewing the procedure beforehand. An expert surgeon evaluated the participants’ performance in terms of completion time, number of errors, and procedure-related scores. Additional metrics included a self-reported confidence score and postexperiment questionnaires.

Results

STAR effectively delivered surgical guidance to nonspecialist health practitioners: participants using STAR performed fewer errors and obtained higher procedure-related scores.

Conclusions

This work validates STAR as a viable surgical telementoring platform, which could be further explored to aid in scenarios where life-saving care must be delivered in a prehospital setting.

Surgical Telementoring Without Encumbrance: A Comparative Study of See-through Augmented Reality-based Approaches

OBJECTIVE

This study investigates the benefits of a surgical telementoring system based on an augmented reality head-mounted display (ARHMD) that overlays surgical instructions directly onto the surgeon's view of the operating field, without workspace obstruction.

SUMMARY BACKGROUND DATA

In conventional telestrator-based telementoring, the surgeon views annotations of the surgical field by shifting focus to a nearby monitor, which substantially increases cognitive load. As an alternative, tablets have been used between the surgeon and the patient to display instructions; however, tablets impose additional obstructions of surgeon's motions.

METHODS

Twenty medical students performed anatomical marking (Task1) and abdominal incision (Task2) on a patient simulator, in 1 of 2 telementoring conditions: ARHMD and telestrator. The dependent variables were placement error, number of focus shifts, and completion time. Furthermore, workspace efficiency was quantified as the number and duration of potential surgeon-tablet collisions avoided by the ARHMD.

RESULTS

The ARHMD condition yielded smaller placement errors (Task1: 45%, P < 0.001; Task2: 14%, P = 0.01), fewer focus shifts (Task1: 93%, P < 0.001; Task2: 88%, P = 0.0039), and longer completion times (Task1: 31%, P < 0.001; Task2: 24%, P = 0.013). Furthermore, the ARHMD avoided potential tablet collisions (4.8 for 3.2 seconds in Task1; 3.8 for 1.3 seconds in Task2).

CONCLUSION

The ARHMD system promises to improve accuracy and to eliminate focus shifts in surgical telementoring. Because ARHMD participants were able to refine their execution of instructions, task completion time increased. Unlike a tablet system, the ARHMD does not require modifying natural motions to avoid collisions.

The System for Telementoring with Augmented Reality (STAR): A head-mounted display to improve surgical coaching and confidence in remote areas

BACKGROUND

The surgical workforce particularly in rural regions needs novel approaches to reinforce the skills and confidence of health practitioners. Although conventional telementoring systems have proven beneficial to address this gap, the benefits of platforms of augmented reality-based telementoring in the coaching and confidence of medical personnel are yet to be evaluated.

METHODS

A total of 20 participants were guided by remote expert surgeons to perform leg fasciotomies on cadavers under one of two conditions: (1) telementoring (with our System for Telementoring with Augmented Reality) or (2) independently reviewing the procedure beforehand. Using the Individual Performance Score and the Weighted Individual Performance Score, two on-site, expert surgeons evaluated the participants. Postexperiment metrics included number of errors, procedure completion time, and self-reported confidence scores. A total of six objective measurements were obtained to describe the self-reported confidence scores and the overall quality of the coaching. Additional analyses were performed based on the participants' expertise level.

RESULTS

Participants using the System for Telementoring with Augmented Reality received 10% greater Weighted Individual Performance Score (P = .03) and performed 67% fewer errors (P = .04). Moreover, participants with lower surgical expertise that used the System for Telementoring with Augmented Reality received 17% greater Individual Performance Score (P = .04), 32% greater Weighted Individual Performance Score (P < .01) and performed 92% fewer errors (P < .001). In addition, participants using the System for Telementoring with Augmented Reality reported 25% more confidence in all evaluated aspects (P < .03). On average, participants using the System for Telementoring with Augmented Reality received augmented reality guidance 19 times on average and received guidance for 47% of their total task completion time.

CONCLUSION

Participants using the System for Telementoring with Augmented Reality performed leg fasciotomies with fewer errors and received better performance scores. In addition, participants using the System for Telementoring with Augmented Reality reported being more confident when performing fasciotomies under telementoring. Augmented Reality Head-Mounted Display-based telementoring successfully provided confidence and coaching to medical personnel.

Augmented Reality as a Medium for Improved Telementoring

Combat trauma injuries require urgent and specialized care. When patient evacuation is infeasible, critical life-saving care must be given at the point of injury in real-time and under austere conditions associated to forward operating bases. Surgical telementoring allows local generalists to receive remote instruction from specialists thousands of miles away. However, current telementoring systems have limited annotation capabilities and lack of direct visualization of the future result of the surgical actions by the specialist. The System for Telementoring with Augmented Reality (STAR) is a surgical telementoring platform that improves the transfer of medical expertise by integrating a full-size interaction table for mentors to create graphical annotations, with augmented reality (AR) devices to display surgical annotations directly onto the generalist's field of view. Along with the explanation of the system's features, this paper provides results of user studies that validate STAR as a comprehensive AR surgical telementoring platform. In addition, potential future applications of STAR are discussed, which are desired features that state-of-the-art AR medical telementoring platforms should have when combat trauma scenarios are in the spotlight of such technologies.

Video Technologies for Recording Open Surgery: A Systematic Review

Video recording of surgical procedures is an important tool for surgical education, performance enhancement, and error analysis. Technology for video recording open surgery, however, is limited. The objective of this article is to provide an overview of the available literature regarding the various technologies used for intraoperative video recording of open surgery. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using the MEDLINE, Cochrane Central, and EMBASE databases. Two authors independently screened the titles and abstracts of the retrieved articles, and those that satisfied the defined inclusion criteria were selected for a full-text review. A total of 2275 publications were initially identified, and 110 were included in the final review. The included articles were categorized based on type of article, surgical subspecialty, type and positioning of camera, and limitations identified with their use. The most common article type was primary-technical (29%), and the dominant specialties were general surgery (22%) and plastic surgery (18%). The most commonly cited camera used was the GoPro (30%) positioned in a head-mount configuration (60%). Commonly cited limitations included poor video quality, inadequate battery life, light overexposure, obstruction by surgical team members, and excessive motion. Open surgery remains the mainstay of many surgical specialties today, and technological innovation is absolutely critical to fulfill the unmet need for better video capture of open surgery. The findings of this article will be valuable for guiding future development of novel technology for this purpose.

Self-debriefing Model Based on an Integrated Video-Capture System: An Efficient Solution to Skill Degradation

OBJECTIVE

Video-based teaching is considered highly effective in debriefing, especially in minimally invasive surgeries. In this study, the benefits of using a new integrated video recording system, were investigated and compared to those of the standard basic skills robotic training procedure.

DESIGN

Fifty residents from the 2nd and 3rd year medical faculty without any experience of robot usage or laparoscopy were randomized into 2 groups: group A--a natural self-training group without a trainer, and group B--a self-training group assisted by an integrated video recording system during training. The training was divided into four 2-hour sessions, with a 72-hour delay between each session. Two tasks were selected for testing on the dV-Trainer, a virtual reality based robotic simulator: Match board 2 and Thread the Rings 1. After each session, the practice video recorded by the system of group B was transferred to the residents' smartphones for self-debriefing. At the end of each session, the performance score was evaluated automatically by using the simulator to plot learning curves A and B.

RESULTS

Group A showed a significant drop in performance score due to skill decay caused by the 72-hour delay. Group B exhibited a regular stepwise rising learning curve. At the end of the training, group B showed a significantly higher performance score both in Match board 2 and Thread the Rings 1. The autoanalysis and capture function, which selects only the critical errors and most valuable parts, could facilitate time saving.

CONCLUSIONS

The use of an integrated video recording system makes the self-manipulated protocol with own smartphone feasible to improve training efficiency and overcome the skill decay during robotic surgical training.

Telementoring of Surgeons: A Systematic Review

BACKGROUND

Telementoring is a technique that has shown potential as a surgical training aid. Previous studies have suggested that telementoring is a safe training modality. This review aimed to review both the technological capabilities of reported telementoring systems as well as its potential benefits as a mentoring modality.

METHODS

A systematic review of the literature, up to July 2017, was carried out in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study quality was assessed using the Oxford Levels of Evidence proforma. Data were extracted regarding technical capabilities, bandwidth, latency, and costs. Additionally, the primary aim and key results were extracted from each study and analyzed.

RESULTS

A total of 66 studies were identified for inclusion. In all, 48% of studies were conducted in general surgery; 22 (33%), 24 (36%), and 20 (30%) of studies reported telementoring that occurred within the same hospital, outside the hospital, and outside the country, respectively. Sixty-four (98%) of studies employed video and audio and 38 (58%) used telestration. Twelve separate studies directly compared telementoring against on-site mentoring. Seven (58%) showed no difference in outcomes between telementoring and on-site mentoring. No study found telementoring to result in poorer postoperative outcomes.

CONCLUSIONS

The results of this review suggest that telementoring has a similar safety and efficacy profile as on-site mentoring. Future analysis to determine the potential benefits and pitfalls to surgical education through telementoring are required to determine the exact role it shall play in the future. Technological advances to improve remote connectivity would also aid the uptake of telementoring on a larger scale.

Are multiple views superior to a single view when teaching hip surgery? A single-blinded randomized controlled trial of technical skill acquisition

Purpose

Surgical education videos currently all use a single point of view (POV) with the trainee locked onto a fixed viewpoint, which may not deliver sufficient information for complex procedures. We developed a novel multiple POV video system and evaluated its training outcome compared with traditional single POV.

Methods

We filmed a hip resurfacing procedure performed by an expert attending using 8 cameras in theatre. 30 medical students were randomly and equally allocated to learn the procedure using the multiple POV (experiment group [EG]) versus single POV system (control group [CG]). Participants advanced a pin into the femoral head as demonstrated in the video. We measured the drilling trajectories and compared it with pre-operative plan to evaluate distance of the pin insertion and angular deviations. Two orthopedic attendings expertly evaluated the participants’ performance using a modified global rating scale (GRS). There was a pre-video knowledge test that was repeated post-simulation alongside a Likert-scale questionnaire.

Results

The angular deviation of the pin in EG was significantly less by 29% compared to CG (p = 0.037), with no significant difference in the entry point’s distance between groups (p = 0.204). The GRS scores for EG were 3.5% higher than CG (p = 0.046). There was a 32% higher overall knowledge test score (p<0.001) and 21% improved Likert-scale questionnaire score (p = 0.002) after video-learning in EG than CG, albeit no significant difference in the knowledge test score before video-learning (p = 0.721).

Conclusion

The novel multiple POV provided significant objective and subjective advantages over single POV for acquisition of technical skills in hip surgery.

Telementoring and Telesurgery for Minimally Invasive Procedures

PURPOSE

Tremendous interest and need lie at the intersection of telemedicine and minimally invasive surgery. Robotics provides an ideal environment for surgical telementoring and telesurgery given its endoscopic optics and mechanized instrument movement. We review the present status, current challenges and future promise of telemedicine in endoscopic and minimally invasive surgery with a focus on urological applications.

MATERIALS AND METHODS

Two paired investigators screened PubMed^®, Scopus^® and Web of Science^® databases for all full text English language articles published between 1995 and 2016 using the key words "telemedicine," "minimally invasive surgical procedure," "robotic surgical procedure," "education" and "distance." We categorized and included studies of level of interaction between proctors and trainees. Research design, special equipment, telecommunication network bandwidth and research outcomes of each study were ascertained and analyzed.

RESULTS

Of 65 identified reports 38 peer-reviewed studies qualified for inclusion. Series were categorized into 4 advancing levels, ie verbal guidance, guidance with telestration, guidance with tele-assist and telesurgery. More advanced levels of surgical telementoring provide more effective and experiential teaching but are associated with increased telecommunication network bandwidth requirements and expenses. Concerns regarding patient safety and legal, financial, economic and ethical issues remain to be reconciled.

CONCLUSIONS

Telementoring and telesurgery in minimally invasive surgery are becoming more practical and cost effective in facilitating teaching of advanced surgical skills worldwide and delivery of surgical care to underserved areas, yet many challenges remain. Maturity of these modalities depends on financial incentives, favorable legislation and collaboration with cybersecurity experts to ensure safety and cost-effectiveness.

Effectiveness of Telementoring in Surgery Compared With On-site Mentoring: A Systematic Review

BACKGROUND

Mentorship is important but may not be feasible for distance learning. To bridge this gap, telementoring has emerged. The purpose of this systematic review was to evaluate the effectiveness of telementoring compared with on-site mentoring.

METHODS

A search was done up to March 2015. Studies were included if they used telementoring between surgeons during a clinical encounter and if they compared on-site mentoring and telementoring.

RESULTS

A total of 11 studies were included. All reported no difference in complication rates, and 9 (82%) reported similar operative times; 4 (36%) reported technical issues, which was 3% of the total number of cases in the 11 studies. No study reported on higher levels of evidence for effectiveness of telementoring as an educational intervention.

CONCLUSION

Studies reported that telementoring is associated with similar complication rates and operative times compared with on-site mentoring. However, the level of evidence to support the effectiveness of telementoring as a training tool is limited. There is a need for studies that provide evidence for the equivalence of the effectiveness of telementoring as an educational intervention in comparison with on-site mentoring.

Video Technology to Advance Safety in the Operating Room and Perioperative Environment

Video is a powerful medium and is underused for patient safety in several areas: education, real-time consultation, process improvement, research, and workflow coordination. We illustrate this point through an overview of uses of video in health care by the authors and others in several institutions. These uses were in the context of team work training, operating room coordination, technical skills of invasive procedures, process improvement, telementoring, and multimedia video records. Also described are several key issues associated with the use of video, such as ethics and legal concerns. Technology advances and new methods will make video an important tool for improving patient safety.

A Novel Method for Real-Time Audio Recording With Intraoperative Video

OBJECTIVE

Although laparoscopic surgery has become widespread, effective and efficient education in laparoscopic surgery is difficult. Instructive laparoscopy videos with appropriate annotations are ideal for initial training in laparoscopic surgery; however, the method we use at our institution for creating laparoscopy videos with audio is not generalized, and there have been no detailed explanations of any such method. Our objectives were to demonstrate the feasibility of low-cost simple methods for recording surgical videos with audio and to perform a preliminary safety evaluation when obtaining these recordings during operations.

DESIGN

We devised a method for the synchronous recording of surgical video with real-time audio in which we connected an amplifier and a wireless microphone to an existing endoscopy system and its equipped video-recording device. We tested this system in 209 cases of laparoscopic surgery in operating rooms between August 2010 and July 2011 and prospectively investigated the results of the audiovisual recording method and examined intraoperative problems.

SETTING

Numazu City Hospital in Numazu city, Japan.

PARTICIPANTS

Surgeons, instrument nurses, and medical engineers.

RESULTS

In all cases, the synchronous input of audio and video was possible. The recording system did not cause any inconvenience to the surgeon, assistants, instrument nurse, sterilized equipment, or electrical medical equipment. Statistically significant differences were not observed between the audiovisual group and control group regarding the operating time, which had been divided into 2 slots-performed by the instructors or by trainees (p > 0.05).

CONCLUSIONS

This recording method is feasible and considerably safe while posing minimal difficulty in terms of technology, time, and expense. We recommend this method for both surgical trainees who wish to acquire surgical skills effectively and medical instructors who wish to teach surgical skills effectively.

The Surgeon's View: Comparison of Two Digital Video Recording Systems in Veterinary Surgery

Video recording and photography during surgical procedures are useful in veterinary medicine for several reasons, including legal, educational, and archival purposes. Many systems are available, such as hand cameras, light-mounted cameras, and head cameras. We chose a reasonably priced head camera that is among the smallest video cameras available. To best describe its possible uses and advantages, we recorded video and images of eight different surgical cases and procedures, both in hospital and field settings. All procedures were recorded both with a head-mounted camera and a commercial hand-held photo camera. Then sixteen volunteers (eight senior clinicians and eight final-year students) completed an evaluation questionnaire. Both cameras produced high-quality photographs and videos, but observers rated the head camera significantly better regarding point of view and their understanding of the surgical operation. The head camera was considered significantly more useful in teaching surgical procedures. Interestingly, senior clinicians tended to assign generally lower scores compared to students. The head camera we tested is an effective, easy-to-use tool for recording surgeries and various veterinary procedures in all situations, with no need for assistance from a dedicated operator. It can be a valuable aid for veterinarians working in all fields of the profession and a useful tool for veterinary surgical education.

Emerging technology in surgical education: combining real-time augmented reality and wearable computing devices

The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of real-time augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery.

Ten-year experience of remote medical education in Asia

BACKGROUND

Moving images are often essential in medical education, to learn new procedures and advanced skills, but, in the past, high-quality movie transmission was technically much more challenging than transmitting still pictures because of technological limitations and cost.

MATERIALS AND METHODS

We established a new system, taking advantage of two advanced technologies, the digital video transport system (DVTS) and the research and education network (REN), which enabled satisfactory telemedicine on a routine basis.

RESULTS

Between 2003 and 2013, we organized 360 programs connecting 221 hospitals or facilities in 34 countries in Asia and beyond. The two main areas were endoscopy and surgery, with 113 (31%) and 106 (29%) events, respectively. Teleconferences made up 76% of the total events, with the remaining 24% being live demonstrations. Multiple connections were more popular (63%) than one-to-one connections (37%). With continuous technological development, new high-definition H.323 and Vidyo(®) (Hackensack, NJ) systems were used in 47% and 39% of events in 2011 and 2012, respectively. The evaluation by questionnaires was favorable on image and sound quality as well as programs.

CONCLUSIONS

Remote medical education with moving images was well accepted in Asia with changing needs and developing technologies.

An evaluation framework for defining the contributions of telestration in surgical telementoring

BACKGROUND

An increasing quantity of research in the domain of telemedicine show a growing popularity and acceptance of care over distance systems among both clinicians and patients. We focus on telementoring solutions, developed for providing remote guidance to less experienced surgeons. Telestration is often regarded as an extra functionality of some telementoring systems. However, we advocate that telestration must be viewed as a core feature of telementoring due to its advantages.

OBJECTIVE

To analyze and define concepts, parameters, and measurement procedures to evaluate the impact of using telestration while telementoring.

METHODS

A systematic review of research dealing with telestration during remote guidance sessions was performed by querying three major online research databases (MEDLINE, Association of Computing Machinery, and Institute of Electrical and Electronics Engineers) using a predefined set of keywords ("laparoscopy", "annotate", "telestrate", "telestration", "annotation", "minimally invasive", and "MIS").

RESULTS

The keyword-based search identified 117 papers. Following the guidelines for performing a systematic review, only 8 publications were considered relevant for the final study. Moreover, a gap in research defining the impacts of telestration during telementoring was identified. To fill this niche, a framework for analyzing, reporting, and measuring the impacts of telestration was proposed.

CONCLUSIONS

The presented framework lays the basics for the structured analysis and reporting of telestration applied to telementoring systems. It is the first step toward building an evidence knowledge base documenting the advantages of live video content annotation and supporting the presented connections between the concepts.

Digital video recording in trauma surgery using commercially available equipment

INTRODUCTION

Although videos of surgical procedures are useful as an educational tool, the recording of trauma surgeries in emergency situations is difficult. We describe an inexpensive and practical shooting method using a commercially available head-mounted video camera.

METHODS

We used a ContourHD 1080p Helmet Camera (Contour Inc., Seattle, Washington, USA.). This small, self-contained video camera and recording system was originally designed for easy videography of outdoor sports by participants.

RESULTS

We were able to easily make high-quality video recordings of our trauma surgeries, including an emergency room thoracotomy for chest stab wounds and a crush laparotomy for a severe liver injury.

CONCLUSION

There are currently many options for recording surgery in the field, but the recording device and system should be chosen according to the surgical situation. We consider the use of a helmet-mounted, self-contained high-definition video camera-recorder to be an inexpensive, quick, and easy method for recording trauma surgeries.

Surgical telementoring in knowledge translation--clinical outcomes and educational benefits: a comprehensive review

BACKGROUND

Surgical telementoring has been reported for decades. However, there exists limited evidence of clinical outcome and educational benefits.

OBJECTIVE

To perform a comprehensive review of surgical telementoring surveys published in the past 2 decades.

RESULTS

Of 624 primary identified articles, 34 articles were reviewed. A total of 433 surgical procedures were performed by 180 surgeons. Most common telementored procedures were laparoscopic cholecystectomy (57 cases, 13%), endovascular treatment of aortic aneurysm (48 cases, 11%), laparoscopic colectomy (32 cases, 7%), and nefrectomies (41 cases, 9%). In all, 167 (38%) cases had a laparoscopic approach, and 8 cases (5%) were converted to open surgery. Overall, 20 complications (5%) were reported (liver bleeding, trocar port bleeding, bile collection, postoperative ileus, wound infection, serosa tears, iliac artery rupture, conversion open surgery). Eight surveys (23%) have structured assessment of educational outcomes. Telementoring was combined with simulators (n = 2) and robotics (n = 3). Twelve surveys (35%) were intercontinental. Technology satisfaction was high among 83% of surgeons.

CONCLUSION

Few surveys have a structured assessment of educational outcome. Telementoring has improved impact on surgical education. Reported complication rate was 5%.

Voice recognition interfaces (VRI) optimize the utilization of theatre staff and time during laparoscopic cholecystectomy

During laparoscopy, members of staff spend time setting up and de-activating the light source, camera and insufflator. Voice Recognition Interface (VRI) devices, such as HERMES (Stryker Europe, Montreux, Switzerland), enable the surgeon to perform and control these and other functions. They recognize the surgeon's voice and adjust the instruments in response to programmed verbal commands. The aim of this study was to evaluate HERMES with regards to the utilization of time and theatre staff during laparoscopic cholecystectomy. A total of 100 patients were randomized to either HERMES-assisted or standard laparoscopic cholecystectomy. Three time variables were measured for performing three VRI tasks: (1) The initial setting up of the light source and camera, (2) the activation of the insufflator, and (3) the deactivation of the insufflator and light source at the end of the operation. The mean (and standard deviation) of the time in seconds required for setting up the light source and camera was 27.6 (26.9) in non-HERMES operations and 11.7 (4.7) in HERMES-assisted cases (p<0.001). Insufflation time was 19.8 (13.3) vs. 6.7 (2.5) (p<0.001), and switch-off time was 19.5 (11.8) vs. 11.8 (5.7) (p<0.001). HERMES optimized the operating time and the utilization of theatre staff during laparoscopic cholecystectomy.

A rare primary diaphragmatic hemangioma successfully treated by laparoscopic surgery: report of a case

This report presents a very rare case of a primary diaphragmatic hemangioma, which was successfully treated by laparoscopic surgery. A 64-year-old man with a left diaphragmatic mass without any significant symptoms was treated by laparoscopic surgery and thus was diagnosed to have a diaphragmatic hemangioma following a pathological examination. Laparoscopic treatment in the deep and narrow abdominal spaces such as the diaphragmatic region is very useful as a less invasive treatment, as well as providing an excellent observation from which to make an accurate diagnosis.

Can the gastrocolic trunk of Henle serve as an anatomical landmark in laparoscopic right colectomy? A postmortem anatomical study

BACKGROUND

The use of the gastrocolic trunk of Henle (GTH) as a landmark has been advocated in laparoscopic right colectomy. The aim of this study was to evaluate the GTH as a possible landmark in laparoscopic right colectomy in the context of the adjacent arteries.

METHODS

Corrosion casting (30 specimens) and anatomic dissection were performed on formol-fixed cadavers (12 specimens).

RESULTS

The GTH was found in 34 specimens (81.0%). Among its closely related neighboring arterial vessels, the right colic artery was the most frequent (19 cases [55.9%]). It passed by the GTH at a mean distance of 3.6 mm. The course of the arteries in relation to the GTH was caudal and parallel in most cases (29 [85.3%]), but there was also a significant portion of crossing schemes (11.7%).

CONCLUSIONS

Although the GTH is a constant and conspicuous anatomic entity, it is not easily accessible, because of its tight relations to the right colon arteries. Instead, the authors advocate the use the superior right colic vein as an anatomic landmark leading to the GTH during laparoscopic right colectomy.

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons

Background

Since the 1960s, there has been substantial development in the uses of video-conferencing (VC) among medical personnel, including surgeons who have adopted the technology.

Methods

A report on our own experience with VC was combined with a comprehensive PubMed search with the key words telepresence, video-conferencing, video-teleconferencing, telementoring and surgery, trauma, follow-up, education, and multidisciplinary teams. A search through two peer-reviewed telemedicine journals—Journal of Telemedicine and Telecare and Telemedicine and e-Health Journal—and references of all included papers and identified additional reports was conducted.

Results

A total of 517 articles were identified with 51 relevant manuscripts, which included the key phrases. VC is widely used among surgeons for telementoring surgical procedures and in trauma and emergency medicine. Furthermore, VC is widely used by multidisciplinary teams and for the follow-up of patients after surgery.

Conclusions

VC is a common clinical tool for surgeons and provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment despite long distances, especially in rural areas.

Remote video management for intraoperative consultation and surgical telepresence

Telemedicine applications can connect surgeons from one operating room (OR) to a distant consultant. The additional capacity of telepresence provides remote consultants the ability to control their own view of the surgical field using robotic management of a network camera. The goal of this study was to compare access to surgical field by robotic camera versus image controlled by the surgeon using a camera mounted to the table. A Stryker laparoscopic camera was attached to the OR table using a Mediflex arm, and video image was transmitted with a Polycom Transfer Control Protocol (TCP)/Internet Protocol (IP) connection. A network Sony camera was mounted on a tripod, connected over the Internet using a parallel TCP/IP connection. A Web interface allowed control of the camera angle and zoom. In 22 consultations effective bandwidth was 800 Kbps for the network camera and 1024 Kbps for the Stryker camera. The operation was thyroidectomy and the consultant was either in Moscow, Russia, or Bucharest, Romania. The quality of the image in both methods was indiscernible. The ability to identify critical surgical anatomy was also indiscernible. No transmission session failed or had an interruption. The robotic camera can be a powerful tool for surgical collaboration.

Multimedia Data Capture and Management for Surgical Events: Evaluation of a System

The objective of this study was to design an electronic form of documentation of surgical procedures, which would include audio and video recording of the entire surgical procedure. Video clips have shown promise for teaching surgical procedures. To date, no systems have been described to fully record video and audio of all events during a surgical procedure. Much as such systems have aided the airline industry, surgical safety, documentation, and education could benefit from comprehensive, multimedia documentation systems. Four camcorders provided views of: (1) anesthetic monitors, (2) laparoscopic images, (3) room view, and (4) surgical field view. All video and audio were combined with real-time written documentation of events within a simple, inexpensive database for archiving, review, and evaluation. Electronic records provided answers to more than 90% of the structured review questions, leaving only 6% unanswered, versus 92% unanswerable based on the traditional paper records. This electronic documentation system provides a much more comprehensive and easily mined means of surgical documentation than traditional paper records.

Telemedicine and Electronic Health Information for Clinical Continuity in a Mobile Surgery Program

INTRODUCTION

An intermittent surgical services program in rural Ecuador was able to benefit from close collaboration between surgeons and primary care physicians through the use of telemedicine technologies.

METHODS

Inexpensive telemedicine workstations capable of patient documentation, imaging, and video-conferencing at extremely low bandwidth were established in collaborative primary care sites in rural Ecuador. Patients were screened for intermittent surgical services by primary caregivers according to the surgeons' guidelines. Real-time and store-and-forward telemedicine allowed appropriate collaborative, informed decision-making. Surgery was performed, and postoperative care was similarly handled by on-site, familiar primary caregivers.

RESULTS

To date, this system has been used in more than 124 patient encounters (74 preoperative and 50 postoperative visits). The system allowed advance screening of patients on the part of the surgeons, leading to cancellations for 9 patients. Postoperatively, the system allowed 100% concurrence in postoperative diagnoses between the primary caregivers and the surgeons.

CONCLUSIONS

Inexpensive, low-bandwidth telemedicine solutions can support intermittent surgical services by providing patients to have contact with specialist care through their familiar, local primary caregivers.

Equipment and technology in surgical robotics

Contemporary medical robotic systems used in urologic surgery usually consist of a computer and a mechanical device to carry out the designated task with an image acquisition module. These systems are typically from one of the two categories: offline or online robots. Offline robots, also known as fixed path robots, are completely automated with pre-programmed motion planning based on pre-operative imaging studies where precise movements within set confines are carried out. Online robotic systems rely on continuous input from the surgeons and change their movements and actions according to the input in real time. This class of robots is further divided into endoscopic manipulators and master-slave robotic systems. Current robotic surgical systems have resulted in a paradigm shift in the minimally invasive approach to complex laparoscopic urological procedures. Future developments will focus on refining haptic feedback, system miniaturization and improved augmented reality and telesurgical capabilities.

Telementoring in Endocrine Surgery: Preliminary Indian Experience

Telemedicine is starting to play an important role in the health field in India. In this case report we describe the successful use of telementoring to remove a parathyroid tumor in a patient with residual hyperparathyroidism after two previous unsuccessful attempts in tumor excision. A 21-yr-old patient crippled with advanced hyperparathyroidism was taken up for third-time exploration at Amrita Institute of Medical Sciences (AIMS), Kochi, with guidance from the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, using telemedicine technology. These two centers are located 2,500 km apart, and telementoring from the more experienced endocrine surgeons at SGPGIMS resulted in successful tumor localization and removal. For this session both the institutions were provided with a dedicated 512 Kbps very small aperture terminal (VSAT) link and two-way video-audio connectivity. Even though two previous explorations were unsuccessful, with the help of telemedicine technology the same surgeon was successful in locating and removing the tumor. The video and audio quality was of good enough quality for the expert at SGPGIMS to guide the team at AIMS satisfactorily. The patient benefited since he did not have to travel to a far-off specialized center for surgery. This case report testifies to the usefulness of telemedicine in the field of surgery, especially in developing countries, which have few medical experts in certain specialized areas.

International transmission of uncompressed endoscopic surgery images via superfast broadband Internet connections

BACKGROUND

Although telecommunication is increasing in popularity, poor-quality images sent through a narrowband network limit its use in the medical field.

METHODS

Kyushu University Hospital in Japan and four hospitals in Korea were linked via superfast broadband Internet connection. The digital video transfer system, which can transmit digital videos without loss of image quality, was used, and the bandwidth was 30 Mbps per line.

RESULTS

Of the 16 teleconferences conducted, 6 demonstrated real-time endoscopic surgery. In addition to the surgical images, preoperative diagnostic images, images of the operating room, and images of the staff in the conference room were transmitted to facilitate discussion. The network remained stable, and the sound delay was restricted to less than 0.3 s. In the other 10 teleconferences, recorded video images were used for discussion.

CONCLUSIONS

The authors have established a high-quality, practical teleconference system that is economical and easy to use in clinical practice. This system shows promise for remote education beyond geographic borders.

Telemedicine for access to quality care on medical practice and continuing medical education in a global arena

Health care practices continue to evolve with technological advances integrating computer applications and patient information management into telemedicine systems. Telemedicine can be broadly defined as the use of information technology to provide patient care and share clinical information from one geographic location to another. Telemedicine can lower costs and increase access to health care, especially for those who live in remote or underserved areas. The mechanism of telemedicine raises some difficult legal and regulatory issues as well since technology provides remote diagnosis and treatment across state lines resulting in unclear definitions for liability coverage. Physician licensing becomes an issue because telemedicine facilitates consultations without respect to state or national borders. With the increased access to current information and resources, continuing medical education becomes more feasible with synchronous or asynchronous access to educational content. The challenge in implementation of these unique educational tools is the inclusion for standards of practice and appropriate regulatory mechanisms to cover the audiences.