Training for excellence: using a multimodal videoconferencing platform to coach surgeons and improve intraoperative performance

INTRODUCTION

Continuing Professional Development opportunities for lifelong learning are fundamental to the acquisition of surgical expertise. However, few opportunities exist for longitudinal and structured learning to support the educational needs of surgeons in practice. While peer-to-peer coaching has been proposed as a potential solution, there remains significant logistical constraints and a lack of evidence to support its effectiveness. The purpose of this study is to determine whether the use of remote videoconferencing for video-based coaching improves operative performance.

METHODS

Early career surgeon mentees participated in a remote coaching intervention with a surgeon coach of their choice and using a virtual telestration platform (Zoom Video Communications, San Jose, CA). Feedback was articulated through annotating videos. The coach evaluated mentee performance using a modified Intraoperative Performance Assessment Tool (IPAT). Participants completed a 5-point Likert scale on the educational value of the coaching program.

RESULTS

Eight surgeons were enrolled in the study, six of whom completed a total of two coaching sessions (baseline, 6-month). Subspecialties included endocrine, hepatopancreatobiliary, and surgical oncology. Mean age of participants was 39 (SD 3.3), with mean 5 (SD 4.1) years in independent practice. Total IPAT scores increased significantly from the first session (mean 47.0, SD 1.9) to the second session (mean 51.8, SD 2.1), p = 0.03. Sub-category analysis showed a significant improvement in the Advanced Cognitive Skills domain with a mean of 33.2 (SD 2.5) versus a mean of 37.0 (SD 2.4), p < 0.01. There was no improvement in the psychomotor skills category. Participants agreed or strongly agreed that the coaching programs can improve surgical performance and decision-making (coaches 85%; mentees 100%).

CONCLUSION

Remote surgical coaching is feasible and has educational value using ubiquitous commercially available virtual platforms. Logistical issues with scheduling and finding cases aligned with learning objectives continue to challenge program adoption and widespread dissemination.

Telestration with augmented reality improves the performance of the first ten ex vivo porcine laparoscopic cholecystectomies: a randomized controlled study

INTRODUCTION

The learning curve in minimally invasive surgery (MIS) is steep compared to open surgery. One of the reasons is that training in the operating room in MIS is mainly limited to verbal instructions. The iSurgeon telestration device with augmented reality (AR) enables visual instructions, guidance, and feedback during MIS. This study aims to compare the effects of the iSurgeon on the training of novices performing repeated laparoscopic cholecystectomy (LC) on a porcine liver compared to traditional verbal instruction methods.

METHODS

Forty medical students were randomized into the iSurgeon and the control group. The iSurgeon group performed 10 LCs receiving interactive visual guidance. The control group performed 10 LCs receiving conventional verbal guidance. The performance assessment using Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores, the total operating time, and complications were compared between the two groups.

RESULTS

The iSurgeon group performed LCs significantly better (global GOALS 17.3 ± 2.6 vs. 16 ± 2.6, p ≤ 0.001, LC specific GOALS 7 ± 2 vs. 5.9 ± 2.1, p ≤ 0.001, global OSATS 25.3 ± 4.3 vs. 23.5 ± 3.9, p ≤ 0.001, LC specific OSATS scores 50.8 ± 11.1 vs. 41.2 ± 9.4, p ≤ 0.001) compared to the control group. The iSurgeon group had significantly fewer intraoperative complications in total (2.7 ± 2.0 vs. 3.6 ± 2.0, p ≤ 0.001) than the control group. There was no difference in operating time (79.6 ± 25.7 vs. 84.5 ± 33.2 min, p = 0.087).

CONCLUSION

Visual guidance using the telestration device with AR, iSurgeon, improves performance and lowers the complication rates in LCs in novices compared to conventional verbal expert guidance.

Telestration with augmented reality improves surgical performance through gaze guidance

BACKGROUND

In minimally invasive surgery (MIS), trainees need to learn how to interpret the operative field displayed on the laparoscopic screen. Experts currently guide trainees mainly verbally during laparoscopic procedures. A newly developed telestration system with augmented reality (iSurgeon) allows the instructor to display hand gestures in real-time on the laparoscopic screen in augmented reality to provide visual expert guidance (telestration). This study analysed the effect of telestration guided instructions on gaze behaviour during MIS training.

METHODS

In a randomized-controlled crossover study, 40 MIS naive medical students performed 8 laparoscopic tasks with telestration or with verbal instructions only. Pupil Core eye-tracking glasses were used to capture the instructor's and trainees' gazes. Gaze behaviour measures for tasks 1-7 were gaze latency, gaze convergence and collaborative gaze convergence. Performance measures included the number of errors in tasks 1-7 and trainee's ratings in structured and standardized performance scores in task 8 (ex vivo porcine laparoscopic cholecystectomy).

RESULTS

There was a significant improvement 1-7 on gaze latency [F(1,39) = 762.5, p < 0.01, ηp2 = 0.95], gaze convergence [F(1,39) = 482.8, p < 0.01, ηp2 = 0.93] and collaborative gaze convergence [F(1,39) = 408.4, p < 0.01, ηp2 = 0.91] upon instruction with iSurgeon. The number of errors was significantly lower in tasks 1-7 (0.18 ± 0.56 vs. 1.94 ± 1.80, p < 0.01) and the score ratings for laparoscopic cholecystectomy were significantly higher with telestration (global OSATS: 29 ± 2.5 vs. 25 ± 5.5, p < 0.01; task-specific OSATS: 60 ± 3 vs. 50 ± 6, p < 0.01).

CONCLUSIONS

Telestration with augmented reality successfully improved surgical performance. The trainee's gaze behaviour was improved by reducing the time from instruction to fixation on targets and leading to a higher convergence of the instructor's and the trainee's gazes. Also, the convergence of trainee's gaze and target areas increased with telestration. This confirms augmented reality-based telestration works by means of gaze guidance in MIS and could be used to improve training outcomes.

Telestration with augmented reality for visual presentation of intraoperative target structures in minimally invasive surgery: a randomized controlled study

AIMS

In minimally invasive surgery (MIS), intraoperative guidance has been limited to verbal communication without direct visual guidance. Communication issues and mistaken instructions in training procedures can hinder correct identification of anatomical structures on the MIS screen. The iSurgeon system was developed to provide visual guidance in the operating room by telestration with augmented reality (AR).

METHODS

Laparoscopic novices (n = 60) were randomized in two groups in a cross-over design: group 1 trained only with verbal guidance first and then with additional telestration with AR on the operative screen and vice versa for group 2. Training consisted of laparoscopic basic training and subsequently a specifically designed training course, including a porcine laparoscopic cholecystectomy (LC). Outcome included time needed for training, performance with Global Operative Assessment of Laparoscopic Skills (GOALS), and Objective Structured Assessment of Technical Skills (OSATS) score for LC, complications, and subjective workload (NASA-TLX questionnaire).

RESULTS

Telestration with AR led to significantly faster total training time (1163 ± 275 vs. 1658 ± 375 s, p < 0.001) and reduced error rates. LC on a porcine liver was performed significantly better (GOALS 21 ± 5 vs. 18 ± 4, p < 0.007 and OSATS 67 ± 11 vs. 61 ± 8, p < 0.015) and with less complications (13.3% vs. 40%, p < 0.020) with AR. Subjective workload and stress were significantly reduced during training with AR (33.6 ± 12.0 vs. 30.6 ± 12.9, p < 0.022).

CONCLUSION

Telestration with AR improves training success and safety in MIS. The next step will be the clinical application of telestration with AR and the development of a mobile version for remote guidance.

Telestration in the Teaching of Basic Surgical Skills: A Randomized Trial

OBJECTIVE

To evaluate how an affordable course using telestration with augmented reality can be compared to the traditional teaching of basic surgical skills.

DESIGN

Prospective, randomized and blinded study.

SETTING

Faculty of Medicine of Porto University.

PARTICIPANTS AND METHODS

Twenty medical students without any experience in basic surgical skills were randomized into two different learning groups: telestration and traditional teaching (on-site mentoring) groups. Five different types of sutures were taught: the single interrupted, the cruciate mattress, the horizontal mattress, the vertical mattress and the simple continuous sutures. Data was obtained on the time taken to learn each of the techniques and to perform each exercise without any support from the faculty, tension of the suture, quality of the procedure using a modified Objective Structured Assessment of Technical Skills and participants' answers to a Likert questionnaire in terms of their learning experience, confidence, and self-evaluation.

RESULTS

Trainees in the telestration group were globally faster when performing independently (1393.40 [SD 288.89] vs 1679.00 [SD 328.22] seconds, p = 0.04) particularly during the cruciate mattress suture (235.50 [SD 61.81] vs 290.00 [SD 68.77] seconds, p = 0.05) and the simple continuous suture (492.40 [SD 87.49] vs 630.30 [SD 132.34] seconds, p = 0.01).Time needed for students to learn the procedures was similar between the groups. There were also no statistically significant differences in terms of the quality of the surgical gesture, tension of the suture, self-evaluation or confidence.

CONCLUSIONS

A basic surgical skills course using telestration through a head-mounted device with augmented reality capabilities can be a viable alternative to traditional teaching, considering time and quality of the gesture. Though costs can discourage from using this technology in basic procedures, the use of free software may turn it into an affordable option in the context of distant learning.

Robust hand tracking for surgical telestration

PURPOSE

As human failure has been shown to be one primary cause for post-operative death, surgical training is of the utmost socioeconomic importance. In this context, the concept of surgical telestration has been introduced to enable experienced surgeons to efficiently and effectively mentor trainees in an intuitive way. While previous approaches to telestration have concentrated on overlaying drawings on surgical videos, we explore the augmented reality (AR) visualization of surgical hands to imitate the direct interaction with the situs.

METHODS

We present a real-time hand tracking pipeline specifically designed for the application of surgical telestration. It comprises three modules, dedicated to (1) the coarse localization of the expert's hand and the subsequent (2) segmentation of the hand for AR visualization in the field of view of the trainee and (3) regression of keypoints making up the hand's skeleton. The semantic representation is obtained to offer the ability for structured reporting of the motions performed as part of the teaching.

RESULTS

According to a comprehensive validation based on a large data set comprising more than 14,000 annotated images with varying application-relevant conditions, our algorithm enables real-time hand tracking and is sufficiently accurate for the task of surgical telestration. In a retrospective validation study, a mean detection accuracy of 98%, a mean keypoint regression accuracy of 10.0 px and a mean Dice Similarity Coefficient of 0.95 were achieved. In a prospective validation study, it showed uncompromised performance when the sensor, operator or gesture varied.

CONCLUSION

Due to its high accuracy and fast inference time, our neural network-based approach to hand tracking is well suited for an AR approach to surgical telestration. Future work should be directed to evaluating the clinical value of the approach.

What device should be used for telementoring? Randomized controlled trial

BACKGROUND AND OBJECTIVE

The paper analyzes behavioral patterns of mentors while using different mentoring devices to demonstrate the feasibility of multi-platform mentoring. The fundamental differences of devices supporting telementoring create threats for the perception and interpretation of the transmitted video, highlighting the necessity of exploring hardware usability aspects in a safety critical surgical mentoring scenario.

MATERIALS AND METHODS

Three types of devices, based on the screen size, formed the arms for the randomized controlled trial. Streaming video recordings of a laparoscopic procedure to the mentors imitated the mentoring scenario. User preferences and response times were recorded while participating in a session performed on all devices.

RESULTS

Median response to a mentoring request times were similar for mobile platforms; expected durations were considerably longer for stationary computer. Ability to perceive and identify anatomical structures was insignificantly lower on small sized devices. Stationary and tablet platforms were nearly equally preferred by the most of participants as default telementoring hardware.

DISCUSSION

As a side effect, incompatibility of daily duties of the surgeons in the hospital and telementoring responsibilities while implementing systems locally was identified. Scaling up the use of the service in combination with the organizational changes of clinical staff looks like a promising solution.

CONCLUSION

The trial demonstrated the feasibility of using all three types of devices for the purpose of mentoring, allowing users to choose the preferred platform. The paper provided initial results on the quality assurance of telementoring systems imposed by the regulatory documents.