Surgical telementoring-emerging technologies: Comparative Technology in...

So, so, uh, we have been involved in several projects related to, uh, to, to surgical telementoring, and I want to, uh, briefly, uh, introduce you to some of the, the projects, and, uh, uh, I will also walk you through what's out there related to, uh, different, uh, surgical telementoring setups. Um, first of all, uh, I have no competing interests or no, uh, financial ties to disclose. Um, Uh, first of all, I want to go to Project 6, and I think that's a fantastic, uh, project. It's, uh, it's named Project 6 after the aviation industry and fighter pilots who needed, uh, uh, a more experienced pilot to watch their back. And I think that's exactly what we need in, in surgery. We need, uh, always need mentors. We need someone who are, are, uh, in certain, uh, circumstances more experienced. And it's, uh, it's, uh, we are speaking about lifelong learning. So, so that's, uh, that's, um, um, uh, very applicable to surgical life, that name. And, uh, from this project 6 meeting, we got several white papers that hopefully will soon be published within, within, uh, Uh, technology and, uh, law and, uh, uh, logistics, uh, and, uh, I will also then walk you through some of the, the technologies. So that's, uh, mostly per my personal opinion. And of course, won't represent an official opinion of, of, of Project 6 or, or uh uh any other uh official organization, but I will walk you through what's published out there and, and show some of the existing systems. And then I want to thank, uh, um, uh, Evelyn for, um, for, uh, being, uh, Evelyn Baron-Clottier at the, the American Medical Foundation for being, uh, such a driving force in this. And, uh, I don't think that this, uh, this event would be possible without her leadership and, and, uh, and, uh, enthusiasm. Uh, so this is the, the systems that I want to walk you through, and, and, uh, I will not talk about the, um, the system, uh, introduced by Carl Swarz, the Wizard of one, and I will not talk about Google Glass, and that will be, uh, as that will be covered by other, uh, speakers tonight, uh, but I will speak about Skype for Business. I will speak something about. Remote desktop platforms, uh, I will briefly mention a new, uh, uh, platform called Search Platform. Uh, I will mention the OR network platform, the store platform, and I speak about the availability, uh, cost, uh, what's the clinical experience, and, uh, also say something about the data security related to the different platforms and telestration. Well, uh, when it comes to surgical telementoring, I think that there are two issues that are very important, and that's, uh, uh, that's, uh, the availability to, uh, perform telestration. And the second issue is the, the data security issue. Um, when it comes to, uh, telestration, there are shown that, uh, that, um, uh, telestration reduces between can come with more than 30%. So for those of you who don't know what Telustration is, it's, it's the availability for the mentor to draw on his screen and, and show, um, uh, planes of dissection, and danger zones, uh, places where you don't want to, to operate on, and, and, uh, this, uh, greatly improves the, the teaching, teaching situation. The second thing I want to, to speak about is, uh, I mentioned is the data security and what you call in, in the United States, the HIPAA compliance. Uh, and of course, uh, all of us have to, uh, to, uh, um, follow the laws and regulations in each other's countries. And, uh, and also at, uh, our hospitals. So, so that's extremely important. So, uh, telestration and, and data security related to the different systems are, uh, are uh of outermost importance. And, then I'll move on to the platform one, and that's Skype for Business. And you all of you know Skype, uh, and I know that Todd and, and Steve has used Skype, uh, in some of their telementoring sessions. And, uh, Skype has now, uh, uh, been improved, and they call it Skype for Business. And, uh, I think the, the most, uh, uh, prominent improvement there is the security, data security. I think it has a huge, uh, potential, but according to my information, it's not HIPAA compliant in, in the United States yet. Uh, but, however, it's, it's approved by the Scandinavian authorities now. So, um, uh, so we have started to integrate Skype in our operational theaters, uh, in, in Norway, and I think other places in, in Scandinavia. And it's integrated with Microsoft Office, and I think that, uh, this creates huge potentials related to, uh, telestration and And other ways of, uh, performing audio visual um help. Uh, so what's published out there, uh, related to Skype? I know that Todd and, and Steve has published a very, very nice paper. Uh, I won't mention that. I'll leave that to Todd, but, uh, but this is a paper, uh, published, uh, by a group, uh, from Houston, Texas, and from Melbourne in Australia. And they, uh, tele mentored, um, uh, 25 cases where the mentor was located in, in Houston, Texas. Um, and it was, uh, um, uh, retro, uh, peritoneoscopic adenolectomy. Uh, it, uh, went, uh, uh, uncomplicated, and, and they conclude that Skype is a very feasible, uh, platform for surgical telementoring. Uh, the second platform I want to mention is what I will call the remote desktop software platforms, and it's actually a group of, of different softwares which you can use in, in the OR. But it's based upon a personal computer desktop environment, and it can be run remotely by one system. And, um, that's, for instance, an iPad, iPhone, a PC or a Mac. And uh it's being displayed separately on a client device, and you can take over the PC that's uh located in the OR uh remotely. Uh, and most of the softwares related to remote desktop softwares have a very, very good, uh, telestration features. And this is, um, the first paper that was published, uh, upon the remote desktop systems, and it was published in 2007 by a group in, in London, uh, where, uh, Doctor Gambadera and uh Adam Margus showed that it was feasible to use uh for uh in uh laparoscopic gynecological surgery. And what they did was that they, they actually um had a PC in the, in the, in the OR. They had a mentor's computer. They had different uh converters for the video. They had Bluetooth connections to the headset, and they had cables related to the setup in the And the OR and then they had the, um, uh, uh, a, a, a remote desktop software installed in both computers, and they had also, uh, uh, a separate system for the audio, and they showed that this is a very feasible and nice way to perform. Uh, surgical telementoring. Actually, I was, uh, was in contact with Doctor Gambadero today and, uh, I would send him, um, uh, his greetings. Um, uh, unfortunately, the, the system is not up and going today, but he will be more than happy to, to, uh, instruct and help anyone who wants, uh, wants, uh, details related to his system. So, uh, in, uh, 2015, we published, uh, a book, uh, related to, uh, uh, quality in pelvic cancer surgery, and this is a schematic setup of, uh, of a remote desktop, uh, system. And it's, um, it's, um, you have a server, uh located in the, in the, or a PC located in the, in the operational theater, which you can stream. Uh, video, uh, from to the, to the PC. You have, uh, it can be attached to a Wi Fi network, and of course, the Wi Fi network can then be attached to different tablets inside the OR or, uh, or, um, uh, or, uh, into hospitals. And then you can use the internet that we Uh, connect to the, to the PC, uh, and you can do what we call external telementoring. Uh, and that can be either, uh, intercontinental, uh, at the hospital, or, for instance, the, the on-call surgeon, uh, will, will be at home and do, uh, telementoring. The problem with most of the remote desktop, uh, um, systems is that you have a set, you have to have a separate line for the, the audio, and that's, uh, that's, uh, uh, might be a challenge, but I will show you some systems that have combined, uh, uh, audio and video later on. Uh, so you can, uh, you can use different, uh, remote desktop system, uh, uh, and install at your computer in the OR. You can assist. You can use something called Jump Microsoft's, uh, setup, uh, the screen connect, uh, and, and so on, and it can be connected to your, your personal computer. And so we tested this, uh, this system and I will show you something, uh, later on, uh, related to, uh, to this, uh, this setup, uh, one very, uh, attractive model for surgical telementing on-site collaboration platform, and that's, uh, that's, uh, widely used in the industry, and, and they have also used it within healthcare and, uh, the nice thing about the on-site collaboration platform is that they can combine audio and video in, in 11, Uh, piece, so you don't have to have two separate systems, and they have, uh, have isolated telestration, uh, features, and they have, uh, have, uh, uh, cameras you can buy, you can stream videos into their cameras, and, uh, and I think it is, it's a very, uh, seems like a very, uh, system that you can be used for the future. So, uh, in, uh, 2014, we went, uh, to Doctor Delaney's basement and we tested some of the, the systems. Hi, Conor, uh, uh, and, um, uh, we, uh, what we did then was that we were connected, uh, connecting this uh remote desktop system to, uh, to, uh, our, uh, colleagues in Norway. And uh what we used there was, as you see, uh, uh, tablets, we used, uh, uh, separate PC and we used the iPhone to, to, uh, to, uh, cover the audio. And the, the PC was used to have a backup system for, uh, in case, uh, of, uh, uh, of, um, of, uh, uh system breakdown. And we also had then installed a, a remote desktop system on, on the PC. So that's, uh, that's what we, we used then and it was fantastic, uh, uh, uh, uh, a fantastic, nice, um, uh, picture, and we had very good quality during the, the setup. So we, uh, at that session, uh, telementored and telestrated, uh, Uh, uh, a low anterior resection, uh, rectal cancer, uh, with, uh, with very good results to, uh, to our Norwegian, uh, colleagues, and I know that, uh, Doctor Konsky has also used this system later on and, and, and Steve. So, so, uh, so it's, uh, it's, uh, been tested widely, and I hopefully it will be published in a larger series, uh, later on. And Evelyn Baron Clotier has been, uh, nicely publishing this in the surgical telementoring news, and as you can see here, we were able to tell us straight, uh, uh, and, uh, uh, our, uh, good colleagues in Norway had the possibility to, uh, to see the lines, and I have also the possibility to do uh intraoperative, uh, telestration. Uh, so then I'll move on to, uh, platform number 3, the upsurge platform. And this is, uh, uh, it's a brand new platform published in, at stages, uh, 2016, actually as a poster presentation. Uh, so if there are anyone out there in the audience that, uh, have firsthand information related to the upsurge platforms, please, uh, speak up. But, uh, as far as I know, it's, it's not widely used within clinical practice yet. And, and I don't know whether it's, uh, uh, commercial available, but, but it seems like it will be soon on the market. They have telestration features and it's HIPAA compliant. And uh you can, uh, you can, uh, look at their setup at their homepage. Uh, and it seems like it is also, uh, completely, uh, compliant with the, the Olympus setup at the, the OR, uh, theater. Uh, so it's, uh, like a plug and play setup, uh, uh, where you can connect iPads, iPhones, and do telementoring, telestration, whatever. Then I'll move on to what we call the OR network platform, and that's actually the platform that's been, uh, uh, most widely used for surgical telementoring, according to my information, uh, worldwide. Uh, unfortunately, it's not published yet, but they have, uh, have telementored 500 cases to, to, uh, Tanzania in, in, uh, in Africa from the United Kingdom. Uh, this platform is HIPAA compliant. They have telestration features, uh, and as I said, they have extensive clinical practice, and it's, uh, fully integrated in the OR and, uh, also fully compatible with all laparoscopic racks and also cameras that you can install in the OR. And, uh, the group in, in London was actually, uh, uh, uh, a group at the, the Northumbria Healthcare Trust and Doctor Lion Horgan, uh, was, uh, was, uh, the, the 2014, uh, Cornru National Surgical Team Prize, uh, in the United Kingdom related to this, uh, this project. So they telementored 500 laparoscopic procedures to, to Tanzania. So that's a, it's a fantastic achievement and uh I want to congratulate Liam Borgen and his team. And then, uh, we have something called the, the star platform or a system for telementoring with an augmented reality. And this is a platform which was published, uh, uh, in, uh, 2016, uh, in, uh, in January this year, and it's actually an, an, uh, a transparent, uh, uh, image you can lay over your operational field, and you can see telestration directly on the operational field. Um, it's, uh, they, they claim and conclude that participants using this, uh, this system. Completed tasks with less placement errors and with fewer focus shifts. So it seems like a very nice platform, but, uh, as far as I know, it's, it's can be used uh for open survey, but not yet for laparoscopic survey. Uh, finally, but not last, we have to, to move on to our friends and colleagues in, in India, and they published a paper now in, in, uh, February in the Indian Journal of Surgery showing that surgical telementoring is feasible with, with a low-cost setup. And they, uh, created a setup, uh, with the, uh, uh, out of use laparoscopic camera used for video capture, and it only costs $4000 to $500. So, and they telementored, uh, uh, several cases. Using this system. So, uh, congratulate the, to our colleagues in, in India for, for this innovation and, and for, uh, creating surgical telementoring platform, uh, with low resources. And, uh, finally, uh, I want to thank the faculty tonight and especially I want to thank, uh, Brian Duncan for having such a, a fantastic speech at his presidential address, uh, at, uh, at SAGES, uh, where he actually introduced the, uh, the term surgical telementoring and spoke a lot about, uh, Project 6. Uh, and I also want to thank my mentor, Doctor Delaney, for, uh, being, uh, such a good mentor during my stay in Cleveland, and that we could, could, uh, do the, the, the, the surgical telementoring, uh, experiments while I was there. And finally, uh, to, to Todd for, for hosting this session and also to Evelyn Baron Clottier at the American Medical Foundation for being such a, a great, uh, inspiration and for, uh, for driving the work related to surgical telementoring forward. Uh, so what's the right system? Um, and I don't think that's, uh, an easy, easy question to answer. I think that, uh, Uh, you have to ask yourself what's the hospital budget? What's, uh, how many, how much money do you have available? And, and, uh, uh, the second thing is, uh, just, uh, the system, uh, uh, has telestration features. Do you need telestration? Is that needed? What's the, what's the data security, uh, issues and How do you want to handle that? And, uh, uh, is the system going to be used as in a fixed educational framework, or is it going to be used uh in uh a 1 to 1, uh, case, uh, in emergency cases? And last, uh, but not least, uh, what's the, the clinic or the technological requirements related to firewalls, bandwidth, uh, latency, and so on. So that's, uh, that's, uh, that's, um, my answer to what's the right question, the right system, I mean. So, uh, then finally, I want to, uh, to move on to, uh, uh, image from the 160,000 in Saint Gallen, where they had a mentor and a mentee, and that's exactly what we, we have, uh, several 100 years later. We have a mentor and a mentee. Uh, within uh surgery and uh that has not, uh, changed much, but what has changed is the technological availabilities and, and the possibility that, uh, that surgical telementoring system is great. And I want to quote the Liam Borgen who, uh, who then, uh, then telementored 500 cases to Tanzania. Saying that to me, this is an example of teamwork and strong relationships that struggle two continents, making our whole world smaller and hopefully safer and better. Thank you, Todd. Thank you, Knut. That was, uh, I have to tell you, that was a great overview. Yeah, if you could stop sharing your screen, that'd be great. That was a fantastic overview of technology and uh it, it was a great way to start off this event. And I really appreciate you, you also mentioning uh Evelyn. Evelyn Barham-Clothier, who really, uh, for those of you who don't know her, uh, has been the, the, the, the engine behind this and pushing all of us all over the world to, to bring telementoring. Uh, into the mainstream. So, Evelyn's here and staying quiet, and, uh, that's, that's OK cause I, she likes to hear everyone here speak, but Evelyn's really been the, the, the driver of this. So, thank you, Evelyn. Um, I, uh, I also want to introduce Doctor Connor Delaney, who uh was able to join us. And as Knut mentioned, uh, Dr. Delaney has been very involved with this, uh, with the Norway Group in, in the area of colorectal telementoring. Dr. Delaney is the chairman of the Digestive Disease Institute at the Cleveland Clinic. Uh, Connor, are you there? Yes, indeed. Thank you for joining us. Sure, it's a pleasure. So, I, I want to, uh, before we move on to the next talk, which is Brian's talk, I want to talk for a few minutes here. There's some comments from the audience, and I also want to ask you, Connor, so you had firsthand experience with this. Tell me what your thoughts were. Where was the technology lacking? What did you like? What did you not like, and where are we going in the future? So I think where we're going in the future clearly is around exploring and utilizing telementoring and and maybe not necessarily surgical training, but I think bringing surgery to certain areas around the world and certain practices practices you're hearing a very big we're hearing the echo we're trying to trying to figure out where that's coming from. Oh, can you, can you, OK, we, we muted it. Go ahead, sorry. OK. So I think, I think it's here to stay. Obviously it's in its infancy, but I think it's going to be an important technique for us as we help train people and as people look for advice. I think particularly in geographically large areas like Norway, Africa, around the US, where people may not have enough experience. I think there's issues with it and questions we need to address and Knut put it very nicely in one of his last slides there about the technical and other bandwidth issues. And you know, I think there's going to be issues in how we structure it and having mentors available, you know, if you're watching someone do a 3 hour operation, that's a lot of time unless you're on the end of a phone that somebody can call for advice. So, we have to figure out how we do it. Uh, time-wise and how we integrate it. And I'm sure Brian is going to talk about how you structure this in training programs, and I think that may be one of the keys. But as we expand new surgical skills for new operations, whether it's transanal TME or lap colon, you know, we have it as a formal part of a training program and that you can have a video mentor helping you. I think one of the interesting areas to explore with this is telestration, but it's not as easy as it sounds because particularly if you're using a laparoscopic video camera, you know, when we drew on the screen to say where to mobilize the inferior mesenteric and how to protect the nerves, if whoever's holding the camera moves the camera, your lines have moved and they bear no relationship to where the camera is now. So, you know, a technique in its infancy. And but I think it's important and it's useful, and I think we'll rapidly find areas where we can integrate it in both structured training programs and then maybe more challenging time-wise and how we get the right mentors available, but in other sites geographically that need mentorship and support with complex cases. I think that was a great overview there, Connor, and I agree with, I was nodding my head emphatically to the comments you were making about the telestration and we've had the same issues, and I think uh Uh, you know, we are really embarking on this because of people like Brian who are putting this in the mainstream of the societies. I think everyone's interested. We just have a lot of questions to answer. If I would sort of summarize, it's medical, legal, it's going to be, how are we paying for this? Can experts really take time out of their day to train people? We have logistic questions. We have credentialing and licensing. We have all these issues that hopefully we'll address in subsequent shows and that Brian's really put together a great white paper out of Sages that he'll talk about. Uh, addressing all of those topics. Um, and I, and I also want to, before we move on to Brian, um, address some of the comments and questions from the audience. So, I asked a question. I said, what's your primary interest in telementoring? And how, I, I said, do you want to be the expert or do you want to receive training? And it was like 25, 25%, but 50% said other. So I asked what those others were. And it was interesting. We, we talked about Dr. Florence, Steven Florence says he's interested, interested in integrating telementoring into the simulation lab at my medical school so that our students are familiar with it if and when they ever encounter it later on because it becomes a reality. I thought that was an interesting comment. And Dr. Rupahetti, who I believe is from Nepal, made comments about how he was doing this back in 2010 with Lee Swanstrom, but the technology was really not great at the time, and he's here to see if there's a newer technology. And I think what Knut just showed us is that not only has technology improved, but it's caught the eye of a lot of industry, and I think you're going to see rapid developments in the near future, so that every country all over the world can participate. Uh, before we go on, Steve or Brian, um, do, do, do either of you have any comments, uh, before we go on? Hi, Brian, yeah, I, I, you know, I, um, I, I think that some of the comments that Connor made are interesting, particularly around kind of use of some of the tools. And one of the things that we have to remember as surgeons is that there are experts outside of our field in the, in the world of education that can really help inform us on how to. Communicate uh in teaching over distance and using this platform. So we'll, we'll talk a little bit about that in my presentation, but there are that telestration example is a perfect example. I'll get to a way to get around that. And when you show that problem to an educational expert, they kind of laugh at us that we're doing what we're doing. Uh, so there's opportunities to tap into uh worlds outside of us, uh, to institute best practice. I also love the idea that someone is planning. Um, for telementoring in the future of, uh, of medicine by introducing their trainees to it. I think that that's very thoughtful and that's right on because my goal is to make this just like having a cell phone. It's, it's available to anybody that needs it. Hey, Brian, before we segue into your discussion, I want you to answer this question. So, and by the way, that was Steven Florence who talked about the Sim lab. This is from Gerald Jean Louis, who says, as telementoring slash telemedicine, which is interesting that that slash was put there, is so important, why don't we initiate an association in which we have representatives in each country and we can link to people willing to participate and help? Is that going to happen, Brian? Is that going to be something that Sage is going to spearhead? You know, we've, we've actually had discussions around that, and I think, I think for the purposes of our discussion today, it's probably important to um talk a little bit about telemedicine versus telementoring because we've, we've been careful to separate the two. There is a telemedicine association in the states. They, they've actually been working quite a long time and telemedicine is a huge field with a lot of issues that if we try to tackle all of the issues in telemedicine, I'm afraid we're not gonna get down the road of telementoring. To, to me and to Sages, um, telementoring and surgery is a very specific thing. It's, it's, um, it actually has to have three elements to it. The first is, uh, uh, is the term mentor. So there's a known relationship between the person who's teaching and the person who's learning. Both of them understand each other and their capabilities. That's a mentor-mentee relationship. So that relationship developed before you churn down the AV uh communication. Second is that the mentoring session happens within an educational framework. So that's different from teleconsultation. Um, and third is that there's a local expertise by the surgery team to manage the disease process that's being managed. So when Canute talked about rectal surgery, I am sure that team in the OR, that was not the first time they saw rectal cancer, but it might have been the first time they were managing with a particular technique or technology. So I think by focusing our efforts um and kind of laser focused like that, we can move this needle forward. And I do agree that we need to marshal forces and get like-minded organizations and like-minded people together to move this forward. So we've certainly had discussions within ages about how do we engage other uh organizations, um, how could we uh work together, registries to gain experience about this. Can you put that idea forward. uh, so I think it's very insightful to have those kind of comments.