Digital video technology and surgical training

Mohamed A., Rafiq A., Panait L., Lavrentyev V., Doarn C.R., Merrell R.C.

Application of minimally invasive surgery represents the future of modern surgical care. Previous studies by our group provided a novel way for viewing open surgery using a rigid endoscope attached to charged coupled device (CCD) camera in proximity to the surgical field using a robotic arm (AESOP) and a stabilizing fulcrum (Alpha port). This study is a follow-up to investigate the technical feasibility, advantages, and disadvantages of relying only on video images displayed on standard monitors in performing open surgical procedures instead of direct binocular eye vision. This study used two surgeons as participants with training in basic surgical skill and previous experience in performing an intestinal anastomosis in an ordinary fashion. The standard task consisted of anastomosing porcine intestine in two layers with digital viewing of the operative field. A total of 40 anastomoses (20 by each surgeon) were compared with 10 control performances using direct vision of the field. All the resulting anastomoses were accurate, well coapted, and fully patent with no leakage. Time for task performance was approximately twice as long (p < 0.05) with videoscopic vision as with direct vision. These findings suggest it is technically feasible to conduct open surgeries with visualization of the open surgical field limited to video display on standard monitors.

Watters D.A., Green A.J., van Rij A.

All trainees are required to keep a logbook as a record of the procedures they have carried out during their surgical training. However, the current logbook is only a record of work carried out and not of the outcome of the operations. It does not prepare the trainee for either a lifetime practice of surgical audit or for a lifetime of learning from the audit process. The logbook requirements of different training boards vary and consequently, trainees find the keeping of a logbook an inconsistent process with ill-defined learning objectives. The Royal Australasian College of Surgeons should define what needs to be collected, how data should be verified and how experience and learning should be reported, and should approve electronic databases that meet logbook standards. The choice of database software and format can then be left to the trainee. Although there are good examples of electronic logbooks being developed, there is, at present, no perfect logbook available. We recommend that all trainees, from the commencement of basic surgical training, should keep a logbook that contains the minimum and expanded datasets in addition to specific trainee data on supervision and learning. In addition to the current reporting format focused on procedural casemix and supervision level, quality/outcome reports and a record of learning are recommended.

Mutter D., Bouras G., Marescaux J.

Telecommunications, multimedia and computer technologies will introduce marked changes in the management of cancer. New modalities in the representation of patient's medical records using computer technology products and services allow unlimited cross-sharing of information. Education taught through multimedia methods, and through the Internet, is available anywhere and any time just like surgical simulation, robotics and virtual reality. Thanks to computer and IT technologies, surgeons will be able to acquire, assess and validate new surgical procedures or concepts from any geographical location. Live demonstrations shared via videoconferencing facilitate mental development through the acquisition of the cognitive aspects of surgical procedures. Virtual reality is a major improvement in the processing of medical imaging. As a result, the interpretation and the simulation of therapeutic approaches to patients with cancer are facilitated through transparency, navigation and manipulation. The Internet eventually offers uninterrupted communication links between healthcare providers (teaching, training or multidisciplinary telementoring included). Computer and IT technologies will undoubtedly contribute to standardized cancer treatment modalities and determined guidelines for good clinical practice worldwide.

Magos A., Kosmas I., Sharma M., Buck L., Chapman L., Taylor A.

To develop a system for recording surgical procedure digitally using a personal computer with real-time compression of the video signal.We built the system around a modern personal computer with a large hard disk to allow recording of over 250 h of continuous surgery. Digital capture from the camera was achieved using a standard external analogue-digital converter linked to the computer via a firewire cable. The software for capturing, compressing and editing movie files were obtained free of charge from the internet. The optimal settings for the software was determined.We have successfully used this system to record over 100 major and minor hysteroscopic, laparoscopic, vaginal and open gynaecological. Despite compression, the quality of the movies was judged to be very good and still images excellent. The recordings could be integrated in to standard presentation. Still pictures could be printed to provide hard copies for patients and medical notes, and movies burnt on to CDs or DVDs.A digital recording system built around a standard personal computer is relatively cheap, versatile and has a huge capacity to record surgical procedures.

Renwick A.A., Bokey E.L., Chapuis P.H., Zelas P., Stewart P.J., Rickard M.J., Dent O.F.

Abstract Background The process of training surgeons in technique for resection of colorectal cancer should not compromise patient care or outcomes. The aim of this study was to compare morbidity, mortality and survival rates after resection performed by trainees with those for a consultant surgeon. Methods Outcomes for 150 patients operated on by a single colorectal surgeon at a private hospital were compared with those of 344 patients admitted under the same surgeon and operated on by closely supervised trainee surgeons in a public teaching hospital between 1995 and 2002. Results Co-morbidity was significantly more common in patients operated on by trainees; their American Society of Anesthesiologists grades were higher and tumours were more advanced. Of 16 postoperative complications evaluated, only respiratory and cardiac problems were significantly more common in patients operated on by trainees. There was no difference in operative mortality, local recurrence or 2-year survival rate after adjustment for age and tumour stage. Conclusion Outcomes after resection for colorectal cancer did not differ between the consultant and trainees in the context of a closely supervised training programme.

Mutter D., Rubino F., Temporal M.S., Marescaux J.

The new means and modalities of communication and information technologies have significantly revolutionized access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information sharing medium offers a wide range of opportunities to healthcare professionals. High-speed Internet broadcasting allows the display of high-quality full-screen videos. Access to surgical procedures through the Internet already plays a major role in continuing medical education nowadays and will undoubtedly be gaining grounds in the future. WebSurg.com, the World Virtual University, a web-based surgical university, is dedicated to minimally invasive laparoscopic surgery. Using brand-new multimedia data, the electronic university provides thorough descriptions of over 150 procedures in minimal access surgery and 265 videos of surgical interventions. Such a teaching tool recreates all the prerequisites and requirements of a traditional School of Medicine, incorporating the manifold standpoints of world-renowned experts about specific topics and hands-on hints in various surgical specialities. Following the evolution of technologies, recent advances have made it possible to display items of Websurg.com on handheld devices (personal data/digital assistance also known as PDAs, Pocket PCs, and smart phones). Integrating all these elements into a unique World Virtual University, Websurg.com epitomizes the concept of a unified academic center providing teaching and tutorials administered by international experts. The Internet assuredly contributes to the worldwide diffusion of scientific information in an easy and user-friendly way.

Robson A.J., Wallace C.G., Sharma A.K., Nixon S.J., Paterson-Brown S.

Abstract Background There is little information about the effects of operative experience and supervision of trainees on outcome in inguinal hernia surgery, one of the cornerstone operations of basic surgical training. Methods All primary inguinal hernia repairs carried out between 1994 and 2001 were registered prospectively in the Lothian Surgical Audit database. Subsequent problems that required re-referral were identified from this database. Patients who required reoperation for recurrence a median of 3 (range 1–7) years after surgery were identified. Results Some 4406 repairs, including 90 recurrences (2·0 per cent), were identified. Open mesh, open sutured and laparoscopic techniques were employed. Senior trainees (registrars and senior registrars) had similar recurrence rates to consultants; supervision did not affect outcome. Junior trainees (senior house officers) had similar recurrence rates to consultants as long as they were supervised by either a senior trainee or a consultant. Unsupervised junior trainees had unacceptably high recurrence rates (open mesh: relative risk (RR) 21·0 (95 per cent confidence interval (c.i.) 7·3 to 59·9), P &lt; 0·001; open sutured: RR 16·5 (95 per cent c.i. 7·2 to 37·8), P &lt; 0·001). Conclusion Senior trainees may operate independently and supervise junior trainees, with recurrence rates equal to those of consultant surgeons. Junior trainees should be encouraged and given more practice in inguinal hernia repair with appropriate supervision.

Rafiq A., Moore J.A., Zhao X., Doarn C.R., Merrell R.C.

To achieve real-time or simultaneous surgical consultation and education to students in distant locations, we report the successful integration of robotics, video-teleconferencing, and intranet transmission using currently available hardware and Internet capabilities.Accurate visualization of the surgical field with high-resolution video imaging cameras such as the closed-coupled device (CCD) of the laparoscope can serve to insure clear visual observation of surgery and share the surgical procedure with trainees and, or consultants in a distant location. Prior work has successfully applied optics and technical advances to achieve precise visualization in laparoscopy.Twenty-five thyroidectomy explorations in 15 patients were monitored and transmitted bidirectionally with audio and video data in real-time. Remotely located surgical trainees (n = 4) and medical students (n = 3) confirmed 7 different anatomic landmarks during each surgical procedure. The study used the Socrates System (Computer Motion, Inc. [CMI], Goleta, CA), an interactive telementoring system inclusive of a telestration whiteboard, in conjunction with the AESOP robotic arm and Hermes voice command system (CMI). A 10-mm flat laparoscopic telescope was used to capture the optical surgical field. As voice, telestrator, or marker confirmed each anatomic landmark the image parameters of resolution, chroma (light position and intensity), and luminance were assessed with survey responses.Confirmation of greater than 90% was achieved for the majority of relevant anatomic landmarks, which were viewed by the remote audience.The data presented in this study support the feasibility for mentoring and consultation to a remote audience with visual transmission of the surgical field, which is otherwise very difficult to share. Additionally, validation of technical protocols as teaching tools for robotic instrumentation and computer imaging of surgical fields was documented.

Patil N.G., Cheng S.W., Wong J.

Recent high-profile cases have heightened the need for a formal structure to monitor achievement and maintenance of surgical competence. Logbooks, morbidity and mortality meetings, videos and direct observation of operations using a checklist, motion analysis devices, and virtual reality simulators are effective tools for teaching and evaluating surgical skills. As the operating theater is also a place for training, there must be protocols and guidelines, including mandatory standards for supervision, to ensure that patient care is not compromised. Patients appreciate frank communication and honesty from surgeons regarding their expertise and level of competence. To ensure that surgical competence is maintained and keeps pace with technologic advances, professional registration bodies have been promoting programs for recertification. They evaluate performance in practice, professional standing, and commitment to ongoing education.

Ross D.G., Harris C.A., Jones D.J.

Aims: To compare the operative activity of two first-year basic surgical trainees working in comparable district general hospitals in 1992 and 2000. Methods: Prospectively collected operating log-book data was compared for the first 15 months of general surgical training of a BST in 1992 to that of a similar trainee in 2000. Both elective and emergency cases were analysed. The surgical speciality and the trainees' role in the case were recorded. Several index operations were also compared. Results: Emergency case numbers were similar (145 in 1992 and 133 in 2000), however, the elective workload was almost halved (435 in 1992 and 225 in 2000). The trainee in 1992 assisted, was supervised and performed more operations, in all grades of procedure, than the trainee in 2000 (Table 1), as a result the trainee in 2000 spent the majority of his time assisting cases but the trainee in 1992 had moved on to be the principal operator. The trainee in 1992 had a greater exposure to most surgical subspecialties than the trainee in 2000 (Table 2). In all index procedures (appendicectomy, varicose veins, hernia and upper GI endoscopy), the 1992 trainee did appreciably more. Conclusions: The emergency workload was similar, however, the elective workload was reduced by 48 per cent, resulting in a reduction in the training available to the 2000 trainee. Training in 1992 was more ‘general’ compared to 2000.

Rosser J.C., Gabriel N., Herman, B.A. B., Murayama M.

Telemedicine has previously been defined as "live two-way interactive video communication between a physician and a patient and/or another physician, where all participants are able to see and hear one another much like a face to face encounter." This concept has gained recent notoriety because of the great advances in telecommunications and the potential future increased cost-effectiveness associated with its utilization. We have developed a telementoring deployment protocol that can be effectively used to introduce a student to telementoring processes. The strict protocol uses military commands to facilitate smooth information transfer. The use of a concept called tactical information deployment provides the surgeon with rapid access to reference information in the operating suite. Multimedia interactive CD-ROMs, with digitized movie clips, illustrations, sound bits, and the latest academic review of the literature arm the surgeon with a database that establishes an unprecedented clinical adaptive capability (CAC). The availability of this information is invaluable to surgeons in their initial advanced laparoscopic procedural efforts. Telementoring simulator opportunities are included to acclimate the participant to the process. If the process seems comprehensive, it is meant to be. This is a high-risk situation, and a patient's welfare is on the line. If this concept is to reach its maximal healthcare delivery potential, responsible and academically credible training programs should be established with directional guidelines.

Caputo M., Chamberlain M.H., Özalp F., Underwood M.J., Ciulli F., Angelini G.D.

Off-pump coronary artery bypass (OPCAB) operations are evolving rapidly and becoming established in many cardiothoracic centers. For the technique to be widely applicable, teaching methods must be developed for surgical trainees. Early and midterm clinical outcomes of OPCAB performed at our institution by trainees as first operators under supervision were compared to those obtained in patients operated on by consultants.Analysis was undertaken on data prospectively inserted in the Patient Analysis & Tracking System. Of the 559 OPCAB operations performed between January 1997 and May 2000, 124 (22%) were carried out by a supervised trainee and 435 (78%) by a consultant.There was no difference in age, sex, angina class, New York Heart Association functional class, or operative priority and extent of coronary artery disease in the two groups. More patients operated on by consultants had a history of congestive heart failure requiring medical therapy, significantly lower ejection fraction, and higher Parsonnet score compared with patients operated on by trainees. Early and midterm clinical results, in terms of morbidity and mortality, were similar in patients operated on by trainees or by consultants.Our data show no differences in early and midterm clinical outcome for patients undergoing OPCAB operations performed either by consultants or by trainees under supervision. The improvements in exposure and stabilization techniques, as well as the use of intracoronary shunts, have made it possible and safe to teach trainees off-pump multivessel coronary artery revascularization.

Bridges M., Diamond D.L.

There have been no published data regarding the cost of training surgical residents in the operating room.At the University of Tennessee Medical Center-Knoxville, in addition to resident-performed teaching cases, some cases are performed without the assistance of residents by the same faculty.Sixty-two case categories involving 14,452 cases were compared for operative times alone. In 46 case categories (10,787 procedures), resident operative times were longer than faculty alone. In 16 case categories, resident operating times were shorter than faculty times. The net incremental operative time cost was 2,050 hours between July 1993 and March 1997. Assuming 4 years of operative training for 11 graduating chief residents, the cost per graduating resident was $47,970.Extrapolated to a national annual cost for the 1,014 general surgery residents who completed training in the 1997 academic year, the annual cost of training residents in the operating room is $53 million. This high monetary cost suggests the need for digital skills, selection criteria, the development of training curriculum and resource facilities, the pre-operating room need for suturing and stapling techniques, and perhaps the acquisition of virtual surgery training modules.

Norris S., Papillon-Smith J., Gagnon L., Jacobson M., Sobel M., Shore E.M.

Study Objective To assess the effect of a surgical teaching video on resident knowledge and performance of a laparoscopic salpingo-oophorectomy (LSO). Design Randomized controlled trial. Setting An urban tertiary care academic obstetrics and gynecology department. Patients or Participants First and second year gynecology residents. Interventions Access to an educational video of an LSO for one week prior to performing this surgery in the operating room. Measurements and Main Results Twenty-four residents were recruited and randomized to either the educational video group or traditional residency training group. All participants completed a demographic survey and knowledge questionnaire preceding their performance of an LSO, which was video recorded. Video recordings of surgical performance were analyzed by two blinded raters using the objective structured assessment of technical skills (OSATS, 20 points) and an LSO specific tool (30 points). Participants completed a self-assessment questionnaire following the procedure. The primary outcome measure was the difference in OSATS scores. The secondary outcomes were the knowledge questionnaire scores and self-assessed confidence scores. There were no significant differences between demographic variables of the two groups. The primary outcome revealed no significant differences in mean OSATS scores (10.64, SD 2.05 vs 11.55, SD 1.85, p=0.3) or LSO specific tool scores (16.45, SD 2.68 vs 17.85, SD 2.63, p=0.24). However, there was a significant difference in mean knowledge scores between the video and the traditional training ((8.42, SD 0.79 vs 7.11, SD 1.36, p=0.01) groups. In addition, residents in the video group had more confidence of their knowledge of pelvic anatomy (3.83/5, SD 0.39 vs 3.00, SD 1.00, p=0.04). Conclusion For junior learners, use of an LSO video improved knowledge and confidence in anatomy but did not translate to improved surgical performance in the operating room. Surgical videos are a useful adjunct and compliment hands-on technical teaching.

Fung A., Kelly P., Tait G., Greig P.D., McGilvray I.D.

The potential for integrating real-time surgical video and state-of-the art animation techniques has not been widely applied to surgical education. This paper describes the use of new technology for creating videos of liver, pancreas and transplant surgery, annotating them with 3D animations, resulting in a freely-accessible online resource: The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery ( http://tvasurg.ca ). The atlas complements the teaching provided to trainees in the operating room, and the techniques described in this study can be readily adapted by other surgical training programmes.

Gambadauro P., Torrejón R.

New technological developments in the field of telecommunications have allowed a wide range of potentially novel surgical applications. The introduction of the World Wide Web in 1991 has been followed by a steep rise of the relevance of telemedicine, as it is witnessed in the latest scientific literature. There has been a consistent, positive trend in publications dealing, respectively, with telemedicine and the Internet. This article reviews telemedicine and other surgery-related innovations that benefit from telecommunication advances, and presents data from a quantitative bibliographic analysis. A number of applications, such as telementoring, teleproctoring and robotic telesurgery are described and their huge potentials are discussed. The integration between surgery and telecommunications could constitute one of the major achievements of modern medicine, and its safe integration into clinical practice should be a priority for modern surgeons.

Magos A.

Gambadauro P., Magos A.

Conventional audit of surgical records through review of surgical results provides useful knowledge but hardly helps identify the technical reasons lying behind specific outcomes or complications. Surgical teams not only need to know that a complication might happen but also how and when it is most likely to happen. Functional awareness is therefore needed to prevent complications, know how to deal with them, and improve overall surgical performance. The authors wish to argue that the systematic recording and reviewing of surgical videos, a “surgical black box,” might improve surgical care, help prevent complications, and allow accident analysis. A possible strategy to test this hypothesis is presented and discussed. Recording and reviewing surgical interventions, apart from helping us achieve functional awareness and increasing the safety profile of our performance, allows us also to effectively share our experience with colleagues. The authors believe that those potential implications make this hypothesis worth testing.