OPERATION
MESSIAH: A DEMONSTRATION OF TELEMENTORING METHODOLOGY
Rosser JC, Herman BS, Gabriel NH, Valdes
V, et al
Purpose:
Telementoring is a telemedicine
application that involves the remote guidance of a treatment
or a procedure where the caregiver has no or limited experience
with the featured procedure. Since the rapid adoption
of the laparoscopic cholecystectomy in general surgery,
we have not seen the predicted similar impact with other
procedures. More and more surgeons are performing advanced
techniques, but the availability of access to the masses
and patient quality assurance has not yet been attained.
There has been a great debate as to why this “failure
to thrive” phenomenon exists. There is no one answer,
but the lack of availability of widespread mentoring and
preceptoring in order to guide surgeons through their
initial experiences is very significant. In the past,
the prospects of the establishment of a qualified mentoring
pool that could serve the global demand for assistance
was not within the realm of reality. The number of people
in the world, who are able to perform these procedures
competently and transfer that information effectively,
is very limited. With this limited pool of specialists,
it is impossible for every surgeon who would like to perform
these procedures to have a preceptor or mentor. Telementoring
has the potential capacity to eliminate this obstacle.
This article describes Operation Messiah, a project that
was conceived as a demonstration of the effectiveness
of telementoring and to showcase the methodology necessary
to achieve consistent positive outcomes. A surgeon in
the Dominican Republic was trained to perform several
laparoscopic procedures, which he had never done before.
Utilizing very refined and tested telementoring training
methodology, he was able to safely and efficiently complete
these tasks. The surgeon’s instruction team was located
at the Yale University telementoring command and control
complex and at the mission commander’s home cyber-office
and global command center in New Haven, CT.
Methods:
Pre-procedural Assessment
and Enhancement of Laparoscopic Surgical Skills The instructor
first administered the Yale Laparoscopy Skill Acquisition
and Suturing Course. This course consists of extensive
inanimate lab drills and intracorporeal suturing training,
as well as computer-assisted teaching by an instructor.
Usually the course requires two days, but it was conducted
in one day, since there was only one student involved.
The instructor conducted the entire course in cyberspace,
only using an assistant in Santo Domingo to aid in administering
the drills and suturing trials, as well as run the telecommunications
link there. Intracorporeal suturing is necessary for the
to accomplish a laparoscopic Nissen fundoplication and
many other advanced procedures. Subsequently, the instructor
reviewed this technique with the surgeon, which the surgeon
had learned from a CD-ROM written by the instructor.
Establishing a Standardized Approach to the Procedure
Surgery has always been considered an art form. Even though
all of us are aware of the standard in surgical techniques
for various surgical diseases, many variations can be
tolerated as far as producing a good outcome. The artistic
freedom that is tolerated in procedures where there is
great experience can be disastrous in a telementoring
situation. There must be a standardized technique algorithm
to put everyone on the same page. There is no time in
the middle of a mission to argue over the next step in
a procedure. The importance of transfer of absolute structure
to the operative process should not be overlooked. Surgeons
must be conditioned to restrain their individual preferences
and follow one pathway.
CBI (Computer-Based Instruction), especially in the multimedia
mode using CD-ROMs as the storage medium, offered consistency
and increased cognitive knowledge transfer rates. The
multimedia format allowed the presentation of a sophisticated,
deconstructed review of the procedure. This review was
reinforced with moving and still images, text, and interactive
gaming (entry level simulation) challenges. This instructional
modality was not designed to eliminate contact with an
instructor, but rather it was designed to assist and enhance
the educational process.
The surgeon and the mentor were both assigned “call signs”
and adhered to the strict military-like command algorithm
while operating the simulator during animal labs. The
same call signs and commands were used when the instructor
telementored the surgeon during Operation Messiah. Utilizing
this command algorithm, a pre-mission check of all equipment
was conducted in order to assure that it was functioning
properly before each phase of Operation Messiah.
Telementoring Simulator
The instructor also oversaw the surgeon during
completion of two laparoscopic Nissen fundoplication animal
labs. A telementoring simulator was used to prepare the
surgeon for the strict telementoring “rules of engagement”
used in Operation Messiah. The instructor’s assistant
served as the mentor while the simulator was being operated
in Santo Domingo. In order to achieve and maintain direct
two-way audio communication between the mentor and the
student, two-way radios were used. Hands-free audio communication
was achieved by plugging a Motorola headset into the radio,
which activated the built in Voice Operated Transmission
(VOX) mechanism. The mentor used the talk button on the
unit in the standard fashion. The communication between
the mentor and student surgeon adhered to standard military-like
guidelines. This eliminated any confusion as well as simultaneous
conversation, which could have caused a disruption in
transmission between the two radios, and ultimately between
the mentor and the student surgeon.
The video component of the simulator was a video camera
in the simulator room, mounted on a tripod. This provided
an external view of the simulated operative field. A 2.4
GHz wireless “Room to Room – A/V sender” transmitted to
the receiving unit in the mentor’s room. Similarly another
wireless “Room to Room – A/V sender” was set in place
to transmit from the laparoscope video source to the mentor’s
room. These signals were channeled through a stereo amplified
A/V selector switch with “four input” to “two output”
capabilities. From the switch box, the signals were forwarded
to a VCR with 4-heads for relatively high quality recording
and instant playback. Sequentially the VCR was connected
a monitor. From the number “2” source of the switch box,
another transmitter component of the wireless “Room to
Room A/V sender” unit was attached. This transmitted to
the wireless receiver component of this unit on the student
side. The surgeon demonstrated excellent understanding
and command of the exchange protocols.
Communication Link
Two types of telecommunication links were used
during Operation Messiah. First, an INMARSAT satellite
link was established between the two sites. A communication
bridge was established, which served as a virtual meeting
place for multiple stateside parties. This allowed a Yale
anesthesiologist, as well as surgeons at the Yale Endo-Laparoscopic
Center to simultaneously communicate with the instructor
in the Stryker cyberoffice and global command center and
the surgeon in Santo Domingo. Second, a digital conferencing
system was used to tie in all participating parties to
the communication bridge. Dual Integrated Systems Digital
Network (ISDN) lines were used to establish this connection
at all the command sites, and the information transfer
rate was 128 Megabytes per second (Mbps). The communication
bridge could be bypassed in the event that the instructor
wished to enhance picture clarity by establishing a point-to-point
connection with the surgeon via the satellite.
Teleguidance Tool Utilization
The instructor used an annotator with residual
yellow tracing to highlight areas of interest on the monitor
displaying the video link, which aided in instruction
during the procedures. A VCR was used for playback and
subsequent instruction during the procedure. The instructor,
surgeon, and surgical assistant all wore headsets for
audio communication. These teleguidance tools and strategies
greatly assist the safe execution of a procedure under
telementoring conditions.
Procedural Execution
The surgeon performed two Nissen fundoplications,
a cholecystectomy, and a liver cyst removal procedure
on patients at the Centro Medizina Avanzada, while being
telementored by the instructor. The instructor had audiovisual
access to the procedure the entire time, and a strict
military communication regiment was employed between the
instructor, surgeon, and surgical assistant.
Results:
The surgeon completed all
instructional courses with excellence even though the
entire evaluation and preparation was done using distant
learning and computer assisted instruction. The porcine
model simulation practicum demonstrated the surgeon’s
ability to achieve communication and performance goals.
Both laparoscopic Nissen fundoplications were performed
successfully, as were the cholecystectomy and liver cyst
removal procedures. There were no intraoperative or postoperative
complications. All these procedures were completed within
operative time to be expected from an experienced surgeon.
Conclusions:
Telementoring is a sophisticated
telemedicine application that stretches current educational,
clinical, and technological capabilities to their limit.
It involves the remote guidance of a procedure where the
student has limited or no experience with the featured
technique, but to deploy this promising application successfully,
specific training methodology must be utilized. These
include: pre-procedural assessment and enhancement of
laparoscopic surgical skills, telementoring simulation,
establishing a standardized approach to the procedure,
creating an adequate communication link, and executing
the procedure while aided by teleguidance tools and applications.
The results of Operation Messiah are encouraging. We
believe that this concept, if properly established, not
only can improve the delivery of healthcare in underserved
areas, but also can accelerate the safe widespread adoption
of advanced laparoscopic procedures.