Center for Minimal Access Surgery Telementoring Program

In Canada, telementoring is currently in routine clinical use, providing community surgeons in two rural cities with access to the expertise of expert laparoscopic surgeons, without the need for extensive travel.

Surgeons at the Centre for Minimal Access Surgery (St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada) routinely mentor surgeons at two community hospitals, one in Northern Ontario and the other in Northern Quebec. Procedures performed to date include laparoscopic fundoplications, splenectomies, hernia repairs, and colonic resections (14). The telecommunications (two-way audio and visual connections) are conducted over either integrated services digital network lines or the Internet Protocol network, which connects most hospitals in Canada.

aComputer Motion, Santa Barbara, CA.

TABLE 1 ■ Outcomes for 19 Telementored Procedures Involving Four Mentees

Mentor's

Mentee's assessment

No. of

Length of

No. of

assessment of

of utility of

Procedure

cases

stay (day)a

complications

surgical quality3

mentoringa

Colon resection

10

5

1

4 out of 5

4 out of 5

Nissen fundoplication

5

3

1

4 out of 5

4 out of 5

Splenectomy

2

2

0

5 out of 5

4 out of 5

Ventral hernia

1

6

0

4 out of 5

4 out of 5

Reversal of Hartmann's

1

7

1

4 out of 5

3 out of 5

aMedian values.

It is of utmost importance that a comprehensive plan exists to deal with all eventualities, including system failures and intraoperative complications. Because the mentor is not physically present to take over if required, such a plan must ensure that in case of a serious system failure or other complication, the local surgeon has the expertise and technical assistance necessary to complete an open procedure if required.

In 2001, Marescaux et al. successfully utilized the Zeus TS system to perform the world's first transatlantic telerobotic surgery in which the remote surgeon, working from a console located in New York City, performed a cholecystectomy on a patient located 3800 miles away in Strasbourg, France.

Detailed questionnaires administered to both the mentoring surgeon and the mentee following each telementoring procedure have been utilized to evaluate the success of each session. Details of 19 procedures performed between November 1992 and July 1993 are given in Table 1.

Telementoring has permitted the community surgeons involved to adopt advanced laparoscopic procedures while providing patients with the same standard of care as at tertiary care centers and has facilitated a reversal of the recent trend toward centralization of health care services. The Centre for Minimal Access Surgery plans to extend this service to include eight teaching hospitals and 32 rural communities within the next few years.

Technical Requirements and Considerations

Recent advances in telecommunications have encouraged the development and evaluation of surgical telementoring as equipment required becomes more readily available. Early telementoring occurred over short distances utilizing hard-wired connections. However, telecommunication currently utilizes integrated services digital network, a fully digital system readily available in many areas via commercial telephone line. These lines offer sufficient bandwidth to ensure adequate image quality. However, ultimately, internet protocol networks are likely to become the medium of choice due to reliability, safety, wide availability, and recent ability to offer quality of service (15). It should be noted that low-bandwidth connections can and have successfully been used in remote areas where telecommunications are limited. However, operators must minimize camera motion and slow movements in compensation (16).

Due to the reliance on technology, telementoring has raised significant concerns regarding patient safety. Loss of communications, poor image transmission, and equipment failure at either location are all possibilities that must be considered well in advance of any surgeries.

It is of utmost importance that a comprehensive plan exists to deal with all eventualities, including system failures and intraoperative complications. Because the mentor is not physically present to take over if required, such a plan must ensure that in case of a serious system failure or other complication, the local surgeon has the expertise and technical assistance necessary to complete an open procedure if required.

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