Trans-Atlantic Telementoring with Pediatric Surgeons: Technical Considerations and Lessons Learned

Introduction

Residency and fellowship are ideal training models for learning surgical procedures. In this model, the training physician is given increasing autonomy while under the close supervision of an expert over several years. However, after completion of residency, new techniques and technology may arise. Currently, new techniques are learned through modalities such as workshops, simulators, animal models, and in-person proctoring, but this may not be enough. Even after these modalities, surgeons face a learning curve with their initial experience independently performing a new procedure. For laparoscopic procedures such as fundoplication, appendectomy, pyloromyotomy, and splenectomy, it has been suggested that 20–35 cases are required to surpass this learning curve.^1–4 In pediatric surgery there are a few rare procedures such as thoracoscopic repair of esophageal atresia with or without tracheoesophageal fistula where it may not be possible to acquire an adequate number of cases during the formal training period. This is where telementoring may be implemented to improve the learning curve for rare or new procedures.

Surgical telementoring is the process where one expert surgeon mentors another, trained surgeon who is early on his or her learning curve for a particular procedure. It may confer several benefits. It may overcome significant distances for both the physician and the patient. A patient in a rural community may be able to receive the most state-of-the-art treatment from a telementored surgeon. By eliminating travel time and expenses, telementoring may even be cost-effective. As well, there is evidence that telementoring may be equivalent to in-person mentoring in terms of knowledge and skill acquisition.^5,6

In the past we have presented our experiences with transcontinental telementoring with pediatric surgeons through 6 cases. ⁷ We then attempted to test and expand the concept to trans-Atlantic telementoring and now present 2 cases.

Materials and Methods

The telementors were fellowship-trained minimally invasive pediatric surgeons in Akron, OH and Denver, CO. The mentees were pediatric surgeons in Paris, France who aimed to improve their skills in minimally invasive surgery. One of the mentees and both mentors had previously met at a professional association meeting. The VisitOR1^® telementoring robot (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was used. The VisitOR1 system is Health Insurance Portability and Accountability Act (HIPAA) compliant and uses 256-bit encryption to ensure privacy. This unique technology allows the telementor to project him- or herself into the operating room (Fig. 1). The telementor uses a laptop where he or she is provided extracorporeal views through a remote-controlled high-definition camera as well as side-by-side intracorporeal views through the endoscope (Fig. 2). In addition to voice and video communication, the telementor has the ability to telestrate on the endoscopic screen and use a laser pointer extracorporeally. The VisitOR1 system requires a minimal bandwidth of 300 kilobits/second and performs optimally at 700 kilobits/second. The screen resolution is 1024 × 768 pixels, and the camera captures 30 frames per second.

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FIG. 1.

VisitOR1 telementoring system (screen on the left) overlooking the operating room.

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FIG. 2.

Software interface from the telementor's perspective. The laser pointer (dot in the upper video feed) is being used to indicate port placement.

In order to serve as a test for the initial experience with this technology, the first case was selected to be an interval laparoscopic appendectomy. In this way, if a technical malfunction or loss of connection occurred, the mentees could still complete the case independently. The patient was an 11-year-old girl with perforated appendicitis with a pelvic abscess 2 months previously. She had initially been treated with intravenous antibiotics and rectal drainage and had recovered well. An ultrasound performed 1 week prior to the procedure revealed a persistent fecalith.

The second case was a thoracoscopic total thymectomy in a 4-year-old boy with myasthenia gravis refractory to steroid therapy. There was no associated thymoma on computed tomography scan. The telementor was a pediatric surgeon in Denver with an experience of 23 cases.

Results

Both cases were completed successfully. The video quality was superb, and the latency was satisfactory. In the first case, telementoring was useful in guiding the surgeon through a very difficult perforated appendectomy. Having a second set of eyes provided comfort and reassurance to the surgeon, despite that fact that the mentor and mentee had never met before. The lack of a prior relationship between the mentor and mentee led to the mentor being less forthcoming in the depth of advice. Telestration was particularly helpful when there was trouble identifying the appendix. The telementor was able to point out the teniae of the cecum and then follow it inferiorly to find the base of the appendix (Fig. 3). Also, using the laser pointer and on-screen telestration, the telementor was able to provide tips and tricks to help facilitate the procedure, many of which may be applied to future cases. Ultimately, the tip of the appendix could not be identified, but the base of the appendix and fecalith were removed. The operative time was 90 minutes. The postoperative course was significant for a postoperative abscess that required intravenous antibiotic therapy.

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FIG. 3.

Telestration was used to indicate the position of the teniae of the cecum and the base of the appendix.

The second case was safely completed from a technical standpoint despite difficulty with intubation with significant bronchospasm, hemodynamic instability, and cardiac arrhythmias. The telementor provided useful insights in thoracoscopic technique and helped the mentee to identify key anatomic structures. There were challenges that were encountered as well. For instance, there was difficulty hearing during this case on both ends due to the ambient noise of the operating room. This was overcome with the use of headsets. Outside of the technical aspects of the cases, there were issues with the logistics. The mentor had a full schedule of cases and had to intermittently telementor between them (Fig. 4). The total operative time was 120 minutes. The patient recovered well and was discharged home on postoperative Day 3. Two months later, this experience led the mentee to be able to independently perform the same operation for the same indication.

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FIG. 4.

S.S.R. telementoring a thoracoscopic thymectomy. Due to time constraints, he had to telementor in the operating room intermittently between his own scheduled cases.

The difference in time zones was also an issue, as the first case began at 5 a.m. and 7 a.m. by the mentors' local times. This was necessary because the mentees needed to reserve a significant block of operating room time to properly install the telementoring system and ensure its connectivity, as in the past a telementoring session was canceled due to an improper connection.

Discussion

This experience of long-distance telementoring in pediatric surgery proved to be feasible and paved the way for a new teaching approach. All surgeons involved with the procedures reflected positively on the experience. However, there were several challenges that were identified. First, the importance of a well-established relationship between the mentee and mentor was recognized. In the first case, although there was an established relationship between the mentor and one of the surgeons in the room, there was no prior relationship with the operating surgeon, which led to the mentor being less forthcoming with his advice. This was different than the prior transcontinental telementoring cases in which all participants had longstanding relationships before the experience. Although patient information was shared in a HIPAA-compliant fashion prior to the case, it did not confer the same benefit during the live telementoring that a meeting may have had. Therefore, we feel that all surgeons should meet and discuss the case, either virtually or in person, or, even better, do a case or two by on-site mentoring to get the opportunity to work together before off-site mentoring.

An additional hindrance was that there was difficulty hearing during the first procedure, as the operating room is often noisy. This was improved by having the operating surgeon wear a headset in the second case. With this change, the audio quality was better.

The financial model for implementing telementoring is challenging. First, the authors' experience with telementoring has been for the purpose of proof of concept for academia. However, if telementoring is to become sustainable, there must be a model for compensation. It is unlikely that expert surgeons or the hospitals that employ them will be able to afford to have the experts spending time telementoring that would otherwise be spent earning revenue in the operating room. Perhaps the novices or the hospitals that employ them and desire the new service line will compensate the expert for their time. The second issue is the cost of the technology. The technology used in the experience described in this report is the top of the line but may prove to be too costly. Other, less advanced options that are emerging may be more cost-effective. Hospitals must weigh this large upfront investment against the costs of traveling to courses, visiting professorships, or other methods of surgical education. All of these things being considered, this is by far the most significant barrier toward implementation of telementoring for most hospitals.

Although all of the cases that our group has presented have been endoscopic, laparoscopic, or thoracoscopic, the capabilities of the VisitOR1 telementoring robot allow for its use in open cases. However, with the ability to provide a direct video feed from the endoscope, endoscopic procedures are easier to telementor, but this does not preclude its application to open surgery.

The issue of telementoring medicolegal liability is largely unaddressed in the United States and throughout the world. In the United States there have been no cases of telementors being involved in a malpractice suit to date. It is the authors' opinion that surgical telementoring should be viewed as an educational service to the physician and that there is no doctor–patient relationship as the mentor is not directly treating or imparting direct care to the patient. Thus, the mentor should not be liable in the case of legal action. Nevertheless, we recommend obtaining supplemental coverage until legislation or case law is established in this area.

From this experience, we have identified multiple challenges that include establishing a mentor–mentee relationship prior to the event, improving audio quality, scheduling times that work for all parties, and developing a successful financial model.

In conclusion, telementoring may be an effective means of overcoming geographic barriers, facilitating the transfer of ideas, and increasing adoption of new techniques, ultimately improving surgical training and patient care.