Elsevier

World Neurosurgery

Volume 86, February 2016, Pages 103-111
World Neurosurgery

Original Article
Virtual Interactive Presence in Global Surgical Education: International Collaboration Through Augmented Reality

https://doi.org/10.1016/j.wneu.2015.08.053Get rights and content

Background

Technology allowing a remote, experienced surgeon to provide real-time guidance to local surgeons has great potential for training and capacity building in medical centers worldwide. Virtual interactive presence and augmented reality (VIPAR), an iPad-based tool, allows surgeons to provide long-distance, virtual assistance wherever a wireless internet connection is available. Local and remote surgeons view a composite image of video feeds at each station, allowing for intraoperative telecollaboration in real time.

Methods

Local and remote stations were established in Ho Chi Minh City, Vietnam, and Birmingham, Alabama, as part of ongoing neurosurgical collaboration. Endoscopic third ventriculostomy with choroid plexus coagulation with VIPAR was used for subjective and objective evaluation of system performance.

Results

VIPAR allowed both surgeons to engage in complex visual and verbal communication during the procedure. Analysis of 5 video clips revealed video delay of 237 milliseconds (range, 93−391 milliseconds) relative to the audio signal. Excellent image resolution allowed the remote neurosurgeon to visualize all critical anatomy. The remote neurosurgeon could gesture to structures with no detectable difference in accuracy between stations, allowing for submillimeter precision. Fifteen endoscopic third ventriculostomy with choroid plexus coagulation procedures have been performed with the use of VIPAR between Vietnam and the United States, with no significant complications. 80% of these patients remain shunt-free.

Conclusion

Evolving technologies that allow long-distance, intraoperative guidance, and knowledge transfer hold great potential for highly efficient international neurosurgical education. VIPAR is one example of an inexpensive, scalable platform for increasing global neurosurgical capacity. Efforts to create a network of Vietnamese neurosurgeons who use VIPAR for collaboration are underway.

Introduction

In much of the world, subspecialty surgical care is not available readily.1, 2, 3, 4, 5, 6, 7, 8, 9 The absence of local subspecialty care has a demonstrable impact on morbidity and mortality,10, 11 and time to surgical intervention is critical in many conditions.10, 12, 13 Hands-on training of local surgeons in their home country is the optimal method for increasing global surgical capacity, and technology allowing a remote, experienced surgeon to provide real-time guidance to local surgeons has great potential for training and capacity building.14, 15, 16

Telesurgery, the use of robotic actuators that allow a geographically remote surgeon to perform a procedure, has attracted growing interest during the past 2 decades,14, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 and robotic tools have been used in multiple subspecialties and across long distances.14, 15, 16, 22, 26, 28, 30, 31, 36, 39, 40, 41, 42 However, the adaptation of telesurgical systems to developing countries is hampered by issues of cost,14, 29, 43, 44 connectivity,33, 35, 45 and the continued need for skilled operators at the surgical site. Additionally, most neurosurgical procedures are not amenable to existing robotic technology, and the cost of complex systems has limited the role of robotic tools in neurosurgery.46, 47

Telepresence involves nonrobotic tools to support interactive video and audio telecollaboration in which a remote surgeon provides guidance and training without directly performing the procedure. Telepresence systems have grown in popularity alongside telesurgical tools,38 but previous systems were limited to providing assistance through verbal exchange or use of a pointer tool.48, 49

Virtual interactive presence and augmented reality (VIPAR) is a recently developed tool that allows surgeons to provide real-time virtual assistance and training wherever a standard internet connection is available.50, 51 The technology provides a hybrid perspective of local and remote video feeds, allowing a remote surgeon to digitally “reach into the surgical field,” to highlight anatomic structures and providing a visual demonstration of complex operative techniques.

VIPAR can be rapidly deployed under sterile conditions,52 and has been used in orthopedic surgery for training of resident surgeons with an attending surgeon immediately available in an adjoining room.53 VIPAR has been shown to be feasible for long-distance telecollaboration in neurosurgical studies on cadaveric specimens,51 but the use of long-distance VIPAR has never been reported in neurosurgical patients or for international collaboration.

Here we describe the performance, utility, and feasibility of implementing VIPAR as a tool for global surgical education and telecollaboration between neurosurgeons in the United States and Vietnam.

Section snippets

Overview

Neurosurgeons from the Children's of Alabama Hospital in Birmingham, Alabama, traveled to Children's Hospital #2 in Ho Chi Minh City, Vietnam, to provide lectures, in-clinic instruction, and intraoperative training to local neurosurgeons on advanced techniques in pediatric neurosurgery. The VIPAR system was implemented and trialed in neuroendoscopy and cases that required the use of the operative microscope and used for international telecollaboration and continuing education after the return

Results

Successful implementation and trial of the VIPAR telecollaboration system took place as part of ongoing neurosurgical collaboration between Children's of Alabama Hospital and Children's Hospital #2 in Ho Chi Minh City, Vietnam. A strong relationship exists between these institutions, with regular exchange of general surgery and neurosurgery teams. Cases requiring either the endoscope or operative microscope were performed using VIPAR assistance. After the return of the visiting team to their

Discussion

In the coming years, the global shortage of surgeons is only expected to worsen.7, 8 Surgical disease is 1 of the top 15 causes of global disability,54 and surgical intervention fills a crucial role in global public health.55 This gap necessitates the development of tools to geographically extend the reach of expert surgeons. Although robotic systems provide an extended geographic reach of a single surgeon, the VIPAR system allows long-distance assistance during complex cases as well as

Conclusions

Giving remote experts the ability to guide and mentor less-experienced surgeons has great potential for global surgical education and capacity building. VIPAR is one example of evolving interactive technology that allows for real-time global surgical telecollaboration and education through commercially available and inexpensive platforms. Use of such technology may increase the safety of surgical intervention and has great potential for training, research, assessing surgical competence for

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    Supplementary digital content available online.

    Conflict of interest statement: Use of proprietary software was provided by Vipaar, LLC. This work was additionally supported by a grant from the Children's of Alabama Global Health Program Initiative and the Kaul Foundation.

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