TELECONFERENCING
Endoscopic surgery has led to changes in surgical practice which may rival the introduction of anesthesia and antibiotics in significance. As a result, an exciting synergy has rapidly emerged between technology and clinical practice. However, questions of training, credentialing, and patient safety have been raised as traditional procedures have been adapted to the minimally invasive approach and new ones are described. Many surgeons have been reluctant to venture beyond laparoscopic cholecystectomy. Halting first efforts at advanced procedures may prolong operative times, increase risk, and raise costs. Older methods of surgical education are not adequate to meet the current need.
Equally exciting advances in telecommunication may provide the means to address these concerns. The adaptation of advanced telecommunication systems to the dissemination of surgical knowledge and innovation is a logical next step. In its fully realized form, "Distance Learning, Telementoring and Teleproctoring," an experienced surgeon can use real-time, two-way audio-video systems to teach residents and guide another surgeon through his early cases. As it employs televised images, endoscopic and microsurgery are ideally suited for this approach. Such linkages between proctor and student will be significantly more cost-effective and less disruptive to the Instructor/proctor's practice than the current approach.
In the teaching laboratory two cameras are used to capture the demonstration/operation. One camera records the instructor and the operative field. The other camera was connected to the laparoscope/microscope. These cameras transmitted the same images to the residents/surgeons, half a country apart.
The transmission began as the audio and video signals were fed to a coder / decoder (CODEC) device The CODEC then converted the images into digitized data and compressed them at a ratio of approximately 800: 1. The compression algorithm refreshed the images of moving people and surgical instruments more frequently than those of the static background elements. The synchronization of voice and picture was another goal of the algorithm. The CODEC can translate PAL and NTSC signals to digitize data in both directions. This eliminates conversion problems between the potentially different television formats standard in two countries.
The interlaced image is built at a relatively low resolution. The images were refreshed at approximately 15 frames / sec, depending on the content. Static objects, such as background features, are in sharp focus, but rapid movement may produce blurred images.
Computer Simulator/Modeling
Computer-assisted outcome measures, which include motion efficiency, are progressively becoming a preferred method of initial training and objectively assessing the technical skill of novice surgical trainees.
It has also been speculated that the motion efficiency indices derived from sources such as the Imperial College Surgical Assessment Device (ICSAD), or virtual reality training systems instrumented with devices capable of estimating motion efficiency can potentially serve as a valuable source of feedback for novice trainees.
However, these means of quantifying motions produced during surgical technical performance may provide only limited educational information about how the skills were actually performed. For example, it might be hard for a trainee to improve their performance based on an objective outcome measure indicating that their spatial pathway and the number of movements performed were greater than that of an expert. The plethora of motor learning literature rooted in theoretical movement sciences should point our attention to alternative methods of quantifying movements.
A different class of computer-based measures, known as process measures, might be a more useful performance parameter when skill improvement is the goal. Process measures describe how a certain movement pattern was achieved.
Examples of process measures include information about the specific movement of limbs or the characteristics of force production throughout the duration of a task. In order to improve the educational utility of outcome and process measures, after the initial Simulator evaluation the trainee practices in a “Black Box” in vitro latex and fresh tissue model. This will provide opportunity for the trainee for experience with real life instrumentation and “tissue feel”.
Alternating the Simulator and Black Box will result in a more efficient and practical skill acquisition, where progress is more obvious. After the novice is familiarized with the simplest mental framework and eye-hand coordination of laparoscopic tasks, on this safe, inexpensively acquired foundation, Black Box skills can be more easily honed.
Simulator information about the number of movements, direction, time and mistakes it took to complete a task gives an idea of the outcome, and conveys useful information and stimulation to help an individual improve their performance. In contrast to the limited environment of digital graphics even in vitro models either Latex based or fresh animal tissue placed into the Laparoscopic / Microsurgical Black Box. The L/MBB is a setup that uses true clinical equipment and instrumentation, life like models, giving a realistic challenge only two steps removed from the clinical setting. Step One: anesthetized live animal.
This model can provide informative feedback or instruction to coach a trainee to improve their performance and possibly achieve a better overall outcome. Thus, movement quantification using process measures in digital as well in vitro setup can quantify changes in behavior and provides rich data on how final outcomes have been achieved.
The importance of the movement processes that occur during the execution of a technical surgical skill are often neglected, yet these measures can be informative for evaluation and performance feedback purposes.
Despite the potential to generate a wealth of information about the psychomotor and technical performance, this type of evaluation is computationally and conceptually very complex, and therefore a careful examination of its application to learning should first be assessed.
However, before this is possible, we first need to identify surgically relevant variables. Consequently, the present curriculum was designed to validate a specific set of movement process measures by demonstrating their sensitivity to discern novice and advanced laparoscopist on a suturing skill, as well as to reveal changes in performance during short practice sessions.
Zoltan Szabo, Ph.D.,F.I.C.S.
MOET Institute, San Francisco