Operation Messiah


Rosser JC, Herman BS, Gabriel NH, Valdes V, et al

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.

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.

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.

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.