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J Robotic Surg (2012) 6:47–52 DOI 10.1007/s11701-011-0304-5 123 ORIGINAL ARTICLE Web-connected surgery: using the internet for teaching and proctoring of live robotic surgeries John Lenihan Jr. · Melissa Brower Received: 16 July 2011 / Accepted: 27 July 2011 / Published online: 25 August 2011 © Springer-Verlag London Ltd 2011 Abstract The purpose of this study was to assess the feasibility of using live teleconferencing for teaching of new robotic-assisted surgical techniques. This was a prospective study with review of outcomes (Canadian Task Force classiWcation II-3) in a community hospital. In 2009, our community hospital acquired the da Vinci Connect™ System, a technology which allows for live surgeon-to-sur- geon interaction during robotic surgery via a secure internet connection. We utilized this technology from March 2009 through March 2011 to perform 28 live robotic surgeries that were observed by surgeons and hospital staV in 14 diVerent US states as well as in France. We also had 14 epi- sodes where new robotic surgeons in our facilities were mentored by experienced robotic surgeons in other geographic locations live through the da Vinci Connect internet connection. We performed two live surgeries for continuing medical education courses with live interactions between the course attendees and the console surgeon. Finally, one surgeon in our hospital proctored new surgeons remotely in distant sites on challenging cases. Uti- lizing computers that allow an experienced mentor surgeon to interact with less experienced surgeons on a live case is invaluable and presages the way we will train surgeons in the future. This feasibility study validates the need to pursue this technology for future education and training as well as for real-time collaboration. Keywords Internet · Robotic surgery · Telesurgery · Web connected · Mentoring · Proctoring Introduction There have been many innovations in surgery over the years that have stood out as “game changers.” These include the discovery of the principles of aseptic technique, utilization of regional and local anesthesia, development of energy sources for cutting and coagulation, as well as the development of endoscopy [1, 2]. Computers have also undergone rapid evolutionary changes during our lifetimes that now aVect and enable almost everything we do, from driving a car to talking on the telephone [3]. It is therefore no surprise that computer technologies are being adapted to the medical profession to enable physicians to take better care of their patients. Utilizing computers in the operating room is now commonplace [4, 5]. Computers control oper- ating room lights and climate, endoscopic cameras, imag- ing devices, energy generators and most recently surgical robots. Arguably, the greatest impact of computers on our lives has been the development of the Internet. It is there- fore also no surprise that innovative surgeons are attempt- ing to utilize the Internet to improve their outcomes in the operating room [68]. This study reviews our experience with using a new dedicated robotic surgery Internet connec- tion system, da Vinci Connect™ (Intuitive Surgical, Sun- nyvale, CA, USA) to communicate and collaborate in real time with other surgeons located in distant sites. Methods Remote robotic-assisted surgery was initially a vision of the US Military who developed the original systems through DARPA (Defense Advanced Research Projects Agency) for use on the battleWeld [9]. Intuitive Surgical developed the da Vinci Robotic Surgical System in 1999 with a view J. Lenihan Jr. (&) · M. Brower MultiCare Health Systems, Tacoma, WA, USA e-mail: [email protected]

Web-connected surgery: using the internet for teaching and proctoring of live robotic surgeries

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J Robotic Surg (2012) 6:47–52

DOI 10.1007/s11701-011-0304-5

ORIGINAL ARTICLE

Web-connected surgery: using the internet for teaching and proctoring of live robotic surgeries

John Lenihan Jr. · Melissa Brower

Received: 16 July 2011 / Accepted: 27 July 2011 / Published online: 25 August 2011© Springer-Verlag London Ltd 2011

Abstract The purpose of this study was to assess thefeasibility of using live teleconferencing for teaching ofnew robotic-assisted surgical techniques. This was aprospective study with review of outcomes (Canadian TaskForce classiWcation II-3) in a community hospital. In 2009,our community hospital acquired the da Vinci Connect™System, a technology which allows for live surgeon-to-sur-geon interaction during robotic surgery via a secure internetconnection. We utilized this technology from March 2009through March 2011 to perform 28 live robotic surgeriesthat were observed by surgeons and hospital staV in 14diVerent US states as well as in France. We also had 14 epi-sodes where new robotic surgeons in our facilities werementored by experienced robotic surgeons in othergeographic locations live through the da Vinci Connectinternet connection. We performed two live surgeries forcontinuing medical education courses with live interactionsbetween the course attendees and the console surgeon.Finally, one surgeon in our hospital proctored newsurgeons remotely in distant sites on challenging cases. Uti-lizing computers that allow an experienced mentor surgeonto interact with less experienced surgeons on a live case isinvaluable and presages the way we will train surgeons inthe future. This feasibility study validates the need topursue this technology for future education and training aswell as for real-time collaboration.

Keywords Internet · Robotic surgery · Telesurgery · Web connected · Mentoring · Proctoring

Introduction

There have been many innovations in surgery over theyears that have stood out as “game changers.” Theseinclude the discovery of the principles of aseptic technique,utilization of regional and local anesthesia, development ofenergy sources for cutting and coagulation, as well as thedevelopment of endoscopy [1, 2]. Computers have alsoundergone rapid evolutionary changes during our lifetimesthat now aVect and enable almost everything we do, fromdriving a car to talking on the telephone [3]. It is thereforeno surprise that computer technologies are being adapted tothe medical profession to enable physicians to take bettercare of their patients. Utilizing computers in the operatingroom is now commonplace [4, 5]. Computers control oper-ating room lights and climate, endoscopic cameras, imag-ing devices, energy generators and most recently surgicalrobots. Arguably, the greatest impact of computers on ourlives has been the development of the Internet. It is there-fore also no surprise that innovative surgeons are attempt-ing to utilize the Internet to improve their outcomes in theoperating room [6–8]. This study reviews our experiencewith using a new dedicated robotic surgery Internet connec-tion system, da Vinci Connect™ (Intuitive Surgical, Sun-nyvale, CA, USA) to communicate and collaborate in realtime with other surgeons located in distant sites.

Methods

Remote robotic-assisted surgery was initially a vision of theUS Military who developed the original systems throughDARPA (Defense Advanced Research Projects Agency)for use on the battleWeld [9]. Intuitive Surgical developedthe da Vinci Robotic Surgical System in 1999 with a view

J. Lenihan Jr. (&) · M. BrowerMultiCare Health Systems, Tacoma, WA, USAe-mail: [email protected]

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48 J Robotic Surg (2012) 6:47–52

to cardiovascular surgery [10]. Robotic surgery, however,moved into the civilian sector in 2001 and was rapidlyadopted by the urologic community to perform minimallyinvasive surgery for prostate cancer [11, 12]. The da VinciSurgical System was approved by the Food and DrugAdministration for use in gynecology in March 2005, andgynecologic surgery now accounts for the majority ofrobotic procedures done in the USA [13].

The Wrst telerobotic surgeries utilizing the da VinciSurgical System were conducted in Europe and reportedin 2002 [14]. Remote surgeries performed on gynecol-ogy patients were attempted in both France and Belgiumand shown to be safe in 2005, just prior to the FDAapproving the da Vinci technology in the USA. Thesestudies demonstrated that a surgeon operating on apatient from a remote console using a surgical robotcould do a surgery safely [15]. Since then, robotic surgi-cal technology has been signiWcantly reWned; and in2009, Intuitive Surgical developed a web-based technol-ogy that enabled live interaction and communicationbetween robotic surgeons in the operating room andanother surgeon or person who could communicate withthe console surgeon from their portable computer conWg-ured with proprietary software. This system, called daVinci Connect™, enabled secure video and audio inter-action in real time between surgeon and observers. Thistechnology uses a third-party solution to provide theportal for communication between the operation roomrobotic surgeon and the observing party (Fig. 1). Theconnections are all secure and are also Health InsurancePortability and Accountability Act of 1996 (HIPPA)compliant. This technology was developed for the sec-ond-generation surgical robot, the S model. It has not

yet been conWgured for the third generation Si model,but that will happen in the near future.

This system allows the observing party to Xip betweenthe console view inside the patient to outside cameras inorder to observe what is happening in the operating room.The console surgeon can see the other party in the consoleusing the “Tile Pro” technology, which is similar to the“picture in the picture” technology found on many high-endtelevisions (Fig. 2). The operating surgeon can enable ordisable this view inside the console. The observing partyhas the ability not only to see and communicate with theconsole surgeon, but also to telestrate, capture images andvideo or even upload other video images to the console sur-geon which will then appear on the “Tile-Pro” screen in thesurgeon’s console (Fig. 3).

After practicing with this technology within our ownhospital campus and with the test facility at Intuitive Surgi-cal’s headquarters in Sunnyvale, California, we decided totry diVerent ways of using this technology to see what itsvalue might be. The Wrst trials involved having outside par-ties observe our surgeon performing robotic surgery. This“case observation” trial would enable us to demonstratebasic and advanced robotic surgical procedures and tech-niques to other surgeons in remote locations. They couldask questions and interact with our surgeons in real timethrough their enabled laptop computers. The second andthird applications we tested were remote proctoring. Thiscould be done as either an incoming or an outgoing proctor-ing event. This would enable our advanced surgeons tomentor new robotic surgeons in a remote location in realtime without having to actually travel to those operatingroom locations. By the same token, we could ask remoteexpert surgeons to help with observation and advice for

Fig. 1 da Vinci Connect remote observation system

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J Robotic Surg (2012) 6:47–52 49

some of our less experienced surgeons performing morediYcult cases. Finally, we thought that this technologycould be used to do live surgery telecasts for continuingmedical education (CME) events. We therefore started aprogram with the cooperation of Intuitive Surgical to trythese various methods of connecting surgeons and observ-ers and proctors via the Internet using the da Vinci Connectsystem. We recorded all of the connections and made notesof issues or problems that occurred during the events. Wethen queried the surgeons on both ends to see if theythought the process provided value for them. Finally, wetracked surgical outcomes to see if there was any adverseimpact on operative times or complications.

All patients were counseled regarding the use of thistechnology and of the observing or mentoring surgeons andall patients were asked to sign a separate informed consentfor this process which had been developed by our hospital’slegal department and reviewed by our hospital IRB.

Results

The da Vinci Connect System was installed in June 2009 atTacoma General Hospital (TGH), part of MultiCare HealthSystems, Tacoma, WA, USA. Tacoma General is a com-munity hospital with a robotics program in place since June2005. The da Vinci Connect System was installed on theconsole of the hospital’s S model robot in 2008. In 2009,the da Vinci Connect technology was also installed at a sec-ond MultiCare aYliated hospital, Good Samaritan Hospital(GSH), Puyallup, WA, USA, which is located approxi-mately 12 miles away. This hospital started its robotic pro-gram in August 2009 and also has an S model da Vincirobotic system. One gynecologic surgeon (J.P.L.) func-tioned as the proctor/mentor when the laptop componentwas used for outgoing proctoring. Several surgeons fromthe gynecology, urology and cardiovascular departmentsparticipated as the console surgeon for either case observations

Fig. 2 Proctor–surgeon interface with telestration demonstrated

Fig. 3 Proctor–case observer laptop screen

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or for actual proctoring by an outside mentor surgeon froma remote location. All patients involved in web-connectedsurgeries were informed of this and signed speciWc con-sents. No patient refused to allow this technology to be used(Table 1).

Case observations of surgery in our facility

From the period of July 2009 through March 2011, therewere 28 live da Vinci Connect case observations done atTacoma General Hospital. These observations were accom-plished from 15 diVerent states: Alabama, Washington,California, Oregon, Idaho, Colorado, Michigan, South Car-olina, North Carolina, Minnesota, Arizona, Tennessee,New Jersey, Ohio and Alaska. There was also one caseobservation from Leone, France in March 2011. 125 sur-geons and medical personnel were able to observe roboticsurgeries in our facility from remote locations during thistime period (Fig. 4).

Remote proctoring outside our facility

The author proctored four remote cases from Tacoma toadvise and assist surgeons performing complex robotic pro-cedures who wished to have an experienced mentor sur-geon on hand for these cases. These surgeons were locatedin the states of Washington, Alaska, New Jersey and SouthCarolina (Table 2; Fig. 4).

Remote proctoring of surgeons in our facility

We had 14 internal Connect cases to proctor gynecology,urology and cardiovascular cases being done at TacomaGeneral and Good Samaritan Hospitals. We started up acardiovascular program in 2010. An experienced cardiovas-cular robotic surgeon from Atlanta, GA, USA, mentoredour cardiovascular surgeon on three occasions and our sur-geon was mentored by a diVerent cardiovascular surgeonfrom Southern California on one other occasion. One of ourgenitourinary surgeons was mentored by a robotic mentorsurgeon from Seattle, WA, USA, on two occasions, andtwo gynecology surgeons at Good Samaritan Hospital werementored by robotic surgeons from Nevada as well as fromTacoma General on several occasions (Table 3).

CME broadcasts

Finally, we broadcast live robotic surgeries from TacomaGeneral Hospital to two diVerent CME courses using thistechnology. The Wrst was a single hysterectomy that wasbroadcasted to a robotics course being given at the Univer-sity of Washington Tacoma Campus, and the second was abroadcast of two complete cases, a robotic hysterectomyand a robotic sacrocolpopexy to a Robotic Masters Coursegiven in Sunnyvale (Table 1). Both cases utilized a livemoderator who was able to relay questions and commentsfrom the audience to the console surgeon.

Outcomes

The case observations of our surgeries in Tacoma usuallywent well. We initially had troubles with the audio portionof the linkage, which were resolved by utilizing wirelessmicrophones for the surgeon to talk into when he was out-side of the console in the operating room. The consolemicrophone always functioned well to communicate withobserving surgeons. We almost always had diYculty hear-ing the observing surgeons watching on their remote laptopunless they held the hand-held microphone very close to

Table 1 Internet-connected live surgical events at MultiCare HealthSystem hospitals using da Vinci Connect technology

Date Case observations

Internal proctoring

External proctoring

CME

2009 8 0 0 1

2010 16 10 3 0

2011 4 4 1 1

Table 2 MultiCare mentor surgeon proctoring robotic surgeons atother sites using live internet (da Vinci Connect) technology

GYN gynecology

Date Specialty Location

25 Jan 2010 GYN Palmer, AK

7 Mar 2010 GYN Puyallup, WA

30 Jul 2010 GYN Trenton, NJ

30 Mar 2011 GYN Portland, OR

Table 3 MultiCare surgeons being proctored from outside using liveinternet technology (da Vinci Connect)

GSH Good Samaritan Hospital, TGH Tacoma General Hospital,GU genitourinary, GYN gynecology, CV cardiovascular

Date Hospital Specialty Proctor location

8 Apr 2010 GSH GU Seattle, WA

15 Apr 2010 GSH GU Celebration, FL

16 Apr 2010 GSH GYN Ft Worth, TX

10 May 2010 TGH GU Seattle, WA

11 June 2010 GSH GYN Reno, NV

3 Sep 2010 GSH GYN Reno, NV

11 Sep 2010 GSH GYN Reno, NV

22 Oct 2010 TGH CV Atlanta, GA

27 Oct 2010 TGH GU Celebration, FL

29 Oct 2010 TGH CV Atlanta, GA

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their mouths. A more sensitive microphone helped if onewas available. The video connections were always verygood in both directions. We did have one of our patient-side view cameras break from falling oV its mounting pole.In the last 4 months of this trial, we have been using anewer PTZ (pan–tilt–zoom) external camera which is stur-dier and which can be controlled from the remote laptop togive the observers more control over what they want towatch outside the console in the operating room itself. The“Tile Pro” picture-in-picture video component did not workon one observation. We did not discover until after the casethat the video cords to the “Tile-Pro” input connecter hadbeen disconnected by our cardiac team during the previouscase so that they could input an EKG into the “Tile-Pro” forthe console surgeon to monitor during the heart valvereplacement procedure. The outgoing remote proctoringconnections all worked well.

Surgeon feedback was excellent whether it was from oursurgeons who were being proctored or from remote sur-geons whom we were proctoring. Our local surgeon’s com-ments ranged from “fantastic” to “extremely helpful” whenthey discussed the advice and help given to them by remoteproctor surgeons. The surgeons being proctored were allimpressed and appreciative for the opportunity to haveexperienced mentor surgeons available during their cases;and the mentor surgeons were grateful to be able to provideteaching without having to leave their communities and Xya great distance to provide live teaching. The live CMEtelesurgeries also went well. These were unique opportuni-

ties for the CME course attendees to interact with the con-sole surgeon during the case to discuss surgical proceduresand choices made by the surgeon.

Discussion

Live real-time Internet-connected surgery is clearly a beneWtto the surgeons and ultimately to the patients. While thistechnology is in its infancy, there is clear potential for its useon a more universal basis in the future, just as live video-con-ferencing is now being used by most other industries. Ofcourse, these connections need to be secure and HIPPA com-pliant. As this technology evolves, it will provide a uniqueopportunity for teaching. This can include teaching new sur-geons how to perform robotic surgery as well as teachingexperienced surgeons about new instruments and new tech-niques. This technology also has the potential to allow real-time collaboration between surgeons of diVerent disciplinesfor management of complex cases. There is also the possibil-ity of a mentor surgeon “on call” who could be available tolog in and discuss an unanticipated complication or diYcultsurgical condition with a console surgeon during an actualcase. This has a great potential to allow expert consultationon a timely basis. Finally, the evolution of direct connectionsbetween surgeons operating on separate consoles has theability to allow real-time collaboration inside the operatingroom from multiple diVerent console locations, i.e. “collabo-rative teleconference surgery.”

Fig. 4 Tacoma General Hospital da Vinci Connect observation sites

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Summary

Over the last two years, we have pioneered performingrobotic surgeries using a novel web-based live observationtechnology called da Vinci Connect. This system, althoughnew, worked well and showed great promise for providingvalue to surgeons and hospital systems in the future. Asweb-based live interactive surgical technologies evolve,there will be increasing development of applications fornetworking, proctoring, teaching, credentialing and forperforming collaborative surgeries. Today’s technologypredicts a bright future for web-connected surgeons.

ConXict of interest John P. Lenihan Jr. is a Speaker, Proctor andEpicenter Surgeon for Intuitive Surgical, Sunnyvale, CA.

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