Heralding New Ringtones of Patient Safety: Blackberry-based Clinical Communication and Telementoring in Laparoscopic Surgery

Background

Laparoscopic Surgery or Minimally Invasive Surgery of the abdomen has grown rapidly in the last years, due to reduced risk of complications and quicker recovery than with traditional surgery. However, attaining the skill-set to enable development of proficiency is associated with a steep learning curve. Several previous studies have validated the effectiveness of telementoring during live surgery.^{1, 2} To improve patient safety and enhance telementoring with routine laparoscopic procedures, we envisioned the need for simple low cost ubiquitous methods. We hypothesized that critical moments and maneuvers of a procedure could be identified for still and brief video transmission to allow adequate visibility for a remote mentor to advise the operative team. This study describes our preliminary experience with telementoring using a Blackberry Smartphone device during live laparoscopic surgery, challenges facing adoption and future directions in research.

Methods

After IRB approval, a method was developed for capture of live HD laparoscopic video using a frame-grabber (DVI-to-USB Solo, Epiphan, Inc.) onto a stock laptop (MacBook, Apple). The video was then e-mailed to a handheld PDA (Blackberry Bold, RIM, Fig 1). Short video snippets of live laparoscopic cholecystectomy, specifically, identification of the cystic duct prior to clipping and division, were created. This is, by far, one of the critical steps in the laparoscopic procedure and error in identification and ligation of the duct could lead to significant complications. A validation survey was conducted using dichotomous measures. Three senior surgeons involved in supervision of residents were asked three questions about each operation. Was the image quality sufficient to render an opinion? (Q1) Was this the cystic duct being demonstrated? (Q2) Was this sufficient to give the ‘go-ahead’ and clip the duct?? (Q3). Reviewers were all senior surgeons involved in supervision of residents. Reviews were done after collection of 10 cases. Statistical analysis was done by using SPSS (SPSS Inc, Chicago, IL)

Fig 1.

Results

Three reviewers saw the same 10 videos. The inter-rater reliability was calculated to be 0 .71. For internal consistency of subject responses for dichotomous responses, Kuder-Richardson (KR-20) rho was estimated to be 0.82. Results were generally favorable: Q1 87%, Q2 93%, Q3 60%. Common comments included: need to better clean and demonstrate infundibulum, need to zoom and pan, need to show the back-side (lateral). Reviewers expected 100% positive on Q3 with the ability to talk to the supervising surgeon.

Conclusions

Early pilot data is very positive and demonstrates need for refinement of video content, zeroing transmission latency and transition to live interaction to improve “go ahead” rate. Asynchronous live-feeds on a small 2.5 inch screen was perceived to be very valuable to busy surgeons who may not always be at their desks to use bigger screens and who may be multitasking during their hospital on-calls. While this is a limited series, the initial evaluation of this remote presence technology in the operating room suggests that it may be extremely useful in enhancing surgical experience and expertise by telementoring during critical operations in minimally invasive surgery.