telementoring: augmented reality in orthopedic education

The Evolution of Surgical Training

The increase in arthroscopy, endoscopy, microscopy, and robotics in surgery has challenged the traditional side-by-side surgical training paradigm. Minimally invasive surgery techniques have steep learning curves which frequently place surgeons-in-training in passive learning roles.

Knowledge and skill acquisition theories emphasize the need for active participation of the student in the learning process and focus on immediate implementation of the newly acquired knowledge. Post-graduate training centers are facing the need to evolve and utilize technical advances to educate.

The benefits of surgical simulators are well documented. Virtual reality (VR) training shortens the learning curve of surgical trainees in addition to the benefits of not injuring patients or extending the length of operations. There are, however, a number of challenges with VR training. Building realistic models of the human body and creating interface tools to view, hear, and manipulate these human body models remain significant hurdles to overcome.

Telemedicine is a rapidly growing sector within medicine. It has the ability, through audio and video technology, to connect

remote healthcare providers with patients or other providers without direct contact. Telementoring, a concept within

telemedicine, is when an expert physician guides another physician at a different geographic location. Access to

expertise using this technology-based approach has been shown to save lives, reduce hospital stay, and reduce cost in

trauma and elective surgical settings. Recently, a new interactive technology has been introduced that takes a dual reality-

based approach to surgical training.

Augmented Reality

Virtual and augmented reality technologies are well-known outside of resident education. While virtual reality can be thought as creating an entirely digital world in which a user interacts in, augmented reality can be defined as enhancing

an individual’s experience in the real world through the addition of digital elements.

Popular augmented reality mobile applications superimpose useful data on top of the real world, in real-time. As an example, certain applications allow a user to view interesting or relevant historical information as he or she walks down a street in a new city. Additionally, many augmented reality applications allow interactivity with the superimposed data. Rotating, resizing, and dynamic user input is often allowed, further enhancing the experience.

Aside from popular mobile applications, field staff are using augmented reality software to view data regarding a mechanical repair in real-time. A staff member, wearing a head-mounted display (HMD) can have the particular points at which he or she should manipulate a mechanical device be digitally highlighted for an added layer of assurance the task is being completed correctly.

While these technologies are continually increasing in pervasiveness outside of resident education, this pilot study examined the viability of augmented reality technology being applied in the educational arena. We utilized a Virtual

Interactive Presence (VIP) (VIPAAR, Birmingham, AL) system that allows superimposition of an instructor’s hand over

imaging of the surgical field in real-time. The objectives of this study were to evaluate the performance of a VIP system implemented in an operating room setting with respect to efficiency, safety, and teaching.

Telementoring: Augmented Reality in Orthopaedic Education

Ponce BA, Jennings JK, Sheppard ED, Clay TB, May MB, Huisingh C, Siegel HJ.

University of Alabama at Birmingham (UAB)Research or other financial support has been received from the same company as the products discussed.

Study Design

• Following VA and University IRB approval, a consecutive cohort of 15 patients scheduled for arthroscopic shoulder

surgery at the Birmingham Veterans Affairs (VA) Medical Center were enrolled from April -August 2012

• Six orthopaedic residents, three PGY-3s and three PGY-5s, and one attending surgeon participated

• For each case, the attending surgeon used the VIP system to remotely proctor one or more resident surgeons as portions

of the surgical case were performed.

• When the attending surgeon felt his presence was necessary in the operating room, he physically entered the case.

• Following each case, the attending, resident surgeons ,anesthetist, circulator and surgical tech completed a Likert-scale

questionnaire (1-5 with 1 = strongly disagree, 5 = strongly agree) that assessed their opinions on the VIP station's effect

on education, safety, and efficiency. A subjective feedback section was also included on the survey.

• Set up times and operative times were recorded. Operative times were historically matched to comparable prior cases by

the same attending surgeon prior to the initiation of this study

Examples of Augmented Reality in Current Use

Google Glass: allows viewing weather, sending text messages, taking pictures & video, performing Internet searches.

Word Lens: superimposes translated text on top of the real world.

Google Sky Map: displays spatially-registered constellation details on smartphone or tablet.

Wikitude: superimposes relevant information on users’ surroundings.




Virtual Interactive Presence (VIP) Setup

• Two Virtual Interactive Presence (VIP) stations (VIPAAR, Birmingham, AL, USA) with an Internet Protocol (IP)-based

connection

• One positioned in the operating room

• One positioned in surgical dictation room outside the operating room suite

• Attending surgeon (proctor) was positioned at a station located in the physician’s dictation area to simulate geographic

remoteness

• The proctor’s hands and other surgical tools were merged directly with the arthroscopic image

• The station positioned in the surgical dictation room additionally had a telestration feature that allowed the attending

surgeon to draw on the image with a two-dimensional pen tool

Virtual Interactive Presence (VIP) Platform

• A virtual interactive presence (VIP) platform (VIPAAR, Birmingham, AL, USA) has been developed that allows a remote surgeon to deliver real-time virtual assistance to a local surgeon over a standard Internet connection

• VIP stations use software that enables the proctor to virtually “reach into” the surgical field in real-time

• This creates an experience of dual reality for the local surgeon that may enhance knowledge transfer and skill acquisition

• While virtual reality can be defined as immersing a user in a virtual world, dual reality merges physical realities to provide a shared first-person environment for learning

• In other words, in a dual reality environment a remote surgeon can see what the operating surgeon sees and virtually identify anatomy or direct the surgical technique




Setup Schematic: Operating Room and Dictation Room




Attending surgeon’s hand superimposed on

arthroscopic image

Resident & attending survey results

Category Statement N

Attending

Mean

(SD)

Attending Median

(IQR)N

Resident

Mean

(SD)

Resident Median

(IQR)P-value*

Efficiency Ease of use 15 4.53 (0.52) 5 (4-5) 19 4.74 (0.45) 5 (4-5) 0.23

Efficiency Reliability 15 4.60 (0.51) 5 (4-5) 20 4.60 (0.60) 5 (4-5) 0.87

Efficiency Lag in motion 15 4.60 (0.51) 5 (4-5) 19 4.00 (0.82) 4 (4-5) 0.01

Safety Sufficient image resolution

15 4.67 (0.49) 5 (4-5) 20 4.65 (0.75) 5 (4.5-5) 0.69

Safety No safety concerns 15 4.60 (0.51) 5 (4-5) 20 4.75 (0.72) 5 (5-5) 0.14

Safety No interference with surgery

15 4.60 (0.51) 5 (4-5) 20 3.85 (1.31) 4 (4-5) 0.05

Teaching Highlighting anatomy 15 4.73 (0.46) 5 (4-5) 20 4.85 (0.37) 5 (5-5) 0.41

Teaching Feedback to resident 15 4.73 (0.46) 5 (4-5) 19 4.84 (0.37) 5 (5-5) 0.46

Teaching Communication 15 4.67 (0.49) 5 (4-5) 20 4.75 (0.44) 5 (4.5-5) 0.61

SD: standard deviation; IQR: interquartile range*p-value to compare median scores obtained via the Wilcoxon rank-sum test

Category Statement N Staff Mean (SD)Staff Median

(IQR)

Efficiency No Increase in Workload 31 4.35 (0.91) 5 (4-5)

Efficiency Unobtrusive to Workflow 35 4.17 (0.92) 4 (4-5)

Efficiency Awareness of Progress of Procedure 35 4.11 (0.90) 4 (4-5)

Safety Reliability 35 4.63 (0.49) 5 (4-5)

Safety Sufficient Image Resolution 35 4.57 (0.50) 5 (4-5)

Safety No Safety Concerns 34 4.47 (0.56) 4.5 (4-5)

Safety Remote Presence Had No Adverse Effect 34 4.44 (0.70) 5 (4-5)

Safety Quality of Patient Care 34 4.35 (0.73) 4 (4-5)

Safety Visualization 34 4.62 (0.55) 5 (4-5)

Teaching Effectiveness as Guidance Tool 35 4.23 (0.73) 4 (4-5)

Teaching Feedback to Resident 35 4.43 (0.61) 4 (4-5)

Teaching Communication 35 4.23 (0.73) 4 (4-5)

OR Staff survey results




Result Summary

• No differences between attending and resident surgeons’

scores on the utility of the VIP to highlight anatomy and

provide feedback to the resident (p>.05).

• No differences were noted between groups in the ease of

use and safety during the procedure (p>.05).

• Majority of resident and attending surgeons reported no

perceptible lag between motions (95% and 100%,

respectively) (p>0.99) and no interference of the VIP with

the surgical procedure (85% and 100%, respectively)

(p=0.24).

• The mean surgical times for rotator cuff and instability

procedures were not significantly different with and without

use of VIP (p=0.57, p=0.61, respectively).

• VIP technology effectively allowed the attending surgeon to

remotely proctor resident surgeons.

• Residents felt training was improved

• Able to do more with greater supervision

• Attending surgeon believed teaching effectiveness as a

proctor was improved through this technology.

• Despite being remote, attending felt had greater control

through this technology

• No difference in surgical time and no observed

complications encountered

• Both residents and faculty believed residents were able to

participate to a greater degree.




•Resident comments

• Communication between staff and resident was

precise; it allowed us to know exactly where to

debride tissue, place anchors and pass sutures

• Attending able to give instruction without taking over

case

• I felt well supervised and yet I had an increased

sense of autonomy being in the room by myself

• Highlighted anatomy great

• Enhanced my understanding

• It allowed for resident autonomy but did not sacrifice

staff oversight and patient safety

• Better than computer or cadaveric models

•Attending comments

• First time in my six years on staff that a resident did an

entire arthroscopic stabilization and the repair was

excellent

• Third year resident did entire subacromial

decompression

• Improved safety – I am able to better monitor the case

and give necessary instruction until my presence for the

more complex portions is required.

• Improved instruction/communication – normally I say ‘go

up, down, etc.’ , now can say and show what to do which

gives resident greater involvement AND me greater

supervision/control

• Only time not comfortable with being remote was when

resident did not have a good view in the subacromial

space and I was unable to help as the outside camera

view was not sufficient

Free Form Feedback

Conclusion

References and Contact

VIP technology may effectively allow attending surgeons to remotely proctor resident surgeons. Both the attending and residents agreed that training was enhanced without sacrificing operative times. Furthermore, the attending surgeon felt this technology improved teaching effectiveness. These results are promising and support further objective quantification.

Aggarwal R, et al. Effectiveness of VR simulation for training in laparoscopic surgery. Ann Surg. 2007;246(5):771-779.Burgess L, et al. Overview of Telemedicine Applications for Otolaryngology. The Laryngoscope. 1999; 109.9:

1433-437.Edelman DA, et al. Laparoscopic training in a 4th-year medical school surgical skills elective. J Surg Res. 2012.

Web published.Farnworth LR, et al. Op. times in arthroscopic ACL reconst. btw. faculty and residents.Iowa Orthop J. 2001;21: 31–35.

Grantcharov TP, et al. Performance of VR simulator to test laparoscopic skills. Am J Surg. 2003;185(2):146-149.

Grantcharov TP, et al. Randomized clinical trial of VR simulation for laparoscopic skills training. Br J Surg. 2004;91(2):146-150.Harrington D, et al. Time-Cost Analysis of Teaching Laparoscopic Entero-Enterostomy. J of Surg Edu.

2007;64.6: 342-45.Hosler MR, et al. Resident Participation in Cataract Surgery on Operative Time and Cost. Ophthalmology.

2011;119.1: 95-98.

Brent A. Ponce, MDAssociate ProfessorUAB Division of Orthopaedic [email protected]

Stan McDuffieDirector, Clinical [email protected]




Discussion

• Telemedicine is a rapidly growing field due to

technological advancements, clinical need, governmental

incentivisation, and increased investment capital.

• Clinical need

�US experiencing a shortage of up to 200,000 physicians

�Specialized care lacking in rural areas for 80 million Americans

• Government incentivization

�Medicare covers certain telemedicine services

�VA Office of Telehealth Services in 2012 hired 1000 telehealth

professionals

• Increased investment capital

�Telehealth sector grew from $3 to $7.7 billion in the last 5 years

• Telementoring is a proven and validated means to

transmit skill and expertise to a site of need.

• VIP technology provides a shared first person learning

environment idea for telementoring anywhere an internet

connection is available

• Consistent with educational theories of active

participation and immediate implementation of newly

acquired knowledge

• Study Limitations:• Limited number of surgical cases• One attending surveyed• Small number of residents surveyed• No patient outcomes collected• Inclusion of only arthroscopic procedures. • Was done over a local internet network

• Potential Benefits

• Possible shortening of surgical skill learning curve

�Potential to offset decreased resident operating exposure due to

work hour restrictions

• Possible cost savings

• With potential condensed learning curve, VIP technology may

allow shorter operative times in cases involving residents without

compromising safety

• Training augmentation

• VIP offers the ability to train residents with a basic orthopaedic

surgical skill set, i.e. upper level residents, with in vivo training as

opposed to traditional cadaveric or virtual reality training

• Potential applications with VIP technology

• Preceptoring of practicing physicians to gain new

surgical skills in real time

• Virtual presence of an industry rep in OR

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.htmlhttps://www.aamc.org/download/286592/data/physicianshortage.pdfLange T, et al. VR in surgical training. Surg Oncol Clin N Am. 2000; 9(1): 61-79, vii.

Larsen CR, et al. Effect of VR training on laparoscopic surgery: randomized controlled trial. Br Med J. 2009;338:b1802.Latifi R, et al. Stud Health Technol Inform. 2004;104: 200-6.

Mendez I, et al. Robotic Long-distance Telementoring in Neurosurgery. Neurosurgery. 2005; 56.3: 434-40.Panait LA, et al. Telementoring vs On-site Mentoring in VR-Based Surgical Training. Surgical Endoscopy. 2006; 20.1: 113-18.Schlachta C, et al. Mentoring & Telementoring Leads to Incorporation of Lap. Colon Surgery. Surg Endosc. 2010;24.4: 841-44.

Seymour NE, et al. Virtual reality training improves operating room performance. Ann Surg. 2002;236(4):458-464.Shenai MB, et al. VIPAR for Remote Surgical Assistance. Neurosurgery. 2011;68(1 Suppl Operative):200-7; discussion 207.

Shortage Desig.: Health Prof. Shortage Areas & Med. Underserved Areas. Web. 31 July 2012. <http://bhpr.hrsa.gov/shortage/>. Wilson MS, et al. MIST VR: VR trainer for laparoscopic surgery assesses performance. Ann R Coll Surg Engl. 1997;79(6):404-404.

telementoring: augmented reality in orthopedic education

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