Evaluation of the effectiveness of portable low-bandwidth telemedical applications for postoperative followup: initial results.

BACKGROUND: The idea of using telemedical applications to evaluate patients remotely is several decades old. It has already been established that x-ray images (and magnetic resonance images) can be transferred using a personal computer and a modem, and many other such applications have been implemented. Over the past 50 years the expense and technical demands of the equipment involved in telemedicine have hindered its widespread deployment. The purpose of this study is to evaluate the ability of a mobile, low-bandwidth telemedicine platform to achieve real-time postoperative visits in the home. STUDY DESIGN: This evaluation was designed to evaluate the feasibility of performing a real-time clinical visit with computer and telecommunications hardware and software. A nurse and medical student (for information gathering only) made postoperative visits at patients' homes while the physician stayed at the office. Clinical evaluations were performed by using low-resolution and frame-rate video, high-resolution still images, and simultaneous telephony over a standard telephone line. These remote visits were followed by a standard visit in the office. Eleven patients were included, all of whom had undergone various laparoscopic procedures. They lived 5 to 240 miles from their surgeon. Efficiency was measured by recording the time required to capture and send data required by the physician to make a clinical decision. The time expense was measured at both the patients' and physician's locations. Technical issues were evaluated and patient satisfaction was assessed by standardized objective questionnaires. The accuracy of the evaluation at the remote visit was determined with a standard office visit. RESULTS: No technical problems were observed. The mean total time of the housecall at the remote site was 86 minutes (range 60 to 160 minutes) and at the base station site was 41 minutes (range 21 to 71 minutes). After personnel became familiar with the system, the last three visits averaged 61 and 25 minutes at the two sites, respectively. This corresponds favorablywith current time requirements for visiting nurses and office visits. The patients were highly satisfied with the home visit and, on average, rated the experience as 4.8 out of a maximum of 5. CONCLUSIONS: Followup visits in patients' homes after laparoscopic procedures can be accomplished by transmitting simultaneous voice, low-resolution video, and high-resolution still images to accurately perform postoperative evaluations over standard telephone lines, with time requirements and clinical accuracy similar to those of standard visits.

Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training.

BACKGROUND: Computer-assisted instruction (CAI) can benefit surgical education by improving efficiency, effectiveness, standardization, and access. This study compares knowledge gains for laparoscopic skill acquisition following a standardized tutorial delivered via CD-ROM versus live instructor. METHODS: A standardized tutorial was written and subsequently converted to multimedia CD-ROM format by its author (JR). During a laparoscopic development course, experienced US-trained surgeons (n = 52) participated in the tutorial delivered live by the author. The CD-ROM tutorial replaced the instructor for the following groups: (1) experienced US-trained surgeons (n = 27); (2) US-trained surgical residents (n = 59); and (3) Greek surgeons (n = 63). A 51-item knowledge test was administered before and after tutorial instruction. RESULTS: The mean increase in scores between pretest and posttest was significant (P <0.01) and of similar magnitude in each group, with nonsignificant posttest mean differences among US-trained groups. CONCLUSIONS: The CD-ROM tutorial effectively transfers cognitive information necessary for skill development. Distance learning modes of this tutorial program may be feasible.

A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement.

BACKGROUND: Percutaneous endoscopic gastrostomy and jejunostomy tube placement have long been considered the standard for supplying enteral nutrition when oral intake is not possible. Both have well-documented roles and limitations and are associated with a higher than generally appreciated incidence of aspiration. A distally placed tube in the jejunum decreases the chance of this morbid complication. Additionally, when percutaneous endoscopic gastrostomy is indicated but cannot be done for technical reasons, a minimally invasive alternative is desirable. METHODS: In prior series, the techniques suggested for laparoscopic enteral access have characteristics that are either difficult for the average surgeon to duplicate, or use nonstandard anchoring techniques of the bowel to the abdominal wall. A simple, laparoscopically directed, percutaneous technique utilizing cost-effective appliances is described, and suggested indications are outlined. RESULTS: This technique has been successfully applied in 46 patients with minimal complications. CONCLUSIONS: A simplified technique for laparoscopic jejunostomy and gastrostomy tube placement is described. This has been successfully deployed in 46 patients with minimal morbidity. The procedure lessens the need for sophisticated suturing skills and duplicates standard small bowel to abdominal wall fixation methods.

Objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons.

BACKGROUND: Laparoscopic surgery adapts poorly to apprenticeship models for general surgical training. Standardized skill acquisition and validation programs, targeted performance goals, and a supervised, enforced, skill-based curriculum that readily can be shared between trainee and instructor must replace the observation and incremental skill-acquisition model used in an open surgical environment. The Yale Laparoscopic Skills and Suturing Program was used to develop a data bank for objective evaluation of dexterity and suturing skills for laparoscopic surgical training. The current study compares trainee and senior surgeon performance in this standardized training program. OBJECTIVE: To compare objectively evaluated laparoscopic surgical skills and suturing capability of senior surgeons and of residents after they have completed the same standardized training regimen. METHODS: Two hundred ninety-one trained surgeons performed 8730 standardized laparoscopic dexterity drills and 2910 intracorporeal suturing exercises in the Yale Laparoscopic Skills and Suturing Program. Their performance was supervised by an instructor who recorded performance and timing of the tasks in a 2 1/2-day program. Ninety-nine residents performed the same drills and exercises the same number of times and followed the same technique for intracorporeal suturing. Percentile graphs were prepared for each type of drill and suturing exercise to allow comparison of levels of achievement among different training groups. RESULTS: The performance of the residents was the same as that of trained surgeons for the rope pass drill and the suturing exercise. Residents in comparison with trained surgeons performed the triangle transfer drill faster and the new cup drop drill and old cup drop drill more slowly. There was no significant difference in performance between male and female residents. CONCLUSION: Basic skills relevant to laparoscopic performance can be acquired with a high level of competence in a brief course unrelated to prior surgical experience, sex, or age.

Minilaparoscopy without general anesthesia for the diagnosis of acute appendicitis.

The timely diagnosis of intra-abdominal pathology continues to be an elusive problem. Delays in diagnosis and therapeutic decision making are continuing dilemmas in patients who are females of childbearing age, elderly, obese or immunosuppressed. Minilaparoscopy without general anesthesia potentially can provide an accurate, cost-effective method to assist in the evaluation of patients with acute abdominal pain. Laparoscopy without general anesthesia is not a new technique, but with the combination of two emerging factors--1) the introduction of new technology with the development of improved, smaller laparoscopes and instruments, and 2) the shifting of emphasis on healthcare to a more cost-effective managed care environment--its value and widespread utilization is being reconsidered. We report the case of a 22 year old female with an acute onset of increasing abdominal and pelvic pain. Despite evaluation by general surgery, gynecology, emergency room staff, as well as, non-invasive testing, a clear diagnosis could not be made. In view of this, minilaparoscopy without general anesthesia was performed and revealed an acute, retrocecal appendicitis. The diagnosis was made with the assistance from the conscious patient. The utilization of this technique greatly expedited the treatment of this patient. Full-sized laparoscopic equipment was then used to minimally invasively remove the diseased appendix under general anesthesia. Both procedures were well tolerated by the patient.

Telementoring. A practical option in surgical training.

BACKGROUND: Telemedicine offers significant advantages in bringing consulting support to distant colleagues. There is a shortage of surgeons trained in performing advanced laparoscopic operations. AIM: Our aim was to evaluate the role of telementoring in the training of advanced laparoscopic surgical procedures. METHODS: Student surgeons received a uniform training format to enhance their laparoscopic skills and intracorporeal suturing techniques and specific procedural training in laparoscopic colonic resections and Nissen fundoplication. Subsequently, operating rooms were equipped with three cameras. Telestrator (teleguidance device), instant replay (to critique errors), and CD-ROM programs (to provide information of reference) were used as intraoperative educational assistance tools. In phase I, four colonic resections were performed with the mentor in the operating room (group A) and four colonic resections were performed with the mentor on the hospital grounds, but not in the operating room (group B). The voice and video signals were received at the mentor's location, using coaxial cable. In phase II, two Nissen fundoplications were performed with the mentors in the operating room (group C) and two Nissen fundoplications were performed with the mentors positioned five miles away from the operating room (group D), using currently existing land lines at the T-1 level. RESULTS: There were no differences in the performances of the surgeons and outcome of the operations between groups A & B and C & D. It was possible to tackle the intraoperative problems effectively. CONCLUSIONS: The telementoring concept is potentially a safe and cost-effective option for advanced training in laparoscopic operations. Further investigation is necessary before routine transcontinental patient applications are attempted.

Skill acquisition and assessment for laparoscopic surgery.

OBJECTIVES: To describe a training method with objective evaluation to enhance laparoscopic surgical skills to provide training in laparoscopic suturing techniques and to assess whether specific training exercises were helpful in the attainment of intracorporeal suturing skills. DESIGN: Trainees (N = 150) were asked to perform standardized drills with distinct mechanical features, and skill acquisition was determined by accuracy and timing. Trainees were tested for the ability to perform an intracorporeal laparoscopic suture before and after analogous skill training with the drills. SETTING: The training courses were held in teaching and nonteaching hospitals. PARTICIPANTS: Board-certified or board-eligible surgeons. MAIN OUTCOME MEASURES: Supervision by trained instructors and documentation of the time required to perform standardized drills. RESULTS: The trainees showed steady improvement in skill acquisition during 10 trials (P < .001). Significant (P < .001) improvement was noted for the performance of suturing after compared with before the drills. CONCLUSION: Three standardized laparoscopic drills have been tested in 150 trainees and demonstrate the incremental acquisition of skills that correlate with improved performance in a challenging and complex laparoscopic skill, intracorporeal suturing.

Recombinant interleukin 12 cures mice infected with Leishmania major.

Resistant C57BL/6 mice infected with Leishmania major are self-healing, whereas susceptible BALB/c mice fail to contain cutaneous infection and subsequently undergo fatal visceral dissemination. These disparate outcomes are mediated by dissimilar expansions of T helper type 1 (Th1) and Th2 CD4+ T lymphocyte subsets in vivo during cure and progression of disease. Because interleukin 12 (IL-12) has potent T cell growth and interferon gamma (IFN-gamma) stimulatory effects, we studied its effect on CD4+ T cell differentiation during murine leishmaniasis. Treatment with recombinant murine (rMu)IL-12 during the first week of infection cured 89% of normally susceptible BALB/c mice, as defined by decreased size of infected footpads and 1,000-10,000-fold reduced parasite burdens, and provided durable resistance against reinfection. Cure was associated with markedly depressed production of IL-4 by lymph node cells cultured with antigen or mitogen, but preserved or increased production of IFN-gamma relative to untreated mice. IL-4 and IFN-gamma mRNA associated with CD4+ T lymphocytes isolated from infected lymph nodes showed similar reciprocal changes in response to rMuIL-12 therapy. A single injection of anti-IFN-gamma monoclonal antibody abrogated the protective effect of rMuIL-12 therapy and restored Th2 cytokine responses. We conclude that rMuIL-12 prevents deleterious Th2 T cell responses and promotes curative Th1 responses in an IFN-gamma-dependent fashion during murine leishmaniasis. Since BALB/c leishmaniasis cannot be cured with rMuIFN-gamma alone, additional direct effects of IL-12 during T cell subset selection are suggested. Because rMuIL-12 is uniquely protective in this well-characterized model of chronic parasitism, differences in IL-12 production may underlie heterogenous host responses to L. major and other intracellular pathogens.