Telementoring proves ideal way of delivering advanced surgical procedures to medically underserved areas

Santo Domingo 23 July 2000On July 23rd 2000, Dr. James C. "Butch" Rosser Jr of the Yale School of Medicine was to be found in his home's cyberoffice & Global Command Center in Connecticut as surgeons in Santo Domingo and Yale University waited for his instructions to administer anaesthesia. Dr. Rosser used cyberspace to prepare Dr. Abel Gonzalez, a surgeon at the Santo Domingo Hospital, to conduct complicated procedures which this physician has little or no experience with. Dr. Rosser promoted the art of telementoring to remotely show Dr. Gonzalez where to make an incision, how to rearrange internal organs, where to place stitches and what kind of dangerous areas to avoid. To this purpose, Dr. Rosser applied "Top Gun" and NASA training techniques to rapidly develop skills in the surgeon and observe the surgeon's reactions.


The surgeon and anaesthesiologist overseeing the operation were in the United States. The patient, Ismael Arteaga, a 55-year-old man with a potentially life-threatening condition, known as GERD or gastro-esophageal reflux disease, was lying in an operating room thousands of miles away in the Dominican Republic. Dr. Rosser used a "telestrater" device, to direct surgical activity and peer into the patient's abdomen from cameras placed in the body. Via the use of television and satellite hookups, Discovery Health Channel organised a live broadcast, in order to take TV viewers inside the new practice of telementoring, a complex and cutting edge component of telemedicine.

Technology and telemedical applications have the promise of rapidly bringing the latest in surgical techniques to people all over the world. This can be accomplished no matter how remote the location and has proved to be less invasive, less traumatic and painful for patients than a traditional surgical operation. The two-way television technology permitted Dr. Rosser, Director of Endo-Laparoscopic Surgery at the Yale School of Medicine, to offer visual guidance to the operating physicians via the "telestrater" device. The patient was undergoing surgery to eliminate acid reflux which has slowly been destroying the esophagus. This results from a weak valve between the esophagus and the upper stomach, which allows digestive acids to enter the esophagus.

Medicines have not worked and if left unattended catastrophic complications could occur. Chronic exposure to the acids could damage esophageal cells, leading to haemorrhage or a pre-cancerous condition, that is called Barrett's metaplasia. Twenty-one million Americans suffer from GERD, as do tens of thousands of Dominicans. The surgical procedure performed to cure Ismael Arteaga is known as a Nissen fundoplication. Dr. Abel Gonzalez and Dr. Nick Gabriel, the surgeons in Santo Domingo, were assisted by advanced surgical machinery including a voice-activated robot controlling the ancillary surgical equipment and a second robot steering the internal laparoscopic camera. Dr. Gabriel, a fellow surgeon at Yale, had come to Santo Domingo to set up and monitor this innovative Hermes and Aesop equipment.

Aesop is a robotic-arm camera holder developed by Computer Motion for use in laparoscopic surgery. Since images from the tiny endoscopic camera are so magnified on the video monitor, each camera movement is exaggerated as well. The slightest tremor in a human hand holding the camera can cause blurring of the image the surgeon is relying on to operate, thus translating into pixilation when the image is transmitted by satellite. In a resource-poor area, trained human camera operators are not easy to find, but the compact Aesop unit only responds to voice commands. So does its partner Hermes, a voice-recognition computer system which can manage all the other devices a laparoscopic surgeon needs to control. By uttering such simple orders as, "Aesop: move right: stop" or "Hermes: light source: brighter", the surgeon can quickly adjust conditions without having to rely on other people.

The "Nissen" procedure forms a complex laparoscopic feat, which involves clearing a window around the lower esophagus, pulling a portion of the upper stomach through the opening, wrapping it around the esophagus, and suturing it into position. When it is performed successfully, the upper stomach will support the esophagus and acids will stay in the lower stomach where they belong. In a pre-operative consultation by videoconference, Dr. Rosser promised Mr. Arteaga that within three-to-seven days following the operation, his pain would be gone forever. "One of my primary goals in telementoring these operations is to enable people in developing countries to take advantage of developments in laparoscopic surgery as well as introduce surgical solutions which do not exist now", Dr. Rosser stated.

Dr. Rosser is one of the world's leading authorities in the field of minimally invasive surgery. As an Assistant Professor of Surgery at Yale University and as a former staff member of the Yale/NASA Commercial Space Center, he received his undergraduate degree and medical training from the University of Mississippi and completed his residency at Akron General Medical Center. Dr. Rosser is also a recognised leader in the field of telemedicine, the remote care for patients, and pioneered the technique of telementoring, the remote guidance of surgeons who have little or no experience, to perform advanced laparoscopic procedures successfully. For his fruitful efforts in this arena, he received Smithsonian Awards for Technical Achievement in Medicine in 1997 and 1998.

Leslie Versweyveld

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