On April 12 of this year, Paul Szotek, MD, FACS, director of the Indiana Hernia Center and clinical assistant professor of surgery at Marian University College of Osteopathic Medicine in Indianapolis, virtually transported his colleague Hugh McGregor, PhD, FRACS, almost 9,000 miles from North Brisbane, Australia, to Greencastle, Ind., during the first live virtual reality transcontinental hernia surgery.
For this case, Dr. Szotek performed a routine umbilical hernia repair. The idea was to test the feasibility of the surgeon point-of-view 360-degree immersive virtual reality technology compared with a conventional two-dimensional live streaming technology over the long distance, knowing that Dr. Szotek could easily and safely complete the case on his own if the technology failed.
Dr. Szotek aired the procedure using the XpertEye telementoring platform, from AMA XPERTEYE Inc., and a streaming platform from the tech startup Livit. During surgery, Dr. Szotek wore Google Glass—a lightweight pair of smartglasses with a built-in camera and monitor above the right eye that provided two-dimensional views—and used a 360fly virtual reality camera to contrast the experiences.
Paul Szotek, MD, wearing a 360fly virtual reality camera during surgery, allowing surgeons thousand of miles away to share the experience.
Dr. McGregor watched from his office in Brisbane with Google Cardboard and his Android phone, essentially allowing him to see through Dr. Szotek’s eyes as he worked. While Dr. Szotek performed the dissection and repaired the defect, Dr. McGregor could talk through the procedure with him, record and archive the video, take pictures and even make annotations on the XpertEye platform using the photoboard interface from Google Glass.
“That first case went really well,” said Dr. McGregor, a general surgeon in North Brisbane. “To think we could communicate at that speed over such a massive distance is incredible. The connection was generally very clear, with a lag of less than a second.”
Dr. Szotek believes that this type of technology will be a game changer in surgery.
“Virtual reality and live streaming will likely be the next step in surgical education, training and coaching, allowing surgeons to immerse themselves from afar,” Dr. Szotek said. “We’re probably about three to five years away from where we want to be, but the technology is still quite young.”
As recently as 2013, surgeons began piloting virtual reality and live streaming technologies in the medical setting. Selene Parekh, MD, an orthopedic surgeon at Duke Medical Center in Durham, N.C., has worn Google Glass during many operations, first using it to record and later for live-streaming procedures.
Other surgeons have used the smartglasses to facilitate their daily clinical activities. In a 2014 study, physicians at a New York children’s hospital wore Google Glass throughout the day for four weeks and found the technology useful for documenting photos and videos, as well as searching for billing codes and medical information (Int J Surg 2014;12:281-289).
Dr. Szotek discovered Google Glass in 2014 while updating his wife’s regular eyeglasses prescription. He immediately saw the potential to use the technology for surgical education and began testing it in the operating room (OR). Later that year, at the Americas Hernia Society conference in Las Vegas, he live-streamed an abdominal wall reconstruction to an audience of 600 surgeons (https://youtu.be/?84aXMYCzo1U). Throughout the operation, Brian Jacob, MD, from New York City, who collaborated from the conference, polled the audience on technique and management strategies, and relayed the feedback to Dr. Szotek.
Shirin Towfigh, MD, and her OR team using virtual reality technology to live-stream a hernia procedure.
The potential of this technology intrigued Dr. McGregor after he saw Dr. Szotek present on virtual reality technology at the 2015 World Conference on Abdominal Wall Hernia Surgery, in Milan.
“I have a busy practice and I frequently mentor surgeons in laparoscopic hernia repair, but the distances in Australia can be prohibitive,” said Dr. McGregor, who met and began working with Dr. Szotek.
And this past July, Shirin Towfigh, MD, FACS, head of the Beverly Hills Hernia Center in California, live-streamed a laparoscopic bilateral inguinal hernia repair on a female patient using the virtual reality 360fly camera to provide panoramic views of the OR (see story on page 26).
“The camera and virtual reality capability allowed viewers to see many details of the room—where the surgeon stands, where the trocars are placed, how the OR is arranged,” Dr. Towfigh said. “Although most attending surgeons are aware of this setup, most students and residents are not, and these details are important for the procedure to be safe and efficient. The virtual reality 360-[degree] view in the OR also allowed scrub tech and nursing students to navigate the OR from their point of view.”
Both Drs. Szotek and McGregor prefer the surgeon point of view for instruction and educational purposes. “It is interesting to see the entire room, though I need to see what the surgeon is seeing,” Dr. McGregor said.
Regardless of the vantage point, this type of technology can help bring surgeons back to the historical operating “theaters” on a grander scale, reaching thousands of viewers, instead of a few dozen. “As a surgical educator at heart, I can see how this kind of technology can help local, national and international students learn from an operation without having to physically be present,” Dr. Towfigh said.
The streaming platforms can extend to medical conferences as well. “How wonderful to be able to ‘attend’ a conference virtually, ask questions, interact with speakers, watch panel discussions and videos,” she said. “This platform would provide wider outreach for education and CME [continuing medical education] at potentially less cost to the physician.”
Despite growing excitement and physician engagement, virtual reality and live-streaming modalities are close but not quite ready for universal use in the clinical setting.
“The cameras, as with most digital imaging in focused light, aren’t completely there yet,” Dr. Szotek said. “The camera quality, dynamic range to prevent whiteout and zoom capabilities will need to improve. Given these barriers, I don’t know what the modality will ultimately look like, but I think the potential is there.”
Internet speed and battery life limitations also will place restrictions on the reliability of the technology. The 2014 pediatric hospital study found that short battery life, internet-related interruptions during video conferences and data protection remained concerns (Int J Surg 2014;12:281-289).
“At the moment, the bandwidth in Australia is holding us back and did cause some momentary connectivity issues during the live stream,” said Dr. McGregor, who noted that the problem should be resolved in Australia when the country installs fiber-optic technology.
“Privacy is a big issue in the United States,” Dr. McGregor said. “The rules are not as strict in Australia, but in the U.S., HIPAA provides many patient safeguards. You can’t just send a photo with clinical information on your phone.”
Other experts have debated whether these technologies may distract surgeons from their main objective—performing safe surgery. In one highly publicized live-streamed surgery, a patient died. During the laparoscopic liver resection, which was part of a live-streaming workshop held in Delhi, the lead surgeon visiting from Japan ran into a significant issue. The patient, a 62-year-old man with liver cancer as well as hepatitis and cirrhosis, began bleeding profusely. Eventually, after many hours, the surgeons switched to an open procedure, but it may have been too late. The patient died shortly after surgery.
Although questions remain about the ethics and circumstances of this incident, it seems that the surgeon was trying to push through the problem because it was a live case, Dr. McGregor said.
To safely telemonitor a difficult procedure, the technology has to be bulletproof.
“We would need to validate the technology first with an expert sitting in the OR, then right outside the room, then down the street, etc., before we can do so over long distances,” Dr. McGregor said. “Plus, we need to have strict ground rules in case something goes awry.”
Despite ongoing debates about the safety of live surgery, Dr. McGregor sees great potential for the future.
“My nirvana is that if I run into strife during surgery, I can call a subspecialist from anywhere who can connect to the OR through their phone and help me with the procedure,” he said. “Already what we have now is 1,000 times more advanced than what we had 10 years ago, so imagine what we will be able to do 10 years from now.”