Virtual Interactive Presence in Global Surgical Education: International Collaboration Through Augmented Reality

Abstract

Introduction The global shortage of neurosurgeons demands tools to geographically extend the reach of expert surgeons. Technology allowing a remote, experienced surgeon to provide real-time guidance to local surgeons has great potential for training and capacity building in medical centers worldwide. Virtual interactive presence and augmented reality (VIPAR), an iPad®-based tool, allows surgeons to provide long-distance virtual assistance wherever a wireless internet connection is available. Local and remote surgeons view a composite image of video feeds at each station, allowing for intraoperative telecollaboration in real time. Methods Local and remote stations were established in Ho Chi Minh City, Vietnam, and Birmingham, Alabama, as part of an ongoing neurosurgical collaboration. An endoscopic third ventriculostomy with choroid plexus coagulation (ETV/CPC) utilizing VIPAR was used for subjective and objective evaluation of system performance. Results VIPAR allowed both surgeons to engage in complex visual and verbal communication during the procedure. Analysis of five video clips revealed video delay of 237msec (range: 93–391msec) relative to the audio signal. Excellent image resolution allowed the remote neurosurgeon to visualize all critical anatomy. The remote neurosurgeon could gesture to structures with no detectable difference in accuracy between stations, allowing for sub-millimeter precision. Both local and remote neurosurgeons felt the system improved procedural safety and efficacy. Conclusion Evolving technologies allowing long-distance, intra-operative guidance and knowledge transfer hold great potential for highly efficient international neurosurgical education. VIPAR is one example of an inexpensive, scalable platform for increasing global neurosurgical capacity. Efforts to create a network of Vietnamese neurosurgeons using VIPAR for collaboration are underway.

Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service

“…We have demonstrated the successful use of Virtual Interactive Presence and Augmented Reality (VIPAR), an iPad-based, interactive 2-way video tool, in long-distance intraoperative guidance and telecollaboration. 10,11 There are significant legal hurdles in implementation and use of certain telemedical tools, including patient privacy, assurance of quality, and distribution of liability. 12–16 Hall and McGraw argue that these issues can be addressed with the development of a comprehensive regulatory framework for telemedicine overseen and enforced by the Federal Trade Commission.…”

Disseminating technology in global surgery

“…Augmented reality has also been explored, allowing surgical trainers to scrub in with an operating LMIC team to teach and deliver surgical care. These technologies have been evaluated in a variety of global surgical training scenarios. Their wider use will be determined by infrastructure challenges, such as power supply and internet access, as well as a better understanding of how they might be incorporated into traditional training.…”

State of global pediatric neurosurgery outreach: survey by the International Education Subcommittee

“…32 Novel telecollaboration and internet-based tools have also demonstrated potential for continuing education following return of the visiting surgical team. 4,7 As an example, HELPLightning, a tablet-based tool for mobile merged reality and virtual interaction, is currently being implemented by CURE International for mentoring of ETV-CPC (https://www.helplightning.com). Such evolving technologies hold great potential for ongoing training, assessing surgical competence, and enhancing relationships among geographically isolated neurosurgeon.…”

“…In addition, short term trips in conjunction with visiting observerships and remote telecollaboration have also proved successful for sustained partnerships and capacity building. 7 Results of this survey suggest that development of an accessible, comprehensive and updated online community of existing and potential collaborations would be valuable for surgeons seeking to initiate new relationships and find creative solutions to providing care in low-resource settings.…”