1. Viewing real surgery remotely in stereo
Stanford OR to
Sydney, Australia
We were approached by our collaborators in Sydney, CSIRO, a major R&D think-tank to put together a teaching event that would demonstrate the value of stereo video!
This was a team effort. Extensive background work between the Canberra team and our colleagues at Stanford got the basic software and logistics in place.
The surgeons (Pat Cregan in Sydney, LeRoy Heinrichs and Camran Nezhat in Stanford) developed the teaching material and organised hospital, patient and audience. Our Sydney colleagues played a major role in setting up and fine-tuning the system in liaising with AARNet to switch to serious bandwidth across the Pacific.
Dr Nezhat and his surgical team performed the operation.
I’m going to show talk about this teaching event first as a technical “proof of concept”: Explain the technical environment and then look at how it could be used to radically shift the way med students, fellows, are taught. So just to put the educational focus in perspective….

2. Stanford Operating Room as seen from Sydney
In the OR, Dr. Nezhat, a teaching Ob-Gyn surgeon with 3 fellows used a Viking endoscope with a stereo camera. He’s wearing headset so that he can view the stereo image. The others in the OR see mono.
Sydney surgeons enjoyed a two hour window into the operating room at Stanford University Hospital from the comfort of the Director’s Meeting Room at CSIRO. They discussed the operation beforehand with the surgeon, went with him into the Operating Room to be briefed on the placement of surgical instruments then followed him in glorious 3D into the patient as he gave running commentary on the steps of the surgery.
The 3D display was the centrepiece of the event in Sydney. The larger-than-life display showed the abdominal organs in stunning clarity as the surgeon inspected them for disease. At one point he needed to remove the appendix, and after explaining that there were several different techniques for doing this he asked the audience which technique they would like to see applied! The display technology used two powerful data projectors projecting through polarised glass filters onto a specially surfaced screen (to preserve polarisation of the reflected light). The audience wore simple plastic polarised glasses.

3. Requirements for Stereo Video Transfer
Our set-up in the OR
We ran four full channels of DV-quality video between Stanford and CSIRO. Two channels formed a connection between the conference room and the OR. The other two channels, running over software developed by the CSIRO team, carried the 3D stereo view from the surgical laparoscope inside the patient. The surgery used a recently developed 3D stereo surgical laparoscopic system developed by Viking.
The display technology used two powerful data projectors projecting through polarised glass filters onto a specially surfaced screen (to preserve polarisation of the reflected light). The audience wore simple plastic polarised glasses. .
Show the traffic results from the Seattle POP during the demo.
Traffic graphs from AARNet, based on router logs at the Seattle POP.

4. Did the technology support the teaching & learning?
If a minutes session (remote live surgery event) were readily available to you at your hospital (e.g. once a month) on a topic in your surgical area of interest, how likely would you be to watch it?
How was it received by the participants?They were residents from the teaching hospital who drove cross-town to see the demo first thing in the AM.
A few technical glitches that I will share since this is an audience that probably cares…
Use the same equipment with the same software with the same versions! After the event we did some troubleshooting to find out why the stereo video images flickered. The two computers with the stereo video codec did not have the same operating system or the same version of the software. As a result the frame rate was reduced.
Ø Use the backchannel when you need to communicate during the event. Although we had set up a backchannel, we did not use it. After the event we discovered that Dr. Nezhatﾕs voice was too loud and Dr. Heinrichﾕs voice was too low. The CSIRO team had tried to signal us by writing it on a piece of paper but we were too preoccupied with other logistics to notice it.
Ø Have a person who can monitor the audio during the event.
Ø Be prepared with extra background material because surgery timing canﾕt be controlled. Dr. Heinrichﾕs had expected to do an anatomy lesson with the residents but when the case turned out to be merely an appendectomy, he dropped that part of the plan. In addition, Dr. Nezhat and Dr. Heinrichs gave an impromptu lecture about the merits of surgical simulation because the surgery was delayed. The previous case was delayed. It would always be preferable to do live surgery with the first case of the day so that the timing can be more predictable. Of course, with Australia, that would not be appropriate because of the time differences.
Definitely Not Not Very Definitely
would not Likely Sure Likely Would

5. Designing environments that optimize learning
New framework emerged from over 30 years of research: cognitive sciences that helps guide the design & evaluation of environments that can optimize learning.
Shift in medical education -- Teaching surgeon must be able to use the tools, the data collected, and talk the learners through the his/her decision-making process, direct a team and model and perform safely. Much more than just a rote procedure.
OR is perfect environment:
The Challenge: Present the case, what you know about the patient;
Have the students write their opinions, thoughts about the case, what they would do to prepare…
Bring in the multi-cultural aspect: what other factors might be relevant? Would you ask different questions?
Perspectives & Resources:
Review the anatomy.
View the video/stop the camera.
Can go back &forth
Can go back and forth between stereo anatomy images & the video.
“Contrasting cases”
Make a prediction about what can be done.