Lights, lap-camera, tele-action!
September 8, 2008 by victor
Remote real-time intraoperative consultation utilizing consumer market technology with laparoscopic solutions
Neil S. Shah
June 19, 2008
Background and Significance
With rising healthcare complexity, costs and diminishing supply of resources available for high physician demand, there is an escalating need for leveraging assets across boundaries [Lai]. Most institutions do not possess the capital and assets necessary to provide authoritative specialist opinion locally on hand. Rather than being concentrated at a particular setting, expert resources need to be allocated across multiple locations and environments. With increasing specialization and mounting general surgeon shortage, there is rising fear that resource insufficiency will lead to diminished quality of patient care [Cofer].
Laparoscopic-assisted surgery provides a minimally invasive technique by which a wide range of operations spanning many subspecialties can be performed with camera guidance. It has many potential applications for traumatic as well as non-traumatic abdominal injuries. The advantages are numerous as laparoscopy allows for organ-specific diagnosis and treatment provision, thus avoiding unnecessary laparotomy, minimizing morbidity, shortening hospital stay, and hastening recovery for the patient [Gorecki, Schulam]. However, the learning curve for the technique is quite high because the two-dimensional working field requires some familiarization [Pokorny, Rosser]. Due to the cost and intricacy of operating the laparoscopic instruments and tower, training surgeons are finding it difficult to practice skills in a nonsurgical setting [Pokorny]. Although some hospitals now have laparoscopic simulators for trainees, most institutions do not due to the high costs. With the difficulty of training surgeons in laparoscopic procedures, the ability to inexpensively teleconference with an expert physician becomes highly valuable.
Telemedicine involves the transfer of medical information for the purpose of remote medical consultation, assessment or procedure. Telementoring entails not only healthcare delivery to a patient, but also educational guidance of a physician by a remote surgeon [Pande, Rosser]. Telesurgical consultation and telementoring provide means by which a patient can be treated at a distance by allowing an expert to educate, assist, and supervise the operating surgeon [Pande]. In many cases, telementoring is considered by primary surgeons to be a highly useful tool to have at hand [Sebajang]. Previous telesurgical mentoring studies have demonstrated viability of such an endeavor using high-cost professional teleconferencing tower cameras that can transmit live video to fixed, predetermined and specially equipped central consultation sites [Schulam, Rogers]. These cameras are often fixed and as such, may not even be able to provide a complete view of the patient. In addition, they are complex to implement and use, such that non-technical physicians would have a difficult time setting such a system up without outside help and an additional expense.
Currently, there has been much press about the “Remote Presence Robot” (InTouch Health®) and its ability to enhance telemedicine. The advantage of the robot over traditional stationary video conferencing equipment is mobility that fixed cameras cannot provide and ease of operation via remote joystick. In Michigan, on-call hospital specialists have used laptops and the Internet to connect to a robot stationed at the patient’s bedside and provide live consultation for emergent situations. They have also been used in hospitals to take the place of physician rounds. However, although the robot has mobility, it nevertheless requires constant monitoring and a real assistant in order to carry out most tasks such as note-taking. The RP-7® model Robot carries a high cost (~$150,000) for the simple telepresence it provides, with RP Connectivity Service ($10,000/mo.) from InTouch Health® required to constantly monitor it.
We will describe the development of an internet-based telemedical system that makes use of low-cost and practical alternatives while providing equivalent and improved services. Studies have already publicized that telemedicine endeavors are more successful when the user interface is simplified and easy to implement [Zahedi]. In addition, real time multimedia data transfer to handheld computers/PDAs via institutional wireless network has also been demonstrated [Gandsas, Georgiadis, Banitsas]. Laparoscopic-assisted cholecystectomy and other procedures have also been sent in real time to remote locations for surgical consultation over low cost, low bandwidth Internet connections [Broderick]. However, in each case the technology was not easy to implement, nor was it highly economical. With the intention of establishing a practical and cost-effective method of providing remote real-time intraoperative consultation, we propose to design, employ, and assess an easily adaptable telecommunications system for the purpose of mentoring clinicians while promoting patient safety.
We expect to be able to successfully integrate the teleconsultation system into a variety of settings and situations, and initiated by personnel with any type of technological background, substantiating the claims of convenience and ease of implementation. We hope to fulfill all proposed aims and expect the utilization of this new method of surgical healthcare strategy will result in enhanced patient safety and care.
- Design a teleconsultation system that can provide a consulting physician with a clear and accurate real-time video feed of the intraoperative situation using laparoscopic cameras
- Employ a teleconferencing system in order to assess ease of utilization in a multitude of settings and circumstances as well as for feasibility
- Assess outcomes on patient safety and standard of care by surveying physicians and consultants
- Design and implement a system that end users can easily acclimatize to with a short learning curve (the users should be comfortable with the system within 1 hour)
- Create an easy-to-use user’s instruction manual for implementation and execution of the system for anyone who will benefit from its application
- Design the system to minimize use of space, circuitry, and power by minimizing components to bare essentials
- Implement low-cost, commercially available hardware/software components to make the system cost-effective but also support the controlled, sterile environment of the OR
- Design a time-invariant system where the system software and components will maintain quality functionality for future use and new technological advances can be incorporated easily
- Complete a working prototype by June 25, 2008 and implement into local intra-hospital clinical setting shortly thereafter
- Once primary goals are met, expand to inter-hospital setting (for example, Henry Ford Detroit campus to Henry Ford West Bloomfield campus) to demonstrate ease of implementation in a variety of locations
- Survey physicians and consultants in order to assess patient care outcomes
Research Design and Methods
Specifically, we will assemble an initial prototypical scheme that will include 3 major components: visual input from the surgical site, a telecommunications link, and a visual output to the desired consulting physician.
Real-time video display is provided by the laparoscope camera input and sent to a DVI2USB Solo frame grabber (manufactured by Epiphan Systems Inc), which can capture single-link Digital Video Interface (DVI) video signals via a male-to-male DVI cable connected to the laparoscopic tower. A frame grabber obtains a large amount of visual data, converts it to RGB format at the highest color depth it can support, then compresses and optimizes the data for transmission. This particular frame grabber model was chosen for its ability to acquire video signals from DVI sources (in this case, the laparoscopic tower), and the Solo specifically because it can support the output of the video source.
The frame grabber dimensions are highly compact (5” x 3.2” x 1.2”) and itself is commercially available to any consumer at a price of approximately 700.00 USD. The Solo package comes with the DVI2USB solo box, DVI cable, USB cable, power adapter and easy-to-apply user’s installation guide:
DVI2USB Solo DVI Cable USB cable Power Adapter
The output from the frame grabber connects to any standard laptop with USB 2.0 standard port via USB mini type B cable, and is compatible with Windows 2000, Windows XP, Windows Vista (x86, amd64), Mac OS X, or Linux (x86, amd64) operating systems. DVI2USB solo transfers substantial amounts of data for each captured frame (30 frames per second at any resolution up to 1920x1200) and as such is not compatible with the slower USB 1.0 and 1.1 buses. The advantage of this is DVI2USB solo does not reduce the resolution of the images it captures in order to transfer it over USB.
Hardware system requirements for the video capture workstation for the DVI2USB solo are 2.66 GHz processor speed, USB 2.0 port, 256 MB DDR2 RAM memory, and 5 MB hard disk space. Software system requirements consist of installation of DVI2USB drivers and application, which can easily be accomplished by following the frame grabber install guide.
Installing the Windows DVI2USB drivers and application compatible with the Microsoft DirectShow application programming interface (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):
- You must install the DVI2USB drivers and application on the Windows video capture workstation before connecting the Frame Grabber to the workstation USB port.
- Download the latest software release to the video capture workstation. Browse to http://www.epiphan.com/products/product.php?ppid=61 and find the latest version of the VGA2USB drivers and application from the Windows section of the download page, noting the download destination folder.
- Unzip/Extract the downloaded file
- Run the Setup Utility (setup.exe) and follow the prompts
- Connect the DVI2USB Solo frame grabber device by following the steps in the connection section. If, after connecting the Frame Grabber, Windows displays the Found New Hardware Wizard, respond to the prompts before continuing with Step 6.
- Open the Windows Device Manager and confirm that Windows has detected the product. Refer to www.epiphan.com/products for any troubleshooting issues.
Installing the MAC OS X DVI2USB drivers and application compatible with the Apple QuickTime application programming interface (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):
- You must install the DVI2USB drivers and application on the MAC OS X video capture workstation before connecting the Frame Grabber to the workstation USB port.
- Download the latest software release to the video capture workstation. Browse to http://www.epiphan.com/products/product.php?ppid=61 and find the latest version of the VGA2USB drivers and application from the Macintosh section of the download page, noting the download destination folder.
- Untar the downloaded file (double-click the .tar file to unpack)
- Double-click the .pkg file and follow the prompts
- Connect the DVI2USB Solo frame grabber device by following the steps in the connection section.
- Open System Profiler and expand the USB Device Tree to confirm the device is recognized. Refer to www.epiphan.com/products for any troubleshooting issues.
Connecting a DVI2USB Solo Device (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):
- Make sure that the drivers and application is installed on the video capture workstation before proceeding with connecting the DVI2USB Solo Frame Grabber.
- Connect the power adapter to the DVI2USB Solo
- Use the DVI cable to connect the DVI signal output source to the DVI2USB Solo DVI port:
- Use the USB cable to connect the DVI2USB Solo to a USB 2.0 port on the video capture workstation
The captured data can be sent by the Epiphan USB device driver to the video capture application as well as to Microsoft DirectShow (on Windows) or Epiphan QuickTime component (on Mac OS X). The Epiphan video capture application receives and processes the data so that users can display, modify, and record images. In Windows, data can be sent to a video codec in order to save as Windows AVI files, and Mac OS X can record video using QuickTime software. This capability is highly valuable for the purpose of data storage and quality control.
The video capture workstation can then be used as a server to stream the video over the internet via consumer market software internet video conferencing software (ooVoo and Skype™) and can be accessed by the consulting physician, who is notified of the assistance needed by a telephone call from the operating room. The telephone line is used as the primary means of two-way communication from consulting physician to the intraoperative setting, while video display characteristics can only be visually delineated by the operating surgeon in a unidirectional manner. Both ooVoo and Skype™ have the ability to detect the DVI2USB Solo Driver and set it as the primary webcam for the software. For privacy issues, the software can be set up to only be accessible to users that are verified by the person transmitting the video feed.
After initial intra-hospital studies, the equipment can be expanded to the inter-hospital setting, with increasingly compact mobile devices such as personal digital assistants like Apple’s iPhone or the Sony PlayStation Portable. In order to judge the quality of consultation opportunity this system provides, the physicians can be surveyed for satisfaction and utility, comparing the use of video image to the previous methods of consultation.
Standard hospital laparoscopes offer the advantage of having in-house, sterile means by which a video image can be captured real-time without the additional expense of purchasing expensive camera equipment for operative situations. Laparoscopic equipment carries an expense, however most major institutions carry them for laparoscopic-assisted surgical procedures anyway, and rarely are all the laparoscopes carried by the hospital in simultaneous use.
This system will not require highly special electronic wiring or extensive cabling of the working areas, and will use free or low-cost, commercially available internet video conferencing software (ooVoo and Skype™) to connect to and collaborate with any consulting expert desired by the operating surgeon. Additionally, the organization of this system is highly adaptable to a diverse array of situations, with increased implementation convenience and portability over previous methods and practices. By streaming the video over internet via an “off the shelf” personal laptop, it has potential to be accessed by technology ranging from lecture hall projectors to desktop workstations to personal digital assistants and smart phones.
The advantages over the “Remote Presence Robot” (InTouch Health®) are numerous, as this system provides many equivalent services at a much lower cost and easier learning curve due to the “off the shelf” components. Currently, the remote presence robot cannot be connected to a laparoscope tower or ultrasound station, nor can it provide written notes. It is simply a telepresence.
This telemedical system also provides an efficient means by which satellite stations of the same hospital health system can intra-institutionally avoid unnecessary duplication of services and leverage subspecialty availability in a beneficial manner for both parties. An affordable and adaptable teleconsultation system incorporating laparoscopic visualization presents many benefits to physicians, and more importantly to the patient due to the accessibility of expert opinion by operating surgeons at any moment necessary. Consulting physicians and mentors are not burdened by the inconvenience of having to travel to confer with colleagues or teach.
A subject of significance is how to decide which situations this consultation system should be employed in. For easily diagnosed disorders, there is typically no need for a consultation. However, a complicated case would benefit from another physician’s opinions, and a video feed of the situation would greatly assist the remote consultation. In most instances, a wise physician gathers as much information as possible in order to make the best and most accurate diagnosis possible. A visual depiction of the patient as well as the treating physician offers additional indications and cues that one otherwise may never have realized. Another example of appropriate use of this system is during transfer of care of patients. In this situation, rather than simply having a telephone description of a patient’s circumstances, it would help to have a video image to aid the new physician in making a better association and providing more patient-centered care.
Shortcomings and Alternatives
Currently there is a one-second latency between real-time and transmission to the consulting physician, however we do not foresee any major difficulties caused by this issue. In addition, the image quality is compressed and reduced when transmitted over the internet, thus for diagnostic purposes it must be studied further to determine if it is sufficient to make an accurate consultation. Finally, with the current methods the surgeon in the operating room must reach the consulting physician via telephone and can point out particular aspects of the image one-way, but the consultant has no means to indicate characteristics visually for the operating surgeon.
This system can be used for many purposes in the future, including resident education by streaming live or stored feeds of surgeries to remote conference rooms, or teleconferencing with a translator for patients who speak a foreign language. The low cost of materials and easy-to-implement features allow for possible future deployment in underserved communities and developing countries [Pande, Zahedi]
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