Remote mentoring during COVID-19: The virtual hernia course that made pigs fly

The training of surgeons has ground to a halt in many parts of the world as operating rooms normally reserved for education have been reassigned for COVID-19 patients and critical surgeries. Other educational venues, such as national meetings and courses, have been cancelled or transitioned to virtual platforms. To negotiate the lack of access to both operating rooms and travel, a pioneering new educational programme from The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), that harnessed the power of Proximie, enabled anatomically realistic porcine tissue models to be shipped directly to the homes of surgeons, where they could continue their procedural education at home.

The restrictions put in place in the wake of Covid-19 have threatened to bring medical mentoring and training to a standstill; fortunately, Proximie was able to ensure that distance was no obstacle in providing expert surgical guidance at a time when access to operating theatres and travel are severely restricted.

Pedro P. Gomez, MD, FACS, had planned to be taking part in a lab-based training at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons — a session that had been due to take place in Cleveland, almost 700 miles away from his home in Bangor, Maine. It was to mark the start of a hands-on training course called ADOPT, after which mentorship would continue throughout the year.

The pandemic forced SAGES’ annual meeting online, thereby making the prospect of face-to-face training and mentoring impossible. However, the course chair, Sharon Bachman, MD, was confident that the training could be carried out virtually — with the aid of augmented reality technology.

“We knew we needed a technical platform that could accommodate live mentoring and a model adapted to mimic a human abdominal wall that could be sent to participants,” Dr. Bachman told General Surgery News, “One fascinating thing about COVID-19 has been the rapid development of innovative technology.”

To enable Dr Gomez and the other participants to virtually scrub-in, SAGES partnered with Proximie in order to make use of the remote surgery platform, and with Kindheart— a company that produces porcine models designed to emulate human tissue.

“SAGES use of Proximie’s tools and Kindheart’s models is improving patients’ outcomes by allowing surgeons to share the world’s best clinical practices at a time when the pandemic has severely restricted the normal teaching process in which a group of surgeons would meet and train in person,” Dr. Sharon, who was the Chair of the SAGES Hernia Hands-On Course, explained before the event. “Now, surgeons can immerse themselves in this virtual technical masterclass from the safety of their own homes.”

In this instance, a pig abdomen would be standing in for a human abdominal wall, to facilitate a review of a complex abdominal wall hernia repair. Proximie, meanwhile, created a course-specific webpage hosting videos and talks to prepare participants in advance of the procedure.

In the days prior to the training session, Dr Gomez received the porcine abdominal model packed in dry ice and, separately, a collapsible box to house the model and tubing to mount the retractors. SAGES also sent a webcam and an arm on which to mount it, in order that Dr Gomez could use Proximie to livestream video of himself carrying out the procedure so that proctors could observe, interact with and provide guidance on his performance.

On Friday October 23rd of last year, Dr Gomez set up an ad hoc operating room in the screened porch of his Maine home, with the webcam pointing at the model abdomen on his table table. As he set about carrying out the operation, SAGES’ course co-chairs Dr Bachman and Jacob Greenberg, MD, were watching over the livestream, preparing to provide guidance on the mesh fixation techniques that Dr Gomez had stated he wanted to focus on.

“I wanted some pointers on how to release the TAR plane to fixate the mesh and avoid wrinkles,” Dr. Gomez said. “My proctor guided me through, telling me to pull the retrorectus plane with my left hand using Allis clamps while dissecting a plane just underneath the xiphoid with the Bovie, reaching this beautiful plane where the mesh can lie flat.”

The proctors could see a real-time close-up of Dr Gomez’s pig model, providing them with all the necessary information to guide Dr Gomez through each step of the procedure.The proctors were also able to use Proximie’s augmented reality tools to enhance their guidance.

“Because I can’t put my hands in the pig and demonstrate what to do next, I had to ask the surgeon to stop, tell me what they’re seeing and thinking, what they want to do next,” said Dr Greenberg. “I’d draw on my screen, which would appear on their screen, to show them what I would do and where I would be. This approach forced both of us to slow down and share our thinking.”

Using Proximie, SAGES was able to remotely connect each of their members to the expert faculty and take each attendee through virtual patient simulations that modelled the fundamental knowledge, decision-making, and comprehensive management strategies that need to be utilised in caring for patients with hernias.

Out of the 10 participants who had previously taken part in a hands-on training course in person, 70% said that the remote course enabled by Proximie was preferable or similar to an in-person course.

“Even though the proctor wasn’t physically by my side, it still felt like they were sitting next to me, like a co-pilot advising me on where to go next,” said Dr Gomez.

The following week, the advice Dr Gomez had received was put into practice when he carried out a procedure in his small community-based practice.

Dr. Gomez has subsequently described the tips he received during the virtual training as having been potentially “lifesaving” for his real-world patient.

The above quotes from Dr. Gomez were taken from an article published in General Surgery News.

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