Real-time Internet connections: Implications for surgical decision making in laparoscopy

Objective To determine whether a low-bandwidth Internet connection can provide adequa te image quality to support remote realtime surgical consultation, Summary Background Data Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the op erating room has been an isolated environment that has been relatively inac cessible for real-time consultation, Recent technological advances have per mitted videoconferencing over low-bandwidth, inexpensive Internet connectio ns. If these connections are shown to provide adequate video quality for su rgical applications, low-bandwidth telemedicine will open the operating roo m environment to remote real-time surgical consultation. Methods Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Domini can Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support realtime consultatio n as well as the transmission of real-time images and store-and-forward ima ges for observation by the consultant panel. A total of six live consultati ons were analyzed. In addition, paired local and remote images were "grabbe d" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to eva luate the effect of transmission on image quality. Results The authors showed for the first time the ability to identify critical anat omic structures in laparoscopy over a low-bandwidth connection via the Inte rnet. The consultant panel of surgeons correctly remotely identified biliar y and arterial anatomy during six laparoscopic cholecystectomies. Within th e Web-based questionnaire, 15 surgeons could not blindly distinguish the qu ality of local and remote laparoscopic images. Conclusions Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and a lmost ubiquitous, Use of these inexpensive, portable technologies will allo w sharing of surgical procedures and decisions regardless of location. Inte rnet telemedicine consistently supported real-time intraoperative consultat ion in laparoscopic surgery. The implications are broad with respect to qua lity improvement and diffusion of knowledge as well as for basic consultati on.