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

BACKGROUND: 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 ongoing neurosurgical collaboration. Endoscopic third ventriculostomy with choroid plexus coagulation with 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 5 video clips revealed video delay of 237 milliseconds (range, 93-391 milliseconds) 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 submillimeter precision. Fifteen endoscopic third ventriculostomy with choroid plexus coagulation procedures have been performed with the use of VIPAR between Vietnam and the United States, with no significant complications. 80% of these patients remain shunt-free. CONCLUSION: Evolving technologies that allow longdistance, intraoperative 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 who use VIPAR for collaboration are underway.