EDITORS CHOICE 22.01.16

3D adds extra dimensions in telemedicine

3D operation

Professor Wilko Grolman from the University Medical Center Utrecht has long been at the forefront of high-resolution telemedicine, and his latest project, using 3D, is no different. Paul Milligan reports.

I’ve always had a big interest in technology, people used to joke that anything with a plug would draw my attention,” laughs Professor Wilko Grolman. 

Based  in  the Netherlands, Grolman is the head of the department of Otorhinolaryngology and Head and Neck surgery at the University Medical Center Utrecht (UMC Utrecht). He has dedicated his  professional  career  to  patient  care,  surgery, research, and training. Nothing new there in the world of medicine you might say, but Grolman is also at the forefront of using high resolution video to help him (and others around the world) learn ever more about the world of  ENT (ear, nose and throat) surgery.

Grolman was one of the first in the Netherlands to adopt 4K, when he was involved in a project transmitting 4K video from the UMC to another university four years ago. Using broadband internet and 4K monitors that cost €20,000 each, it was a very different 4K environment to the one we inhabit now.

Grolman has long been an exponent of video conferencing,  “To become a great surgeon, you have to watch the same operation being performed many times, preferably by different surgeons.  Two surgeries are rarely identical.”

Grolman takes his teaching responsibilities very seriously, as he is in charge of 18 ENT residents at the UMC, as well as an additional 14 interns who pass through his department every two weeks. To help assist the education programme, the UMC links with a hospital in France, the  Causse Ear Clinic,  every  Tuesday where a specialist in one field of ENT surgery leads an interactive session, where  students  can  ask  questions  via  video conferencing. Every Thursday the UMC also links with a hospital in the UK , Wexham Park Hospital, to teach another specialism of ENT surgery.

To help create a network of knowledge sharing, Grolman was involved in setting up LION (Live Interactive Otolaryngology Network) in 2006. LION is a group of ear surgeons based around the world (its members range from Sao Paulo to Sydney), whose aims are to learn from each other and provide a continuous educational network, in which members can provide consultation to others  when  needed.  Nearly ten years on from its inception LION hosts multiple live ear-surgery events every year, using video conferencing. The transmissions are publicly available and aimed at Otolaryngology residents and specialists.

In  its  early  days  it  was  all  done  over  ISDN, which although significantly faster than regular broadband services at the time, had huge associated running  costs.  “It  was  a  hassle to get four ISDN lines in one OR. The phone bill was huge from just a one-day event.” Now the internet is far more stable and reliable around the globe, costs have shrunk dramatically, making it far more widely available. “Since we moved to IP we can now transmit in 1080p in 30Hz or 60Hz. We  transmit  in two different qualities,  so  even mobile devices can watch live surgeries.”  The UMC now has the ability to stream via 4G as well.

Professor Grolman is constantly searching for ways to improve his surgeries and his teaching. His next big challenge was to be able to broadcast in stereoscopic 3D, as he knew it would make a significant difference.

“I was already intrigued by 3D, when I look at surgeries though an endoscope or a microscope I see depth, proportion and dimensions,which you don’t see when you use a video camera, and that is the added value of stereoscopic images. Surgery  is  all  about  what  you  feel  with  your hands, but also what you see with your eyes; the colour of things, the dimensions, Is it big? Is it small? Is it deep? Is it shallow? These dimensions are  added  when  you  add  stereoscopic to the images you see. Try  driving  with  one eye  closed,  it’s much harder  to  estimate the speed you are driving and the distance of people to you. I wouldn’t recommend  it  but  it  does  give  you  an  idea  of how  important  dimensions  and  speed  are.  It’s the  same  for  surgery.  3D  doesn’t  necessarily give  you  more  detail,  what  it  does  do  is  give you more information about the dimensions and orientation and size and location.”

Grolman  began  planning  a  3D  broadcast  in the Spring of 2015, and was able to fully realise his dream in late October using a Polycom RealPresence  video  conferencing  system  with a 3D lab kit. The surgery, which was a stapedotomy, was performed by the Professor on two patients suffering  from  otosclerosis, (a  bone growth in the ear that causes hearing loss). Grolman used a Zeiss Trenion HD 3D operating microscope to perform the surgery. For the first time, residents learnt how to perform the surgery by receiving the identical stereoscopic 3D view as the surgeon.

This  system also makes it easier for a resident to perform the surgery under supervision, as the supervisor is able to guide him/her while looking at a 3D screen in the OR with a reliable representation of what the resident sees through the microscope.

In combination with a regular 3D display, any viewer  is able  to  have  the same orientation as the surgeon. Being such an enthusiast of live streaming,  and  through  his  work  with  LION, much  of  the  infrastructure  at  the  UMC  was already in place, including the vital element of a 3D stereoscopic microscope. The final piece was waiting on a video conferencing manufacturer to offer a 3D system to meet his needs.

Now  it’s  all  in  place,  has  Grolman  seen any  resistance  to  the  technology within the surgical community? “No,not at all. What makes this different than most is that we are able to combine  the  IP  and  the  codec  and  MCUs  and bandwidth  technology  with  the  desires  of  the surgeon.”  The 3D broadcasts have proved so effective  it’s  now  being  used  for  most  live transmissions.

So what’s next for the professor? He  is  hoping  to  get  3D  surgical  procedures posted on YouTube to extend its global range, and sees a lot of potential for the footage to be shown on VR headsets such as Zeiss VR One or the Oculus Rift.