title: Real-time Internet connections: implications for surgical decision making in laparoscopy.
abstract: OBJECTIVE
  To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation.
  
  
  BACKGROUND
  Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation.
  
  
  METHODS
  Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican 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 real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality.
  
  
  RESULTS
  The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images.
  
  
  CONCLUSIONS
  Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.
authors.affiliation: Department of Surgery, Medical College of Virginia Campus at Virginia Commonwealth University, Richmond, Virginia 23298-0519, USA. tjbroder@hsc.vcu.edu
authors.forename: T J
authors.initials: TJ
authors.lastname: Broderick
authors.forename: B M
authors.initials: BM
authors.lastname: Harnett
authors.forename: C R
authors.initials: CR
authors.lastname: Doarn
authors.forename: E B
authors.initials: EB
authors.lastname: Rodas
authors.forename: R C
authors.initials: RC
authors.lastname: Merrell
mesh_terms: D017081:Cholecystectomy, Laparoscopic; D003199:Computer Systems; D003658:Decision Making, Computer-Assisted; D004293:Dominican Republic; D004484:Ecuador; D006801:Humans; D020407:Internet; D009870:Operating Room Information Systems; D019114:Remote Consultation / Q000295:instrumentation*; D014768:Virginia