Ronald C. Merrell, Virginia Commonwealth University
Asif Zafar, Holy Family Hospital, Rawalpindi
Pakistani Funding (Department of State): $204,000
US Funding (Department of State): $93,150
Project Dates on US Side: February 1, 2011 - January 31, 2013 (completed)
This team has worked together successfully on two previous projects related to telemedicine and surgical training, and this new grant will allow them to continue and expand their partnership. In their project in Phase 2 of the program, they developed and presented training to 50 Pakistani surgeons in laparoscopic or minimally invasive surgery (MIS) using training simulators. By using simulators, trainees can acquire the skills needed to perform complex procedures prior to practicing them on live patients, but until recently MIS training facilities were unavailable in most Pakistani teaching hospitals. In this new project they will enhance the facilities at the virtual training laboratory at Holy Family Hospital (HFH) by adding simulator modules for gynecological procedures to the existing modules used for gall bladder surgery training. They will also develop telementoring capabilities so that US specialists can provide training and guidance remotely using videoconference technology. In response to high demand for training in this area, they will also stage hands-on MIS training courses for 100 more surgeons from throughout Pakistan during the course of this two-year effort. The project should not only improve the training capabilities at HFH but also enhance the ability of Pakistani doctors to provide the latest standard of care for their patients.
Minimal access Surgery (MAS), which is gradually replacing traditional open surgery in most parts of the world, is still at the infancy stage in Pakistan. In majority of the medical teaching institutes, it has not been introduced in surgical practice while laparoscopic cholecystectomy is the only procedure performed by limited senior faculty of those institutions. There are concerns regarding patient safety, cost of operation theaters and time to teach these skills in operation theaters. Hence trainees have almost negligible exposure to this advanced technique during their complete surgical specialization training.
The Virtual Trainer Lab (VTL) was established at Holy Family Hospital (HFH), Rawalpindi Medical College in 2007 under phase 2 of Pakistan-US Science and Technology Cooperation Program in collaboration with Virginia Commonwealth University (VCU). It had focus to teach MAS Skills to surgeons outside the operation theaters. The VTL was equipped with advanced training tools such as Virtual Reality simulators and full procedural simulators that enabled surgeons to practice these skills in a simulated environment and not on actual patients. More than 50 surgical faculty members from Rawalpindi and Islamabad hospitals completed their training at the lab during 2008-09. This project was presented at various national medical and surgical organizations such as the Pakistan Medical Association, Society of Surgeons Pakistan, Society of Laparoscopic and Endoscopic Surgeons Pakistan, and College of Physicians and Surgeons Pakistan where the concept and progress of the VTL training center was greatly appreciated. As a result, there was a great demand from these professional organizations and individual institutions that their faculty members and post graduate trainees be trained in MAS. As a follow-up to the previous phase 2 project, this project (phase 4) was initiated to train faculty members and post graduate trainees in MAS skills from hospitals throughout Pakistan. HFH continued the original collaboration with Virginia Commonwealth University (VCU). During the initial phase the facilities of the VTL were upgraded with additional simulation tools while in the operation theaters advanced laparoscopic surgery equipment was procured. Curriculum for MAS training workshops was jointly developed by both collaborating institutions. Training manuals were finalized jointly along with relevant training content for conducting national workshops.
Subsequently 15 MAS workshops were conducted to impart laparoscopic skills to residents and qualified surgeons and gynecologists at national level. Eight National MAS workshops were conducted for qualified Surgeons and allied specialists while seven Resident MAS workshops were conducted. A total of eighty eight surgeons and gynecologists and 72 residents were trained during the two year project. Trainees were selected from all regions of the country from Karachi to Gilgit. These training workshops were based on 3 modules. The first module included an introduction to basics of MAS and lectures from local faculty, master trainers and faculty from USA. Module 2 included hands on training in the VTL using MAS training tools such as Box Trainers, Virtual Reality Simulators, and Full Procedural Simulators. Third module was demonstration of live surgical procedures from the OR and hands on training in the operation theaters using tele-mentoring and tele-presence surgery. This was followed by evaluation and certification of each trainee. This training program is unique in a sense that it is a hybrid model where participants spent time not only in the virtual training lab but also practical demonstration in the operation theater. Moreover two advanced workshops were also conducted on laparoscopic approach to hernias and upper GI pathologies.
Research was a regular feature during the project. Faculty members, medical students and residents were actively involved in the research. These research topics were not only presented locally at national level but were also presented in the annual meetings of the American Telemedicine Association (ATA), Society of American Gastroenterology and Endoscopic Surgeons (SAGES), and the American College of Surgeons (ACS). Moreover regular exchange visits were conducted between faculty of US and Pakistani institution to enhance the technical skills related to the subject.
This project has overall improved the capacity and quality of medical research and also increased the capacity of Pakistani institutions to contribute to the medical well-being of ordinary Pakistani people by increasing the number of trained medical professionals in MAS skills.
Resident trainees at the MIS workshop in January 2013.
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2011 Show summary || Hide summary || Download full report
2012 Show summary || Hide summary || Download full report
The spring of 2012 was a very busy season for the participants in this project, beginning with another successful minimally invasive surgery workshop April 23-26, which provided training to 11 physicians in several gynecological, urological, and general abdominal surgical procedures. Following the workshop Dr. Asif Zafar and Dr. Faisal Murad traveled to San Jose, CA to participate in the 17th Annual International Meeting and Exposition of the American Telemedicine Association April 28 through May 1, 2012. After the conference, Dr. Murad returned to the Mayo Clinic for a second round of training in colorectal surgical techniques, following up on his previous training visit in 2011. Meanwhile, back at HFH, other faculty members conducted a one-day MIS workshop on May 3 (48 participants), and Dr. Zafar later led a two-day training workshop on advanced laparoscopic upper gastrointestinal and hernia procedures May 25-26 (28 participants). The next in their series of MIS residents' workshops was held at HFH for 10 trainees June 11-14. Two other activities in June were especially focused on outreach to medical institutions and patients in other Pakistani cities, including (1) an HFH team visit to Muzaffarabad Hospital to provide information about the potential role of telemedicine in treating blood disorders among patients in isolated areas and (2) a two-day training workshop on thyroid surgery procedures that was presented to students in Karachi via videoconferencing. The final major activity in June was a one-day EXYLENT workshop for young engineering students from the National University of Sciences and Technology aimed at introducing them to engineering applications in the medical field, including biosensors, virtual simulators, and customizable robotic surgical devices. The students, along with a several younger children who attended, were enthusiastic about the opportunity to learn more about ways they might apply their skills in the future, and they particularly enjoyed trying out the surgical simulators for themselves (see photo above).
Dr. Zafar and his team are planning additional national MIS workshops in August, September, and November 2012, as well as MIS residents' workshops in September, October, and November. Dr. Qasim Ali is scheduled to take part in the second phase of his training at the Mayo Clinic in September, and he and Dr. Zafar will also attend the 98th American College of Surgeons meeting in Chicago beginning September 30. Dr. Ronald Merrell and his colleague Dr. Azhar Rafiq are also expected to visit Pakistan to take part of one of the planned training workshops in late 2012.
Practice session on the Promis simulator (Photo courtesy of Dr. Zafar)
Hands on session in the operating theater, with Dr. Asif Zafar supervising Dr. Qasim on a laparoscopic cholecystectomy (Photo courtesy of Dr. Zafar)
2013 Show summary || Hide summary || Download full report
In January 2013, the team organized the 7th Resident Minimal Invasive Surgery Workshop at virtual training lab at the Holy Family Hospital. A total of 12 faculty (6 female participants) attended the 3 day workshop. Trainings and lab sessions on various aspects of MIS were delivered at the conference. The number of the Resident trainees who participated in the workshop reached to 84 (72 attendees at the previous workshop). In March, the project team presented the research papers at the International Surgical Conference 2013 (Lahore Chapter). Five papers related to this project were presented at the conference. The project is expected to be completed by the end of May this year. The last National MIS national workshop will be organized in April, 2013. Pakistani faculty Dr. Qasim Ali will attend and present papers about this project at Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting in Baltimore in April, and Drs. Asif Zafar, Tariq Nawaz and Faisal Murad will attend and present papers at American Telemedicine Association (ATA) meeting in Austin, TX in May. The team will then prepare the final report in by the end of May 2013.