The advantage that TELEMEDICINE grants is an excellent complement for our mobile surgery program, as this technology is applied to an efficient, well-designed and established surgical relief mission rather than developing a exclusive program to be compatible with the technological application.

Since 1997 we have conducted several telemedicine projects, initially with the support and collaboration of the Department of Surgery of Yale University, New Haven, Connecticut; and now with MITAC (Medical Informatics and Technology applications Consortium), Department of Surgery, Virginia Commonwealth University, Richmond, Virginia.

We have conducted several telemedicine projects at the different stages of our surgical relief missions, such as, in the pre-operative evaluation and patient selection, during the beginning of anesthesia and in the course of surgical procedures, for medical education, and as an instrument for follow-up at some stage in the postoperative course.

Figure 6. Base Telemedicine Station in the CINTERANDES Foundation Headquarters in Cuenca, Ecuador, in use for the Mobile Surgical Program.

Appling telemedicine in the pre-operative consultation has made us more effective in organizing the operating schedule, patient selection and foreseeing medical supplies. It has also enable us to save precious time during our remote visits, which in turn translates into more operating room time. Overall, the surgical team feels much more comfortable being acquainted with the patients and their specific needs in advance. We are also conducting a validation study to determine patient and physician satisfaction with the use of this technology.

During the intra-operative period we have also conducted several projects listed below:

1) Teleanesthesia: We have reported the use of telecommunications to monitor anesthetic events from a remote location, including the intubation phase, as well as vital signs monitoring while the patient is under the effects of anesthesia.

2) Telementoring: In May, 1998, we successfully conducted the first international telementoring session from Yale University in New Haven, Connecticut to Sucua, in the jungle in Ecuador, where a surgical resident safely complete a laparoscopic cholecystectomy under the tutelage of a laparoscopic surgeon. Although the operating team, being mentored, always had the capability to solve the problem by its own means.

3) Telepresence: We have validated real time agreement with the consultants at a remote location regarding identification of anatomical landmarks and surgical decisions at critical steps of surgical procedures.

4) Teleconsultation: We have obtained highly specialized consultants from abroad via telemedicine in unusual situations that required a specific level of expertise, such as pediatric urological surgical pathology.

5) Medical Education: Due to the limited space in our mobile operating room demonstrating anatomical structures and surgical procedures to students seating comfortably in front of a video screen, has been more effective than looking over the surgeon's shoulder, trying to obtain a close view while at the same time maintaining enough distance to avoid contaminating the operating field and/or members of the operating team.

Finally, in the post-operative period our surgeons have been able to conduct follow-ups of their patients at a distance, assessing the surgical wounds for signs of potential complications. Therefore, telemedicine allows us to maintain contact with our patients for close surveillance until their complete recovery, overcoming one of the main constraints of itinerant mobile surgery. This has also been validated by a study showing 97% agreement between the surgeon in a remote location and a physician on site.

Several presentations and publications have emerged from all of our projects and are listed in the reference section.

With the above experience we have concluded that TELEMEDICINE may reduce time required for preoperative planning on site, and may provide reliable postoperative surveillance, thus improving the efficiency of mobile surgery. It is also an invaluable aid in areas of our country, and perhaps remote areas around the globe where patients have limited access to an experienced surgical team.