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E-education and e-training in minimally invasive surgery

Didier Mutter
Professor of Surgery
E: [email protected]

Jacques Marescaux
WeBSurg Editor-in-Chief
E: [email protected]

Thomas Parent
WeBSurg Chief Technical Officer
E: [email protected]

Guy Temporal
Webmaster and Project Coordinator
E: [email protected]

The internet has become an important way of delivering educational services in the field of minimal access surgery. This article presents a web-based university dedicated to
surgical education and training that provides an interactive, self-paced learning environment for physicians and healthcare professionals.

In recent years, surgical training and education have switched from paper textbooks to web-based tools and multimedia video-conferencing. Although clinical experience is key to surgical education, the evolution of the medical education system, the reduction in working hours and the higher level of technical and scientific knowledge require new ways of teaching. Additionally, the acquisition of scientific knowledge and skills must be achieved within a precise time interval in the teaching hospital setting. In this context, the internet represents an ideal way to fulfil educational needs. The community of healthcare professionals, physicians and surgeons may find extensive theoretical and practical information that may be used in order to acquire, test, and validate new operative skills from any geographical location in the world.

Surgeons spend a significant amount of time in educational activities and online educational activities are increasingly gaining acceptance. A case in point is the survey by Gandsas et al which demonstrated that 78 members of the Society of Gastrointestinal Endoscopic Surgery (SAGES) expanded their knowledge of surgery by using the internet; 74% learnt about new technologies relating to the practice of surgery; and 68% located resources for academic purposes.(1) Other studies demonstrate the interest of internet accessible computer-aided learning programmes that are widely used out of the academic institution.(2) The internet-based educational tools are currently well accepted for theoretical training. There is still an ongoing debate about whether or not training in minimally invasive surgery (MIS) could be conducted outside of the operating room (OR). Today, it is widely accepted that technical skills should be partially taught outside the OR since all basic surgical skills can be practised on inanimate, computer-based or animate
models. It has, therefore, become evident that conventional surgical methods may not be appropriate for minimal access surgery. The learning curve in basic MIS training requires
hours of video tape viewing and repeated practice, especially in the field of suturing using all available simulators. As demonstrated by Rogers, a surgical procedure is not merely an add-on of basic surgical skills but a thorough surgical act that involves surgical decision-making and management of surgical teams and resources.(3) In order to achieve such a holistic attitude, new methods of education and training have to be established. In this respect, multimedia computer-aided learning has introduced major changes in surgical education. Apprenticeship methods include the use of multimedia programmes in which the internet plays a significant role. The enormous amount of websites found through search engines yields both reputable and hazardous websites run by individuals,
business, advocacy groups and clubs serving different audiences. Sorting through such a massive amount of material can be frustrating.

Based on the model of the IRCAD International School of Surgery (also known as the European Institute of TeleSurgery), we developed a concept of a website with unified academic teaching and tutorials with world- renowned experts able to share and confront their opinions about the most recent approaches in laparoscopic surgery. The website ( is a web-based surgical university dedicated to new and minimal approach in surgery (Figure 1). represents a new educational tool. Using cutting-edge multimedia, video streaming and web-enhanced technologies with high-speed internet connectivity, it provides a wide range of data making up a novel electronic textbook in minimal access surgery. The format of the WeBSurg website incorporates text-based chapters of surgical procedures, first-rate colour drawings and animations elaborated by medical illustrators and high-definition videos to provide an interactive, self-paced learning environment.


Surgical operative techniques
E-learning must not be copied and pasted from conventional literature. It has to be specially created using brand-new technologies. The essentials of the website are made up of surgical operative techniques. Over 130 procedures in MIS have been thoroughly described and published online. The content of these chapters has been designed for multimedia education and learning. Internationally renowned experts were invited to write texts and send ideas for illustrations. Editors, medical illustrators and audiovisual and multimedia technicians worked out an original way of processing key information to provide first-rate illustrations and  photographs suitable for watching on any computer screen. New technologies allow rethinking of the anatomical artwork in order to achieve the best representation from a surgical standpoint. New developments have enhanced navigation with many functional options including full-screen display of information, slide shows, voice dubbing, as well as an easy and permanent navigation through the entire chapters of operative techniques with one single “click” (Figure 2). The worldwide audience means that many chapters are translated into several foreign languages: English, French and Japanese. Translation into Chinese and Spanish are anticipated for the end of 2006.


Video footage
Education in the field of surgery is based on mentoring with a view to performing surgical procedures. MIS is specific in that the OR assistant has exactly the same view as the operator thanks to the video display of operative images, which can be recorded and used for educational purposes. Videos are a great asset to MIS education and can be quickly uploaded onto the internet.(4) WeBSurg contains more than 370 videos of surgical interventions, available in three different media players (Figure 3), with different encoding bit rates. They are chronologically sequenced, meaning that each operative step can be separately analysed and accessed independently of the full-length procedure. The success of these videos is confirmed by the rate of hits on the videos, with an increase of 725% in 2006 (from 14,007 in January 2004 to 115,260 in February 2006) (Figure 4). Since October 2005, the introduction of high- definition (HD) videos has been tremendously successful.



Expert opinion
Advice from the experts remains of major importance in the learning acquisition process, making the link between theoretical teaching and realtime practice. To ensure and
promote this feature, the website provides more than 770 examples where top experts share their opinions on specific topics in different fields of surgery (Figure 5).


New improvements for access to surgical education
Recent developments in wireless access points (WiFi) means that WebSurg can be accessed in many diverse areas. However, most professionals manage their schedules and data on handheld personal data assistants (PDAs). Thanks to the latest technological advances, such PDAs allow images and sound, and the management of data on makes it possible to use such technology (Figure 6).


Other educational services
Accreditation is increasingly under the supervision of state governments with their own requirements of nationally approved continuing medical education (CME) for physicians
in order to maintain medical registration. Today the internet represents one way of obtaining CME credits and WeBSurg has gained a solid recognition among the community of healthcare professionals: contents have constantly been peer-reviewed by leading experts. The WeBSurg website offers 24 hours of American  Medical Association (AMA)
category 1 credit through different educational online sessions. Each chapter and learning session is a self-contained learning opportunity that can be viewed
independently. Self-assessment questions in the form of a post-test following each learning session provide the validation of important concepts in the learning activity.
These activities also include videos that represent an actual and original new way of acquiring CME credits. In Europe, the same validation process is under way headed by
the European Accreditation Council for Continuing Medical Education (EACCME), Institution of the European Union of Medical Specialists (UEMS).

An evaluation of the website’s influence and acceptance among healthcare professionals shows it has a big impact on the clinical and operative skills of surgeons. For instance,
the number of visits increased dramatically in 2005, totalling 490,000 visits and 2,837,000 pages viewed, while every day, about 110 surgeons become members of WeBSurg. All this reflects a keen interest in online learning through WeBSurg, showing that web-based learning is considered as an effective, accepted and efficient way of education for physicians.(5) However, credibility and reliability of such information remains a major determiner for any physician searching the web for information.(6) Many criteria can be taken into consideration to assess and validate credibility factors of a website. The number of active members and pages viewed are not as important as the total number of returning visitors. The total number of returning visitors (over 9,000) may appear to be a good indicator of satisfaction with regards to the quality of the scientific surgical content provided. As an example, has over 49,000 registered members and 33,260 active members who have visited the website more than once over the past 12 months. The high rate of returning visitors means that surgeons, when looking for a specific piece of information on the website, consider the content of the site as valuable and useful allowing them to make regular visits to the website for further information.

Quality is also correlated with the internet connectivity and access speed dependent on the technology used for hosting and streaming of information, such as access to high- definition videos. Between October 2005 and January 2006, two high-definition videos available on WeBSurg were watched more than 50,000 times. In November 2005, more than 130,000 hits on videos were reached. The content delivery network is ensured by the AKAMAI platform allowing the streamlining and broadcasting of videos and operative technique chapters all over the world through 16,000 servers located in 65 countries.

With approximately 50,000 monthly visitors’ sessions, represents a remarkable model of internet-based surgical education. It epitomises the concept of e-education and e-training in minimal access surgery. To achieve such goals, it integrates multimedia e-learning and e-training models using the latest technologies to display videos, texts and illustrations simultaneously. Its success originates in professional self-commitment and forceful determination to make things change.

It will certainly help in the development of nations that had, until recently, underequipped transmission systems such as China or India. By taking into account cultural diversity and languages and by presenting various approaches to surgical problems, the virtual university has the objective to offer adapted educational tools to surgeons of today and surgeons-to-be.


  1. Gandsas A, et al. Laparoscopy and the internet. A surgeon survey. Surg Endosc 2001;15:1044-8.
  2. Healy DG, et al. Electronic learning can facilitate student performance in undergraduate surgical education: a prospective observational study. BMC Med Educ 2005;5:23.
  3. Rogers DA. Ethical and educational considerations in minimally invasive surgery training for practising surgeons. Semin Laparosc Surg 2002;9:206-11.
  4. Ellis DG, Mayrose J. The success of emergency telemedicine at the State University of New York at Buffalo. Telemed J E Health 2003;9:73-9.
  5. Cook DA, et al. Web-based learning in residents’ continuity clinics: a randomized, controlled trial. Acad Med 2005;80:90-7.
  6. Murphy JO, et al. Surgical informatics on the Internet: any improvement? Surgeon 2003;1:177-9.