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SNI, Surgical Neurology International, a 2D Internet Journal,
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an SNI Digital, Innovations in Learning, a 3D video journal, interactive with discussion, in association with the Sub-Saharan African neurosurgeons,
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they're pleased to present the Sub-Saharan International Neurosurgery Grand Rounds, held in the first Sunday of each month. This is the fourth Sub-Saharan Africa
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International Grand Rounds meeting, devoted to the topic of global solutions to clinical challenges in neurosurgery.
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The discussants are from Africa, Iraq, France, Persia, USA, and other countries The
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moderator. is a start-up Bernard, who's the head of the program committee, and James Houseman.
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The first part of this meeting, the talk will be on tele-proctoring in neurosurgery,
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is this the future of global medical cooperation, a lecture and discussion lasting 60 minutes.
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It'll be given by Samir Hose, a hybrid vascular neurosurgeon from the Neurosurgery Teaching Hospital in Baghdad, Iraq, also a research fellow at the Department of Neurosurgery, University of
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Cincinnati, in hybrid neurosurgery and welcome everyone to the this is the fourth conference and we as you know we're having this monthly. We're talking about aneurysm management today. Dr. Osman
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will lead that discussion and we'll be talking about managing it anyway in the world. But before that we also have Dr. Amr Ho was talking about tele-proctoring for
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endovascular surgery. So, Amr, would you like to get started? Welcome. Thank you. Thank you, Dr. Strada. Thank you, everybody. Hi, everyone. I'm Amr Ho. I'm
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a vascular neurosurgeon. Was practicing in Iraq now doing endovascular fellowship in Cincinnati, Ohio, and US And there we will talk about our experience back in Iraq in 2022 and later about the
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tele-proctoring and investment neurosurgery. Can I share my screen? Yes, you should be able to - I will try to just make a focus presentation just to start points for discussion for the after that.
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So that
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experience is about tele-proctoring, as we said, surgery in general and endovascular in particular as an example,
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and that's my affiliation as we already know, and I usually start my presentation with this slide, and that we are not superior to our fathers and we are shown fully inferior to them if we do not
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advance beyond them, and with the more mentors we have the, the more wealthy scientifically we will be And so when we are talking about vascular neurosurgery in general lines of treatment and be
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open surgery or in the vascular treatment, sometimes people can do one of them, sometimes they can do both of them, and I think the future are more towards comprehensive vascular neurosurgery when
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you can do open and do and maybe also harmonize if you are treating ABM, or at least some principles on on each of them so you can choose the better for your patient. So when we start to do vascular
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neurosurgery, we start in ERAC. It was a very primitive experience starting with the surgical loops first because basically anesthesia all don't trust us. And then with the time getting confidence,
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having microscope, better and better in quality. And most of the practice was based on the ruptured aneurysm. So, ruptured aneurysm, it's very critical. Patient cannot travel outside to be
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treated in more established centers. And that's why we can offer this, that we can try to clip this aneurysm on
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the urgent basis. This is an advantage for indication. However, there is a risk
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as well, which is operating acutely or on the hyperacute stage, which is the first day or two of our entrepreneurial museum. not easy and always there is high risk of rupture. And with the time
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you will get confidence, yes, but still it's very risky and how to deal with the surgery and complication. So I'm just trying to show some of our real cases. Basically, those are not the first 20
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or 50 cases Those are more about the later cases when we have a very established recording, maybe two years after starting the process of treating subarachnoid homogeneous cases. Before we start
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that, usually the cases will stay in neurology world, treated conservatively because
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obviously it's not available treatment everywhere And with the time, more and more skills will be developed. we are more comfortable doing temporary clip. We are doing more procedure with
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intraoperative monitoring, which is not available at the beginning. And also the clips may be not available. Sometimes you will use oversized clip or whatever available clip quality or quantity
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sometimes. It depends on what's available. So it's not the typical practice of vascular neurosurgery, but it's more a modified practice. Definitely, we will try to discuss those cases.
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Pre-unforced output mentors, mainly online. And then that would be very helpful while dealing with more and more difficult cases. This is the last example for open cases when we are operating in a
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very thick cloth
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cases all of those cases we are just showing are. left become aneurysm rupture. So just to give an example on how different some surgeries for the same lesion on the same setting with the acute
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rupture, sometimes it's very easy. Sometimes the anatomy is very helpful. Sometimes not. And the timing also is an important factor.
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One of the incidents that will be always in the mind of surgeon is this
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moment with the intraoperative rupture and how you can manage that. Once you are managing more and more intraoperative rupture, you will build some confidence, you and your team. And then all the
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next steps will be just improvement of the quality of service, especially focusing now on more pre-entpose of improvement rather than enthrall. And then the endovascular. Once we tried the
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endovascular for the first time, for this and yours, and for example, is of lack of.
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calmic segment aneurysm. This case, the patient, 26 years male, have up-descent palsy, not rupture. And we try to operate, but the open surgery failed. We couldn't localize the neck of
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aneurysm and the surgery. The shape, intraoperative luar, was not like this. It's more about the aneurysm is like aneurysm sagging around the operative field. We cannot see the carotid with the
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para-clinid carotid. We cannot reach with the section to the neck of the aneurysm and we stopped the procedure because we feel that's too much. We cannot handle that. And also the proximal control
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from the neck was not typical. So we stopped that procedure. And then a few months later, we started this experience I'll do it in the basket procedure. in a private clinic just close to the
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hospital, but still we need some supervision. So that's what we are sharing today. So with the help of online proctor, he's just joining us on Zoom during the procedure and he will
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take us together that what to use, when to use and how to use each step, like step by step, in addition to pre-op planning and then post-op discussion, sorry for it. And a few minutes later,
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this aneurysm is just gone.
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As you can see, it's
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very, very beautiful if you are thinking of the patient as one of your family and his unfortunate to have this joint aneurysm and he's very young. You will, you will be happy to have this treatment
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for him. And it's a, we just apply flow diverter, flow diverter usually take a few months to close the aneurysm and to shift the blood out of the aneurysm But in this case, because it's a off time
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mix segment, sometimes loading flow diverter will close the neck completely. And this is also, we prepare that as a test report and literature review that immediate closure of the giant aneurysm
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after using a flow diversion. For us, actually, it's a miracle at that time. Wow. This is the result. It's just gone And just remember that we already operate the patient and we fail to clip
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that. Yeah, this is a new extension. So then we start with Dr. Hassan Jani. A big thank you for this human. Actually, he already started to contact us. He is from Saudi Arabia. He has
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training and outside on endovascular and open vascular and neurocritical care. So they call them a triple the train because they have the neurocritical care advantage as well. And he contacted us
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and he said that I like what you are doing now and I see that you are growing as a team. But if you want some extra support, I'm happy to be available online for any procedure you want. So then we
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start the real work. So we start with the setting. It's just simple setting. It's just a monoplane in the vascular service It's usually used from the cardios.
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And we start to do one of the team, do a zoom meeting with the, with Dr. some journeys. And this is a sample of what we are doing and the idea and the advantage for the new, you're on the
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vascular And that we operate basically on the screen, which is the exercise screen. And if we both have the vision or direct vision for the screen, we can take a combined decision. So we start
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this experience. And we, as a, as a collective, we end doing seven cases for each case, we will do approximately four sessions, a session to prepare A
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session to take decision first is to operate or not. And what's the best treatment option is it open or in the vascular that session very important for me as a practice practicing local neurosurgeons,
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because after discussion. with Dr. Hassan, I will go back to the patient and give him the update of the discussion. I will talk to the patient that we have contact and supervision from a professor
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outside. And after discussion, we decide that we should operate you or the best option for you will be through in the vascular, for example. So that's the advantage of first session, which is the
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decision and the initial plan. And the second session, which is, I think, very unique, is that in Iraq, at that time, and I think that will be the example for any, for example, centers in
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Africa, starting soon, will have the same issue, which is we don't have all the devices available. We don't have all the types of coils or sizes. It's not available. So I need to request that
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from the left, from companies before the procedure. This means I need to know what I need exactly. which is not easy for those have
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some contact with the endovascular they will understand it's not easy to prepare yourself. Yeah, I need this size exactly offload diverter and that's it. Usually you will you will prepare a size
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more or less and also you will prepare two or three flow diverter because some cases will require that. Again, that's very helpful because this session which is preparation of the devices is very
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important for me and for the rep to understand and most importantly because this is a private private practice for the vascular only service so I need to approximate the cost and I need to talk with
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the patient about that exact cost Each coil will cost almost1, 500 for us back in Iraq so that's by its own huge number. So I need to know it's not about annual small coiling. Okay, how many coils
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for coils is totally different from eight coils for each patient. So I need to know exactly how many devices I need for this case. And also we will modify a lot of steps just to make the cost as
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reasonable as possible for the patient, because it's already costy. We don't have insurance system
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So the first session is the decision, second session is the plan exactly the devices and I know the cost for each step and third session will be the intro operative, which is when he joined us
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during the procedure. And the fourth session is reflective session after we finish the procedure, we will discuss what we did right what we did wrong how to improve That's basically provide like
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around 28 session in total. for this case, as we say, it's different to step. I think this is unique. We don't have this full idea before starting the experience, but for the time we develop
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more based on the need. And this is exactly how we will do that. Like one of the surgeon, or let's say the local team, they start to do the endovascular. One of the team, usually medical student,
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told the Zoom meeting with Dr. Hassan and showing him exactly step by step And Dr. Hassan will be online, usually happy at the end of the procedure, because he have the same citrus. And we
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published that on a paper, I think, in the SI. And part of the paper saying the perspective of the proctor as well, like the supervisor, because he have his type of citrus, and also his concerns
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is different from the pro, like the local surgeon. So yeah, as we said, how we will do the cases. It's not easy, sometimes complex AVM. And then at the end, we are very thankful for him. I
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think our patients also very thankful for this experience. And it's much different, very cost effective as an alternative to travel outside and much
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safer as compared to non-supervised procedures. In the vascular, the procedure will be much technically easy as compared to the open vascular. However, complications have a huge impact in the
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vascular. So you need people with huge experience to supervise most of the first few years of practice. Yeah, so a lot of advantages. I don't think that we need to go through each of those, but
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just to list what will be expectation of advantages and also.
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there is a challenge, there are challenges. From the advantage is radiation exposure because the proctor is outside is not, and they're on with us. Also, of course, reduction, we said, avoid
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the scheduling delay. At any time we can do that, it's easier. And no, but no, I don't know many proctors and supervisors are ready to visit back that Iraq at any moment because sometimes it's
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stable, sometimes it's not, sometimes it's risky, sometimes it's not. So that will be just overcome by this online proctoring. And the other concerns are like the challenges, how to improve that.
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It depends on how to, how image quality. We will just simple 4G connection
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from the mobile phone, and that's it. I think we can improve that, but I don't think we need to complicate the steps because keeping those. Some people will be more and more effective to have more
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sessions. That's a summary of all the cases that we are doing through the online proctoring, the coiling of the timing on the embolization of AVM,
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coiling and
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your own embolization of a feeder for a tumor flow diversion session, which is failed, failed, which means we didn't deploy flow diversion at the end, but because of difficult anatomy, but that's
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very important. I will show you as a final example before ending this talk, and then different type of sessions. And this, for example, a case AVM, we try to do a pressure cooker technique,
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which means using coil to block the high flow vessel and then deploy the ONEX and through the cooling process. one of the coil just migrated outside going into the one of the branches, the stair
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branches of ACA, at that moment, me as an operator, I have no experience with that complication. And the presence of the proctor online, very helpful. He, he take me through the steps, how to
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do a trial. We try three different techniques. And at the end, we decide, no, it will not work We just push the coil distally in the branch. And there is no signs of stroke on the patient.
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There is no change in blood pressure. There is no change in vitals. And this is the only thing that we can do at that moment. And we continue the process of embolization. And at the end, it went
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uneventful, asymptomatic. There is a sign of local ischemia from that coil, which is a migrated coil, but that's I cannot imagine how I will do with that complication without that online
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proctoring. I don't know how to do all the techniques, how to try to pull that. So after all the trial is done, then we feel that, okay, we tried all our best under supervision and that's the
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only thing that we can do right now. Yeah, so it can be tough at any moment and the moment we agree with the proctor that no more intervention is required, that's very helpful, also very helpful
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for the family when they understand that. We just discussed this, another tricks like how to mark the screen, to understand where is the embolizing material, just very simple basic tricks that
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will be very effective in dealing with real cases This is the view from his. and how he will see the images with us, this is me operating, and another example, just some
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fistula, which is of tarmac fistula, and post closure with just one simple coil, but very long because we need to reduce the cost. It's not typical treatment always, but this will be very
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modified to maintain the standard we want to do. Again, it's very clear as compared from like, if you say that, oh, you are using phone and just regular internet, yeah. And it's okay, it's
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doable.
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And like a last example, maybe this is, we have a stroke case, we called him, and we have this anatomy, which is common carotid, R3, left common carotid,
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internal carotid, non-internal carotid, and then intracranial, we can see the internal carotid, again, giving me the cerebral. So this is called occlusion of the internal carotid adenic with the
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reconstitution through the internal auxiliary branches of the internal carotid intracranial. At that time, we don't know how to do with this. Is it stroke or not? Should we treat this occlusion or
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not? And then we end with, this is not a acute occlusion. And this is not the anatomy should be treated with stroke and should be defined as intracranial or reconstitution through the internal
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auxiliary artery branches. Again, that's the variation that you may not know, but having a proctor with good experience would be very helpful. Yeah, I just want to remember this for all of us.
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Because this is the point, if you can deliver this treatment to your patients, your local patients, that's a huge. And that's a thanks again to Dr. Hassan for this. I think it's an example for
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others to follow. And we are happy with this collaboration. And we are happy to maintain that. Thanks for the team. And thank you
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for listening. Okay, why don't we stop sharing screen for a minute? Yeah, that's great. So we're almost at 40 people already. So first of all, people have some questions for Sam.
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Yes, I have one question. Dr. Hassan, did you try first to use the temporary clip before you put the final one? Because that's one of the trends that I see in our neurosurgery group. They put
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the temporary to make a better dissection. Then they put the permanent clip. Do you do that on your
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practice over there or no?
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Yeah, basically. So it depends. In general, we will try to avoid temporary clipping in general because there is a risk of injury or vessel or a perforator on the backside. But if we deem that
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it's important or if it's the rupture case with very adherent structure or folds to the aneurysmal drum, yeah, temporary clip can be safely applied. So do we use temporary clips? Yes, do we use
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it for all? No, I think for only percent of the equipping we will use that because the temporary clip has some risk by its own, especially in the early experience for experienced surgeons, it will
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be just easy step. But for the early experience, there is a huge potential for complication from the temporary clipping, especially with old age patient atherosclerotic disease, you can, you can
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cause trouble with that temporary if you are not using that for the
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Correct indication. Second question I have for the patient that you showed that there was a blockage of the internal carotid artery. Do they do external cranial ECIC bypass in your in Iraq, or they
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don't have the facility because that's another option when they have this Obstruction, they can come in, make the ECIC bypass
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exrocaroneal intercaroneal and it works in many cases, and I don't know if they have that experience. in Iraq and because it is a facility.
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Yeah, I think you are totally correct, sir. Yeah, that's one of the options
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if they decrease vascularity or dynamic fluid and try crannially, one of the options is to do ECR, IC bypass, actually we did that bypass, high flow bypass, for a few patients, we will use more
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indirect bypass like EDAS or EDAMS for Moya Moya cases. We have like more than 25 Moya Moya cases treated with EDAS and
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EDAMS. So it depends on the type of anestomosis, but both of them is
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ECIC bypass. I think the high flow bypassed are technically more difficult,
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but it's doable. Once you have the basic micro-instrument, you can do it, but we will definitely do that. without the ICG without the Doppler. It's not always available. Because typically, as
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you know, most people will use ICG or Doppler address to confirm the pay tensi of anestomosis. We will not use the app. We will use direct visions that's available. And definitely, we have
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intraoperative monitoring that will be also very helpful in the bypass to show pay tensi
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Okay, any other questions? I noticed Sam Al-Brahmani, who is, are you in Azerbaijan, Sama? Are you back in Baghdad?
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I think the other student is the other region student, I think someone is still like that, she's just graduated, but she give the, she give
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the classification lecture. Okay, good Good. Oh, she did the classification lecture. I'm confused her with the other one. Yes. Yeah. And up on the approaches to the Petrus Petrus rich, right?
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Exactly. Yeah. Okay. Great. Well, I have a, I have a question for you, Sam. My, my understanding is that in the session to you say there were four sessions in prep of the process in session
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to you. You reviewed the process and try to predict the materials that you would need. Correct. How well were you able to do that prediction of the materials needed?
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That's very important session because with the first session, with the decision, the family will agree on the treatment in general and then I will prepare a session to agree on the, what's the cost
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to and do they accept that or not. So that session will be going through all the potential steps and try to eliminate one by one. For example, we are using a re-sterilized instrument which is not
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usual. So for diagnostic, we will use one kit for patients for diagnostic cerebral angiography, just to reduce their cost. So we already will ask for each device do we have all gone? Can we use
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that for the rest
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of the rest?
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And this is definitely off label because most of the company will say, no, this should be one use, but at the end, I cannot use a lot of
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optional devices. Yeah, you should have this in case you need it. Yeah, I will keep that restaralysed just in case needed because it's very costly I can say,
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for the one flow diverter, the cost may be15, 000 and without
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insurance and the patient paying that directly, this will create a total cost of surgery around20, 000, at least without any fees from the surgeon And this is, I can say, it's never heard of and
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Baghdad Iraq.
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This better to travel outside. That's the standard. So that's that's the issue.
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And is it in my, did I understand it correctly? So you, you have someone recording the monitor with an iPhone and that's transmitted to the Proctor.
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It's not recording. It's a direct zoom call like the one we are doing right now It's a direct zoom call so we can have a full interactive discussion. Okay, so how is the practice seeing the monitor?
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Yeah, because if you open the zoom from your phone, you can put the on your camera or on the front. Oh, okay, good. Okay. Okay. Thank you
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So let's, let's take our case examples, Sam, or somebody comes in the hospital. And they have, let's say we're going to go through that in the next lecture, but let's say you've identified they
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have an aneurysm. And
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if it's ruptured, if you've done any acute ruptures, or are they mostly patients who are un ruptured or ruptured and stable?
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So for ruptured, we have only one option which is the open surgery. Because the patient is a critical, because it's a free service And because the neuro-critical care is a free and the public
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hospital. So, and you know, the acute rupture, you cannot predict the course of the patient. So those emergency settings will be only treated in the public hospital, pre-off charge, and the
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only available treatment will be open surgery, open clipping of the patient to present an R rupture, or, like. any other lesion that can't be considered elective case, then we can offer both open
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surgery versus endovascular. It's similar to the standards in general. So have you done an open acute ruptured aneurysm but this technique or it's mostly, it has time. You have to schedule it.
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You have to do some other things So it's mostly unwraptured or stable, which we've done in a setting there. Yeah, with the proctoring, we will do like, not only like endovascular treatment for
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acute aneurysm rupture, we don't. Well, what I'm driving at is we're talking to people
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and there's a billion people in
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sub-Saharan Africa. And we've just heard from a number of people that are limited neurosurgeons. And we know from Alvin, he's the only one in Liberia. So the question is, if somebody comes in
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with an aneurysm and they are
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stable, would there be a way to interact with a proctor to help guide somebody, clip the aneurysm because coiling in those situations is probably too expensive, it's not reasonable. And so you're
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dealing with surgery. Have you had that experience or is that something we ought to look into?
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Actually, we have a similar experience. Now while we are dealing with, I'm outside the country, they are inside and we can communicate directly within the team. Yeah, we are trying to do that
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But
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yeah, I think this is something to look like.
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forward in the future because you will need that during the procedure, definitely, at specific moment. I think you're sorry, you already have a huge experience in the vascular that once you
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dissect the
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aneurysm and before reaching the neck, you need some discussion with somebody if there is like, I have this on this coil only. Is that enough? Should I quit? Should I continue? Something like
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that. Sometimes just weird anatomy, that's not available
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in the pre-op planning, that would be very helpful to have someone online. And this experience will add the visual part, which is you can't call somebody to for consult, yeah. But this visual
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part, because you cannot describe the second aneurysm that I present. The pre-op image, which is three days,
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CTA pre-ops, three days, is showing a small aneurysm picon. And intra-operatively, there is aneurysm just changed the shape into three bulges with very thin wall. So it's just something
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unexpected
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if we have something online, through zone with consult from anywhere in the world, that's the advantage of this type of
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supervision, will be definitely helpful.
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So I'm trying to get this for everybody, and maybe I'm the only one who doesn't understand, but so you identify a case, it has to be a case that you have some time to prepare for, right? So you'd
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have to connect to the proctor, you have to show him the films, talk about the patient, and then you think about, you talk to the obviously the patient and it says you can go ahead and do this
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procedure and then you have some planning sessions where you go through the various steps of the procedure that you're going to do if it's surgery or it's intervention and then you have the actual
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live conduct of the procedures, is that correct?
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Yes, with the man focusing on the endovascular. No, I understand that, I understand that, but that's what we're driving at because if to have endovascular then you have to have other facilities
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too, you have to have coiling, you have to have the imaging, you have to have all these other things which many people don't have but the question I have is I'm let's say I'm Alvin and I'm in
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Liberia and somebody comes in with a Separatite hemorrhage, I don't have any help Oh. We'll come to that in the second lecture, but practically, is this a system that can be used in Africa for
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other kinds of cases other than interventional?
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Yeah, I think if we decide that we will start with whatever available, I mean type of cases, the more most frequent just to establish a system, and then you can take that system to the more and
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more acute setting, that would be just reasonable option. Sure, it would take a little, a little organization, a little time to do the name, Professor Nim, is this something you think would be,
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you have a number of neurosurgeons in Kenya, would this be a value in communicating with others? Well, currently, they're. We do coiling at Agacan University Hospital. They have a center which
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they've set up, which they're doing that. And in our teaching hospital, not yet, in the private hospitals, I think some neurosagions are attempting it. The problem is the cost, you know, in
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developing countries. It turns out to be very, very expensive And this is why up now we really emphasize on clipping, you know, because that's quite affordable. Remember that in our country, the
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patients have to buy the clips. So even in public hospitals, the patients have to buy the clips. So the cost element becomes quite high, even in a public hospital, because the clips are quite
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expensive But when we now look at the calling aspect, it becomes quite, quite. enormous. But in the private hospital, I know there are neurosurgeons who have set up that aspect. And because it
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needs a lot of backup, we must have a center which has the table facilities for that to be done. Now, this teleproctoring is
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very interesting, and is there one question is, does the patient know that he's being subjected to that type of treatment? Is the patient aware that and what are the medical legal aspects if
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something went wrong? So who takes the responsibility?
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Yeah, so I think this is a very interesting question, but I think very important. So basically, it's my patient and I'm the surgeon and I will take the responsibility and that option of
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will be an additional level of standardization that I want to do in my cases. This is the way that we present that to the patient that I will do the case. In addition, I will invite some professor
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from outside through zone to be with me throughout the process So I have also another layer of supervision just to improve the standards So we will present that to the patient, the patient will be
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informed on all the steps. And I think based on real practice, that was very helpful. Like, at the end of a few, remember, we present that failed flow diversion at the end of that procedure
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However, I will say to the patient that we try all our best, and to deploy that flow diverter but due to difficult enough anatomy is not effective. And that is not only my experience that's
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confirmed by the proctor who's online with us throughout the procedure. So it makes sense. Go
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ahead, go ahead
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That's it. So now the other question would be, this can be applied on the other areas of neurosagerie therefore. Exactly. It's coming to them. Yes.
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Because, and if this can be applied to the other areas of neurosagerie, it can also be applied in the training of,
42:40
of neurosagerie locally You know, I mean, it's a, if, if, for example, it's an emergency and then Rosage, my resident has to do a case as an emergency. You know, I could take him through that,
42:54
because then that would be quite applicable and it's, it's quite, it's very interesting. I mean, I would like to discuss it with. So some of my other colleagues would like to try it, but as I've
43:04
said, that the big issue here would be the medical legal. We are very little just in my country and if you make a small mistake, the lawyers will be after you. So that's what worries us. That's
43:15
what
43:16
would worry me, frankly. Thank you. Okay, I'm sorry to add his hand raised. Dr. Serada and Dr. Osman, if you permit me two minutes, I tell you a story which has happened to share with our
43:31
young colleagues. Two weeks before the September 11th happens in New York with the bombardment of the twin tower. Two weeks before that, the French telecommunication arranged for this type of
43:45
surgery. The surgeon was in the twin tower and the patient was in the stress book. And he did the callist's take to me through the internet with some people in the stress book to put the endoscope
43:59
inside the abdomen. And he did the colesistectomy from New York when the patient was in the stress work. Until the communication of France, close 1, 000 channel of internet, not to have a
44:16
interruption of the surgery. That is one of the point that having the good communication, because even here in the US, sometimes the internet is suddenly disconnected because of the problem with
44:29
the electricity or no. And this was the case happened almost 20, 24 years ago. And unfortunately, when the twin tower came down, they tried not to bring this issue up because of the damage with
44:45
what's happened. But the correct internet that is exactly that we have to be careful and thank you for Dr. House and all those who are involved with this But that was the first case, as far as I
44:59
know. They did it for the general surgery from New York with the patient in Westeros book. That's what I wanted to share with all of our colleagues. Thank you very much. I'd like to ask Sam and
45:13
Nigeria, are you there, Sam?
45:21
Yes, I'm enjoying the discussion. Sam, yes, yes, yes. This is technology, Sam, that would be, you could see it in Kenya, you could use to consult with other people, or how do you think this
45:35
would be practically used
45:38
Yeah, the technology looks very attractive,
45:44
but as a new device, as I said in an environment, it may take some time to achieve that goal. Because of the problems already highlighted, internet instability, cost of the process, etc The more
46:01
importantly for aneurysm, so vascular problems, I was hoping that after your presentation, they will discuss holistically about aneurysm management as it impacts the subs are in Africa. But really,
46:16
the art problem is volume. volume volume volume. As we have drawn attention in several publications, the volumes of aneurysm cases in South Africa are not very encouraging at the moment. So
46:32
whether we are missing them or what we don't know. But my center is one of the high volume centers in Nigeria. But I know that in a year the number of
46:47
aneurysm you see are quite few compared to other parts of the world that are trending. So how do you advance this technology if you have a low volume? I think let's discuss this later. Every
46:57
technology is worth developing. But how far is affordable because of volume that we can address later. Thank you We'll come to that in the second talk and I think those are good points.
47:16
I'd like to follow up on what NIMM said at NIMM. I was saying, well, can this be used? Let's see, somebody has a tumor or some complicated tumor or somebody's doing a pediatric case with
47:29
myelomeningocele or something. These may be common, but we have some people in the talk are going to country that has one or two neurosurgeons. And the question I have, is this going to be
47:45
practically helpful? And Nim, if you would answer that, and Jill Bear, and maybe some of the other people, is it not just for vascular, would it be helpful for other things?
47:59
Yes, I think it would be helpful, but as Herbalam has said, the problem is connectivity.
48:07
Our internet is very, very unreliable. So if it breaks down, then that's a challenge which one would face. Now, as I said, you know, we, it would, it's worth trying And I think, I think I'll
48:26
get the nitty-gritties from Samir and see whether it's applicable. What I would
48:35
like to comment is,
48:41
I know there's more bleeds. In the alias, we were also not getting as many, but nowadays we get a lot. We get a lot of,
48:50
I know there's more bleeds and we get a lot, a lot of patients with with vascular aneurysms, which will undergo. undergoing surgery. And this aspect of training, of our training has improved a
49:06
lot and quite a number of our residents, when they finish, then they go through a process where they do some fellowships in vascular work. And unfortunately, one of our senior chap couldn't join
49:20
us, but he would have given you the comments on how we are handling this. And therefore, we do get these types of problems. And it's part of our training. And in the AAAS,
49:32
we used to say, to think it's not common, but no, no, it's quite common nowadays. And I really don't think there's any difference between what you see and what is seen in the Western world,
49:41
because the lifestyle has changed, completely changed. I'm getting young young people getting struck at the age of 14 now in Arabic. And therefore, the lifestyle has changed. And our population
49:55
is very young
49:57
72 to 80 percent of our population is below the age of 45 and therefore these problems now we're seeing them quite quite quite quite often and therefore we have to teach our residents how to handle
50:08
them also have to teach our medical students how to manage and raise small blades. Okay Alvin you had a question I saw you had your hand up did you have something you wanted to ask Calvin. Thank you
50:23
professor for recognizing me and I want to use this time to extend appreciation to Dr. Hors for that brilliant presentation and actually it had me thinking because it just reminded me of a
50:42
collaboration that my hospital was about to enter into with a company regarding the surgical glasses wherein there will be a mentor in another country while doing surgeries and he will be seeing what
50:57
I'm doing and we'll be doing them together. But I think with what Dr. Horz presented, I think in my country, Liberia, I think the challenges here are huge. And number one, a stable electricity
51:16
that you need.
51:19
Number two, internet connectivity. And then I think we could work with it, but I don't think it will be in those
51:29
conversations by taking other cases, like most relative cases that are going to be planned. For example, if
51:39
you have some complex fine cases and you need a mentor to guide you to the process, I think with that, that will be much easier, especially if it is scheduled. But for emergency, I think it will
51:50
be a huge challenge for my hospital.
51:55
Okay, Albin, I think that's right. We probably ought to go on to part two because it's almost a continuation of this, but so you want to do that? Yeah, let's go ahead. We almost had an hour,
52:10
so please proceed, Jen. We hope you enjoyed these presentations.
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