Pedro P. Gomez, MD, FACS, had everything ready to go.

On his enclosed deck, Dr. Gomez had created a mini-OR: surgical tools, a webcam and an iPad laid out precisely across a large wooden table. In the center sat a pig abdomen, modified to mimic a complex hernia.

Dr. Gomez had originally planned to be in a bustling lab surrounded by other general surgeons at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, which was supposed to take place in Cleveland. But the COVID-19 pandemic moved the entire SAGES meeting online, including a hands-on course known as ADOPT, which begins training in the lab and extends mentorship throughout the year.

On Friday, Oct. 23, at his home in Bangor, Maine, Dr. Gomez scrubbed in virtually with a surgeon proctor and another mentee logging on at their homes for a two-on-one virtual session. The focus of the course: a review of complex abdominal wall hernia repair.


Dr. Pedro Gomez, at home in Bangor, Maine, ready for a virtual hands-on course in complex hernia repair.

“Even though the proctor wasn’t physically by my side, it still felt like she was sitting next to me, like a co-pilot advising me on where to go next,” Dr. Gomez, a general surgeon at St. Joseph Hospital in Bangor, said.


Making the hands-on course a virtual one took careful planning. Sharon Bachman, MD, the course chair, wondered whether it could even be done.


For Dr. Gomez, one of the best parts of the course was the reaction from his 2-year-old daughter. “She kept asking to play with piggy,” he said. “I may have a surgeon in the making.”

“We knew we needed a technical platform that could accommodate live mentoring and a model adapted to mimic a human abdominal wall that could be sent to participants,” Dr. Bachman, the director of minimally invasive surgery at Inova Fairfax Hospital in Falls Church, Va., said. “One fascinating thing about COVID-19 has been the rapid development of innovative technology.”

After speaking with several companies, Dr. Bachman and the course’s co-chair, Jacob Greenberg, MD, decided to partner with two: Kindheart, which creates real-tissue simulations and specially designed a porcine model of a human abdominal wall for this course; and Proximie, a technology platform that allows surgeons to scrub in virtually. Proximie also set up a course-specific webpage that the SAGES faculty populated with videos and talks to prep participants before the training began.


Dr. Gomez received a collapsible box to house the pig abdomen and tubing to mount retractors.

The next step: making sure the technology and porcine model shipped to 15 attendees. A few days before the session, Dr. Gomez received a rather large package with the pig abdomen carefully nestled on dry ice. A second package arrived with a collapsible box to house the pig abdomen and tubing to mount retractors. For the telementoring, SAGES shipped a webcam and an arm on which to mount it. Proximie’s augmented reality platform allowed participants to operate while proctors watched and interacted with the livestreaming video.

Dr. Gomez wanted to focus on mesh fixation techniques while performing a transversus abdominis muscle release (TAR) technique for posterior component separation.

“When you are close to the ribs during a complex abdominal wall repair, things can get tight, and I wanted some pointers on how to release this TAR plane to fixate the mesh and avoid wrinkles,” Dr. Gomez said. “My proctor guided me through, telling me to pull the retrorectus plane with my left hand using Allis clamps while dissecting a plane just underneath the xiphoid with the Bovie, reaching this beautiful plane where the mesh can lie flat.”

This tip came in handy during a procedure Dr. Gomez performed just a week later in his small community-based practice. Dr. Gomez called the virtual training potentially “lifesaving” for his patient.

On the proctor side, Dr. Greenberg divided the training time between his two attendees, each of whom had familiarity with the procedure but wanted to focus on different aspects of it: one on tips and tricks during more challenging parts of the component separation and the other on mesh fixation. As the first attendee moved through the hernia repair, the second could watch and absorb the session, and then they swapped.

While the attendees operated, Dr. Greenberg could see a close-up of their pig model on his screen, as they moved through each step of the procedure.


Dr. Gomez’s full setup for his virtual hands-on course.

“But because I can’t put my hands in the pig and demonstrate what to do next, I had to ask the surgeon to stop, tell me what they’re seeing and thinking, what they want to do next,” Dr. Greenberg, an associate professor of surgery at the University of Wisconsin–Madison, said. “I’d draw on my screen, which would appear on their screen, to show them what I would do and where I would be. This approach forced both of us to slow down and share our thinking.”

Dr. Bachman, one of the eight faculty teaching the course, found that the virtual aspect of the course enhanced the learning experience. “In every course I’ve taken, you have to share your cadaver or faculty’s time with a lot of other surgeons, or the faculty takes over the procedure when they teach,” she said. “But, in this course, the participants had their own model and the undivided attention of their mentor.”


SAGES proctor Dr. Jacob Greenberg’s setup at home.

Another benefit: For surgeons who work in small community practices, taking days away to attend a conference may not be feasible. Having a hands-on virtual course can provide access to techniques and training that some surgeons otherwise wouldn’t have.

“Amid the COVID pandemic and upheaval of 2020, it was great to be able to continue learning and growing as a surgeon,” Dr. Gomez said.

A video of Dr. Greenberg’s training session is below: