Surgical telementoring: Feasibility, applicability, and how to

Teleproctoring of endovascular treatment of aortic diseases in times of pandemic and war

Telemedicine encompasses various activities leveraging technology for remote health care. Surgical teleproctoring is described in the literature and has been used by some medical specialties for real-time and remote intraoperative guidance. However, there is still limited evidence on its use for the implantation of aortic endoprostheses. Technological progress and the advancement of telemedicine encourage surgical telementoring, especially in circumstances where in-person proctorship is not feasible, such as in remote areas, during pandemics and wars, and in settings lacking financial resources. In this context, we present the successful application of easily available and low-cost online teleproctoring of real-time aortic endoprosthesis implantation, addressing aortic diseases in a country experiencing social isolation due to the ongoing pandemic and war.

Dynamic Augmented Reality Cues for Telementoring in Minimally Invasive Surgeries: Scoping Review

BACKGROUND

Remote surgeons use telementoring technologies to provide real-time guidance during minimally invasive surgeries (MIS). Such technologies are continuously improving with the integration of dynamic augmented reality (AR) cues. This includes virtual overlays of hand gestures, pointers, and surgical tools onto the operating surgeon's view. The operating surgeon comprehends this augmented information to operate on the patient. Thus, understanding these dynamic AR cues (either during surgical training or live surgery) is crucial.

OBJECTIVE

In this paper, we aimed to review the existing telementoring technologies that use dynamic AR cues during MIS. This review describes the MIS (including surgery type, specialty, procedure, and clinical trial), the telementoring system, the dynamic AR cues generated by these systems, and evaluation of the technology in terms of technical aspects, user perceptions, skills gained, and patient outcomes.

METHODS

A scoping review was conducted using PubMed, Web of Science, Scopus, IEEE Xplore, and ACM Digital Library databases. The search terms included "telementoring," "minimally invasive surgery," and "augmented reality" without restrictions imposed on the publication year. Articles covering telementoring using dynamic AR cues during MIS, including laparoscopic and robot-assisted, were identified.

RESULTS

A total of 21 articles were included and categorized based on type of surgery, the telementoring technology used, and evaluation of the technology. Most of the articles reported on laparoscopic suturing performed using synthetic phantoms. Hand gestures and surgical tools were the most frequently used dynamic AR cues (10 articles on each cue), while the mentors and mentees primarily consisted of experienced surgeons and medical students. The studies assessing the telementoring technologies were either descriptive (7 articles) or analytical (14 articles) where it was compared against no cue, prerecorded visual cue, in-person guidance, audio cue, or static AR cue. Outcomes were measured mostly using skills gained (13 articles) and user perception about the telementoring system.

CONCLUSIONS

In general, telementoring using dynamic AR cues resulted in positive outcomes during MIS. In some cases, they were considered on par with conventional methods such as audio cues and in-person guidance. Further randomized controlled trials are required to objectively assess its clinical benefits.

Educational Effectiveness of Telementoring as a Continuing Professional Development Intervention for Surgeons in Practice: A Systematic Review

Objective

We performed a systematic review to determine the educational effectiveness of telementoring as a continuing professional development (CPD) intervention for surgeons in practice.

Background

Surgeons can mentor their peers in remote locations using videoconferencing communication, referred to as telementoring.

Methods

We searched MEDLINE and EMBASE and included studies assessing the educational effectiveness of telementoring interventions used by surgeons in practice. We excluded studies involving only trainees and those not evaluating educational effectiveness. Two reviewers independently screened, extracted data, and assessed study quality using the Medical Education Research Study Quality Instrument (MERSQI; maximum score 18). Educational outcomes were categorized using Moore's Outcomes Framework.

Results

We retrieved a total of 1351 records, and 252 studies were selected for full-text review. Twenty-eight studies were included with 1 randomized controlled trial, 19 cohort studies, 5 qualitative studies, and 3 case studies, totaling 178 surgeons and 499 cases. The average MERSQI score was 10.21 ± 2.2 out of 18. Educational outcomes included surgeons' satisfaction with telementoring interventions (Moore's Level 2) in 12 studies, improvement in surgeons' procedural knowledge (Level 3b) in 3 studies, improvements in surgeons' procedural competence in an educational setting (Level 4) in 4 studies, performance in a workplace-based setting (Level 5) in 23 studies, and patient outcomes (Level 6) in 3 studies. No studies reported community health outcomes (Level 7).

Conclusions

Moderate-level evidence demonstrates the use of telementoring as effective in changing surgeons' knowledge and competence in both educational and workplace-based settings. Its use is also associated with changes in patient outcomes.

Coaching in Sports Medicine

Similar to elite athletes, surgeons use their skills on a daily basis but coaching for skillset refinement is not common among surgeons. Surgeon coaching has been proposed a method by which surgeons can gain insight into their performance and optimize their practice. However, many barriers exist to surgeon coaching such as logistics, time, cost, and pride. Ultimately, the tangible improvement in surgeon performance, the elevation of surgeon well-being, the optimization of the practice, and better patient outcomes support a wider implementation of surgeon coaching for surgeons at all stages of their career.

Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper

BACKGROUND

Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS.

METHODS

This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements.

RESULTS

Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency.

CONCLUSIONS

Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.

Preliminary design and evaluation of a remote tele-mentoring system for minimally invasive surgery

BACKGROUND

Tele-mentoring during surgery facilitates the transfer of surgical knowledge from a mentor (specialist surgeon) to a mentee (operating surgeon). The aim of this work is to develop a tele-mentoring system tailored for minimally invasive surgery (MIS) where the mentor can remotely demonstrate to the mentee the required motion of the surgical instruments.

METHODS

A remote tele-mentoring system is implemented that generates visual cues in the form of virtual surgical instrument motion overlaid onto the live view of the operative field. The technical performance of the system is evaluated in a simulated environment, where the operating room and the central location of the mentor were physically located in different countries and connected over the internet. In addition, a user study was performed to assess the system as a mentoring tool.

RESULTS

On average, it took 260 ms to send a view of the operative field of 1920 × 1080 resolution from the operating room to the central location of the mentor and an average of 132 ms to receive the motion of virtual surgical instruments from the central location to the operating room. The user study showed that it is feasible for the mentor to demonstrate and for the mentee to understand and replicate the motion of surgical instruments.

CONCLUSION

The work demonstrates the feasibility of transferring information over the internet from a mentor to a mentee in the form of virtual surgical instruments. Their motion is overlaid onto the live view of the operative field enabling real-time interactions between both the surgeons.