Laparoscopic telementored adrenalectomy: The Italian experience

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.

Telemedicine and Telementoring in Urology: A Glimpse of the Past and a Leap Into the Future

Telemedicine is the process of utilizing telecommunications and digital relay to perform, teach, or share medical knowledge. The digital era eased the incorporation of telemedicine to different areas of medical care, including the surgical care of Urologic patient mainly through telementoring, telesurgery, and telerobotics. Over the years, Telemedicine has played an integral part in a physicians' ability to provide high quality medical care to remote patients, as well as serve as an educational tool for trainee physicians, in the form of telementoring. During the COVID-19 pandemic, telemedicine has played a vital role in combatting the health implications of confinements. Challenges of telemedicine implementation include cost, ethical considerations, security, bandwidth, latency, legal, and licensure difficulties. Nevertheless, the future of telemedicine, specifically telementoring, promises several improvements and innovative advancements that aim to bridge the gap in technological divides of urologic care. In this review, we build on what is already known about telemedicine focusing specifically on aspects related to telementoring, telestration, and telesurgery. Furthermore, we discuss its historical role in healthcare with a special emphasis on current and future use in urology.

Overcoming the Impact of COVID-19 on Surgical Mentorship: A Scoping Review of Long-distance Mentorship in Surgery

BACKGROUND

Mentorship in the surgical field has been increasingly recognized as a crucial component of career success. Distance mentorship models may be utilized to overcome geographic limitations, increase mentorship access, and strengthen mentoring relationships in surgery.

OBJECTIVE

This review aimed to identify the scope of literature on distance mentoring in surgery, the range of its application, its effectiveness, and any gaps in the literature that should be addressed in order to enhance mentorship in the surgical field.

DESIGN

A comprehensive PubMed review was performed in January 2021 on distance mentorship of students, trainees, and surgeons in the surgical field. Reviews, replies, and non-English articles were excluded. Data was extracted regarding publication year, author's country, specialty, subjects, aim of mentorship model, and efficacy.

RESULTS

134 total studies met inclusion and exclusion criteria. Most studies were published in 2020, written by authors in the United States, from general surgery, and featured an expert surgeon paired with a more junior fully trained surgeon. In all, 93.3% of studies utilized distance mentorship to enhance surgical skill through telementoring and only 4.5% were focused on mentorship to enhance careers through professional development. The remaining studies utilized distance mentorship models to increase surgical research (0.7%) and clinical knowledge (1.5%).

CONCLUSION

The results of this review suggest successful implementation of distance mentoring in surgery through telementoring, but a lack of professionally aimed distance mentorship programs. Amidst COVID-19, distance mentorship is particularly important because of decreased face-to-face opportunity. Future studies in the surgical field should investigate distance mentoring as a means of increasing mentorship for professional development.

Integration of aquablation through telemetry: an alternative to onsite proctoring?

PURPOSE

To evaluate the feasibility of telementoring for aquablation by comparing the outcomes of onsite versus telemetry proctoring.

METHODS

The telemetry device of choice was Proximie, an innovative digital platform that uses live video stream with an augmented reality technology. Our study retrospectively reviewed outcomes from our IRB approved prospective Aquablation database from March 2018 till October 2019. Procedures were guided by a proctor either onsite or remotely through telemetry. One-way ANOVA or Chi-square was used to compare perioperative parameters and mixed model ANOVA was used to compare functional outcomes.

RESULTS

Our data included 59 patients who underwent a proctored-based Aquablation of which 21 were telementor guided and 38 were onsite guided. The initial ten procedures were done with the latter approach. There was no statistical difference in age, comorbidities, prostate size, and baseline serum markers amongst the two groups. In contrast, telementor guidance was associated with increased general anaesthesia use (76.2% vs. 21.1%) and haemostatic cauterization (81.0% versus 47.4%) with a p value < 0.00001 and 0.004 respectively. However, the main procedure outcomes: operative time, time to Foley catheter removal, haemoglobin drop, urinary retention, and adverse events were statistically insignificant (p value > 0.05).

CONCLUSION

Following an initial phase of onsite proctoring, telementoring can be safely used in the adoption phase of a new robotic technology. This approach allowed more flexibility in patient scheduling and reduced travel costs with similar surgical outcomes.

Training in endocrine surgery

BACKGROUND/PURPOSE

In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.

METHODS

A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.

RESULTS

For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.

CONCLUSIONS

Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.

Telementoring of Surgeons: A Systematic Review

Background. Telementoring is a technique that has shown potential as a surgical training aid. Previous studies have suggested that telementoring is a safe training modality. This review aimed to review both the technological capabilities of reported telementoring systems as well as its potential benefits as a mentoring modality. Methods. A systematic review of the literature, up to July 2017, was carried out in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study quality was assessed using the Oxford Levels of Evidence proforma. Data were extracted regarding technical capabilities, bandwidth, latency, and costs. Additionally, the primary aim and key results were extracted from each study and analyzed. Results. A total of 66 studies were identified for inclusion. In all, 48% of studies were conducted in general surgery; 22 (33%), 24 (36%), and 20 (30%) of studies reported telementoring that occurred within the same hospital, outside the hospital, and outside the country, respectively. Sixty-four (98%) of studies employed video and audio and 38 (58%) used telestration. Twelve separate studies directly compared telementoring against on-site mentoring. Seven (58%) showed no difference in outcomes between telementoring and on-site mentoring. No study found telementoring to result in poorer postoperative outcomes. Conclusions. The results of this review suggest that telementoring has a similar safety and efficacy profile as on-site mentoring. Future analysis to determine the potential benefits and pitfalls to surgical education through telementoring are required to determine the exact role it shall play in the future. Technological advances to improve remote connectivity would also aid the uptake of telementoring on a larger scale.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database.

METHODS

Patient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups.

RESULTS

A total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group ($42,659 versus $33,748, p < 0.0001). There was a significant trend towards more adrenalectomies being performed robotic assisted by year. Only 22% of adrenalectomies were performed robotic-assisted in 2009 compared with 48% in 2012.

CONCLUSIONS

The overall benefit for RA remains small and higher total charges for RA may currently outweigh the benefits. These findings may change as more cases are performed robotically assisted and robotic technology improves.

Telementoring and Telesurgery for Minimally Invasive Procedures

PURPOSE

Tremendous interest and need lie at the intersection of telemedicine and minimally invasive surgery. Robotics provides an ideal environment for surgical telementoring and telesurgery given its endoscopic optics and mechanized instrument movement. We review the present status, current challenges and future promise of telemedicine in endoscopic and minimally invasive surgery with a focus on urological applications.

MATERIALS AND METHODS

Two paired investigators screened PubMed^®, Scopus^® and Web of Science^® databases for all full text English language articles published between 1995 and 2016 using the key words "telemedicine," "minimally invasive surgical procedure," "robotic surgical procedure," "education" and "distance." We categorized and included studies of level of interaction between proctors and trainees. Research design, special equipment, telecommunication network bandwidth and research outcomes of each study were ascertained and analyzed.

RESULTS

Of 65 identified reports 38 peer-reviewed studies qualified for inclusion. Series were categorized into 4 advancing levels, ie verbal guidance, guidance with telestration, guidance with tele-assist and telesurgery. More advanced levels of surgical telementoring provide more effective and experiential teaching but are associated with increased telecommunication network bandwidth requirements and expenses. Concerns regarding patient safety and legal, financial, economic and ethical issues remain to be reconciled.

CONCLUSIONS

Telementoring and telesurgery in minimally invasive surgery are becoming more practical and cost effective in facilitating teaching of advanced surgical skills worldwide and delivery of surgical care to underserved areas, yet many challenges remain. Maturity of these modalities depends on financial incentives, favorable legislation and collaboration with cybersecurity experts to ensure safety and cost-effectiveness.

Current status and effectiveness of mentorship programmes in urology: a systematic review

The objectives of this review were to identify and evaluate the efficacy of mentorship programmes for minimally invasive procedures in urology and give recommendations on how to improve mentorship. A systematic literature search of the PubMed/Medline databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In all, 21 articles were included in the review and divided into four categories: fellowships, mini-fellowships, mentored skills courses and novel mentorship programmes. Various structures of mentorship programme were identified and in general, mentorship programmes were found to be feasible, having content validity and educational impact. Perioperative data showed equally good outcomes when comparing trainees and specialists. Mentorship programmes are effective and represent one of the best current methods of training in urology. However, participation in such programmes is not widespread. The structure of mentorship programmes is highly variable, with no clearly defined 'best approach' for postgraduate training. This review offers recommendations as to how this 'best approach' can be established.

Telementoring in education of laparoscopic surgeons: An emerging technology

Laparoscopy, minimally invasive and minimal access surgery with more surgeons performing these advanced procedures. We highlight in the review several key emerging technologies such as the telementoring and virtual reality simulators, that provide a solid ground for delivering surgical education to rural area and allow young surgeons a safety net and confidence while operating on a newly learned technique.

Telemedical technologies in urological cancer care: past, present and future applications

Since the initial development of telegraphy by Sir Charles Wheatstone in 1837 and the telephone by Alexander Graham Bell in 1875, doctors have been able to convey medical information across great distances. The exchange and sharing of medical information has evolved and adapted to suit the vast array of today's medicine. Early adopters of telemedicine within clinical practice have gained significant health economic benefits. The arrival of wireless connections has further enhanced the possibilities for all clinical work with focus on diagnosis, treatment and management of urological cancers, as highlighted in this article.

Telepointer technology in telemedicine: a review

Telepointer is a powerful tool in the telemedicine system that enhances the effectiveness of long-distance communication. Telepointer has been tested in telemedicine, and has potential to a big influence in improving quality of health care, especially in the rural area. A telepointer system works by sending additional information in the form of gesture that can convey more accurate instruction or information. It leads to more effective communication, precise diagnosis, and better decision by means of discussion and consultation between the expert and the junior clinicians. However, there is no review paper yet on the state of the art of the telepointer in telemedicine. This paper is intended to give the readers an overview of recent advancement of telepointer technology as a support tool in telemedicine. There are four most popular modes of telepointer system, namely cursor, hand, laser and sketching pointer. The result shows that telepointer technology has a huge potential for wider acceptance in real life applications, there are needs for more improvement in the real time positioning accuracy. More results from actual test (real patient) need to be reported. We believe that by addressing these two issues, telepointer technology will be embraced widely by researchers and practitioners.

Surgical telementoring in knowledge translation--clinical outcomes and educational benefits: a comprehensive review

BACKGROUND

Surgical telementoring has been reported for decades. However, there exists limited evidence of clinical outcome and educational benefits.

OBJECTIVE

To perform a comprehensive review of surgical telementoring surveys published in the past 2 decades.

RESULTS

Of 624 primary identified articles, 34 articles were reviewed. A total of 433 surgical procedures were performed by 180 surgeons. Most common telementored procedures were laparoscopic cholecystectomy (57 cases, 13%), endovascular treatment of aortic aneurysm (48 cases, 11%), laparoscopic colectomy (32 cases, 7%), and nefrectomies (41 cases, 9%). In all, 167 (38%) cases had a laparoscopic approach, and 8 cases (5%) were converted to open surgery. Overall, 20 complications (5%) were reported (liver bleeding, trocar port bleeding, bile collection, postoperative ileus, wound infection, serosa tears, iliac artery rupture, conversion open surgery). Eight surveys (23%) have structured assessment of educational outcomes. Telementoring was combined with simulators (n = 2) and robotics (n = 3). Twelve surveys (35%) were intercontinental. Technology satisfaction was high among 83% of surgeons.

CONCLUSION

Few surveys have a structured assessment of educational outcome. Telementoring has improved impact on surgical education. Reported complication rate was 5%.

A comprehensive review of telementoring applications in laparoscopic general surgery

BACKGROUND

Incorporation of advanced laparoscopic procedures in the practice of institutions without respective experience is a significant impediment in the dissemination of minimally invasive techniques. On-site mentoring programs carry several cost-related and practical constraints. Telementoring has emerged as a practical and cost-effective alternative mentoring tool. The present study aimed to review the pertinent literature on telementoring applications in laparoscopic general surgery.

METHODS

A systematic review using the Medline database was performed. Articles reporting on clinical experience with telementoring applications in general surgery were included. Variations in methodology, study design, and operative procedures precluded cumulative outcome evaluation. Instead, a critical appraisal of current evidence was undertaken.

RESULTS

Seventy-five articles were identified in the primary search, and ten studies were considered eligible. No randomized studies comparing on-site mentoring with telementoring were identified. The included studies reported on a total of 96 laparoscopic telementored procedures: 50 cholecystectomies, 23 colorectal resections, 7 fundoplications, 9 adrenalectomies, 6 hernia repairs, and 2 splenectomies. Completion of remotely assisted procedures was feasible in the vast majority of cases, whereas technical difficulties included video and audio latency with low transfer rates (<128 kbps) and inadequate guidance regarding the correct plane for dissection.

CONCLUSION

Current evidence supports the feasibility and safety of telementoring programs in general surgery. Their clinical effectiveness as teaching alternatives to traditional mentoring programs remains to be further evaluated.

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons

Background

Since the 1960s, there has been substantial development in the uses of video-conferencing (VC) among medical personnel, including surgeons who have adopted the technology.

Methods

A report on our own experience with VC was combined with a comprehensive PubMed search with the key words telepresence, video-conferencing, video-teleconferencing, telementoring and surgery, trauma, follow-up, education, and multidisciplinary teams. A search through two peer-reviewed telemedicine journals—Journal of Telemedicine and Telecare and Telemedicine and e-Health Journal—and references of all included papers and identified additional reports was conducted.

Results

A total of 517 articles were identified with 51 relevant manuscripts, which included the key phrases. VC is widely used among surgeons for telementoring surgical procedures and in trauma and emergency medicine. Furthermore, VC is widely used by multidisciplinary teams and for the follow-up of patients after surgery.

Conclusions

VC is a common clinical tool for surgeons and provides a great opportunity to alter surgical practice and to offer patients the best expertise in surgical treatment despite long distances, especially in rural areas.

Reinforcement of endocrine surgery training: impact of telemedicine technology in a developing country context

AIMS AND OBJECTIVES

Technology-based outreach programs for knowledge sharing and skill development using telemedicine is a novel approach to developing subspecialties in regions where there is a lack of specialists and dedicated departments. Endocrine surgery is one such emerging subspecialty. There are few dedicated surgeons and centers even in the developed world. India has only one such center. The aim of this study was to assess the feasibility and impact of telemedicine on the reinforcement of endocrine surgery training at distant places to develop this subspecialty in a developing country such as India.

MATERIAL AND METHODS

Two faculty members from the General Surgery Department at SCB Medical College in Cuttack, Orissa, India registered at Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow for a short 3-month training course in endocrine surgery in 1998 and thereafter consulted through telephone calls and e-mail when required. Telemedicine-based mentoring was introduced in 2001 as a reinforcement method for continuing training and skills development. Various training modules were used, including tele-consultation, case presentation, treatment planning, tele-radiology, tele-pathology, and tele-continuing medical education (CME) programs and workshops. The outcome was assessed in terms of the increase in the number of patients with endocrine disorders seen and operated on by trainees and the complication rates.

RESULTS

A total of 70 telemedicine sessions were held between 2001 and 2005. They included tele-education and surgical treatment planning (n = 44), tele-consultation including tele-pathology and tele-radiology (n = 26), and tele-surgical conferences/CME (n = 6). The number of endocrine surgical cases performed by trainees after training (phase II) increased significantly compared to those before training (phase I), with a further increase after starting telemedicine-enabled mentoring (phase III). Most of the patients operated on by the trainees had thyroid problems, although these surgeons started operating on a few patients with parathyroid and adrenal disorders as well. The morbidity figures for the thyroidectomy operations (including total thyroidectomy) were comparable to those at the training institution.

CONCLUSION

The concept of training a group of motivated general surgeons to practice safe endocrine surgery at a remote center via telemedicine-aided reinforcement of their training is thus feasible. This is particularly true in the case of thyroidectomy operations, which constitute the major workload of endocrine surgery in our country. The same program might be applicable to the development of other medical subspecialties in a developing country as well.

Telementoring: an application whose time has come

BACKGROUND

Telementoring offers the possibility of making extended education oversight available on a cost-effective, large-scale basis. It expands the mentor/proctor pool and makes these educational assets more widely available to assist in protecting the public. However, it is an application that if haphazardly implemented rapidly losses its effectiveness and is more dangerous to the patient. Like all programs that can cite demonstrable outcome consistency, telementoring should be established on a foundation of sound training methodology. This article discusses the history of telementoring and where this modality stands today and outlines a validated methodology for successful telementoring missions.

METHODS

This algorithm includes preprocedural assessment and enhancement of laparoscopic surgical skills, establishment of a standardized approach to the procedure, tactical information deployment, telementoring simulation laboratories, and establishment of the doctor/patient relationship.

RESULTS

Telementoring can make cost-effective extended education oversight available on a large-scale basis.

DISCUSSION

Because of an overwhelming need for mentors/proctors and supporting evidence in the literature, telementoring is an application whose time has come.