Effectiveness of Telementoring in Surgery Compared With On-site Mentoring: A Systematic Review

Telesurgery and telementoring

Telemedicine has revolutionized the field of surgery, with telemonitoring and telesurgery being 2 of its most promising applications. Telesurgery and telemonitoring are revolutionary applications that have the potential to change the way surgical operations are performed. These applications can allow surgeons to perform operations, enable surgeons to perform operations by assisting or supervising others through mentoring from a different location (telementoring). Despite the potential benefits of telemedicine and telementoring, there are still challenges that must be overcome before they can be widely used in clinical practice. For example, latency in data transmission can be a problem in telemedicine, as even a small delay in data transmission can affect the accuracy of the operation. Additionally, a sophisticated and expensive technological infrastructure is required, which can limit their use in some clinical settings. Although we need to work on its development technologically, ethically and legally, it is a promising tool.

Robotic surgery as a driver of surgical digitalization

Classical surgery, also called analog surgery, is transmitted to us by our mentors, whose knowledge has been delegated from generation to generation throughout the history of surgery. Its main limitations are limited surgical precision and dependence on the surgeon's skill to achieve surgical goals. So-called digital surgery incorporates the most advanced technology, with the aim of improving the results of all phases of the surgical process. Robotic platforms are currently considered to be one of the main drivers of the digital transformation of surgery. They bring considerable advances to the digitalization of surgery, including: higher quality visualization, more controlled and stable movements with elimination of tremor, minimized risk of errors, data integration throughout the patient's surgical process, use of various systems for better surgical planning, application of virtual and augmented reality, telementoring, and artificial intelligence.

Technologies Used for Telementoring in Open Surgery: A Scoping Review

Background: Telementoring technologies enable a remote mentor to guide a mentee in real-time during surgical procedures. This addresses challenges, such as lack of expertise and limited surgical training/education opportunities in remote locations. This review aims to provide a comprehensive account of these technologies tailored for open surgery. Methods: A comprehensive scoping review of the scientific literature was conducted using PubMed, ScienceDirect, ACM Digital Library, and IEEE Xplore databases. Broad and inclusive searches were done to identify articles reporting telementoring or teleguidance technologies in open surgery. Results: Screening of the search results yielded 43 articles describing surgical telementoring for open approach. The studies were categorized based on the type of open surgery (surgical specialty, surgical procedure, and stage of clinical trial), the telementoring technology used (information transferred between mentor and mentee, devices used for rendering the information), and assessment of the technology (experience level of mentor and mentee, study design, and assessment criteria). Majority of the telementoring technologies focused on trauma-related surgeries and mixed reality headsets were commonly used for rendering information (telestrations, surgical tools, or hand gestures) to the mentee. These technologies were primarily assessed on high-fidelity synthetic phantoms. Conclusions: Despite longer operative time, these telementoring technologies demonstrated clinical viability during open surgeries through improved performance and confidence of the mentee. In general, usage of immersive devices and annotations appears to be promising, although further clinical trials will be required to thoroughly assess its benefits.

Applying augmented reality in teaching of surgical residents-telementoring, a "stress-free" way to surgical autonomy?

BACKGROUND

Achieving surgical autonomy can be considered the ultimate goal of surgical training. Innovative head-mounted augmented reality (AR) devices enable visualization of the operating field and teaching from remote. Therefore, utilization of AR glasses may be a novel approach to achieve autonomy. The aim of this pilot study is to analyze the feasibility of AR application in surgical training and to assess its impact on intraoperative stress.

METHODS

A head-mounted RealWear Navigator® 500 glasses and the TeamViewer software were used. Initial "dry lab" testing of AR glasses was performed in combination with the Symbionix LAP Mentor™. Subsequently, residents performed various stage-adapted surgical procedures semi-autonomously (SA) (on-demand consultation of senior surgeon, who is in theatre but not scrubbed) versus permanent remote supervision (senior surgeon not present) via augmented reality (AR) glasses, worn by the resident in theatre. Stress was measured by intraoperative heart rate (Polar® pulse belt) and State-Trait Anxiety Inventory (STAI) questionnaire.

RESULTS

After "dry lab" testing, N = 5 senior residents performed equally N = 25 procedures SA and with AR glasses. For both, open and laparoscopic procedure AR remote assistance showed satisfactory applicability. Utilization of AR significantly reduced intraoperative peak pulse rate from 131 to 119 bpm (p = 0.004), as compared with the semi-autonomous group. Likewise, subjectively perceived stress according to STAI was significantly lower in the AR group (p = 0.011).

CONCLUSION

AR can be applied in surgical training and may help to reduce stress in theatre. In the future, AR has a huge potential to become a stepping stone to surgical autonomy.

Telementoring versus face-to-face mentoring in the training of scleral fixation surgery of intraocular lenses

PURPOSE

To assess telementoring as a complementary tool for surgical training of a scleral fixation technique.

DESIGN

Randomized, controlled, two-arm, blinded clinical trial.

METHODS

Using a 3D visualization system, 132 participants were randomized in order of enrollment into traditional face-to-face mentoring (n = 66) and telementoring (n = 66). A single surgeon mentored all participants in the 2 groups. The procedure was performed in a model suitable for training in intraocular lens fixation SimulEYE® (INSEYET, WESTLAKE VILLAGE, CA, USA). In the telementoring group, the images captured on a local computer were sent to a second computer located in another room through a teleconferencing platform in real-time. Nine steps of the recorded procedure were evaluated and scored by two masked independent surgeons experienced in the technique.

MAIN OUTCOMES MEASURES

The primary outcomes evaluated were the global score (the sum of each score on the rubric), surgical failure, and surgical time (in seconds).

RESULTS

Surgical success was achieved in 98.5% in the face-to-face group and in 95.5% in the telementoring group (p-value = 0.619). Minimal technical problems were reported in 8 procedures in the telementoring group (12%), without interfering with the surgical result, and completion of the procedure.

CONCLUSIONS

Telementoring is an encouraging educational tool that can overcome geographical barriers to ease the transfer of abilities and knowledge. We lack evidence in terms of group differences for superiority comparing face-to-face and telementoring, in addition to presenting comparable results regarding surgical success and failure. More studies are needed to explore the impact of telementoring in other ophthalmological surgeries.

TRIAL REGISTRATION

The Federal University of São Paulo institution's Research Ethics Committee reviewed and approved this study protocol (approval number, 5.383.484).

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.

Remote guidance of percutaneous coronary intervention: A pilot study

The safety and effectiveness of remote guidance of percutaneous coronary interventions (PCI) have not been fully appraised in controlled studies. We hereby presented the results of a study on remote guidance (vs on-site guidance) of PCI to explore its feasibility, safety, and effectiveness. Patients were recruited from those who received PCI procedures from January 2018 to June 2019 in a secondary hospital (Jincheng, Shanxi, China), in collaboration with a tertiary medical center (Beijing, China) approximately 680 km away. According to the type of guidance during the procedure, the patients were assigned to two groups: the remote guidance group and the on-site guidance group. Remote guidance was assisted with an advanced commercial telemedicine system. Interventional strategies, procedural success rate, peri-procedural complications, procedural duration, radiation doses, and the amount of contrast medium were compared between the two groups. A total of 352 patients were included in this study, with a total of 411 PCI procedures and 446 target lesions. The baseline clinical characteristics, as well as the distribution and characteristics of coronary artery lesions, did not differ significantly between the two groups. No significant differences were noticed in procedural success rate, peri-procedural complications, procedural duration, radiation dose, and in-hospital major adverse cardiovascular events. However, the amount of contrast medium was slightly higher in the remote guidance group. The results of the present pilot study showed the feasibility of remotely guided PCI, with safety and effectiveness measures at acceptable levels comparable to the traditional on-site guidance. Randomized studies with long-term follow-up are warranted to further confirm our findings.

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.

A Novel Scenario-Based, Mixed-Reality Platform for Training Nontechnical Skills of Battlefield First Aid: Prospective Interventional Study

BACKGROUND

Although battlefield first aid (BFA) training shares many common features with civilian training, such as the need to address technical skills and nontechnical skills (NTSs), it is more highly scenario-dependent. Studies into extended reality show clear benefits in medical training; however, the training effects of extended reality on NTSs, including teamwork and decision-making in BFA, have not been fully proven.

OBJECTIVE

The current study aimed to create and test a scenario-based, mixed-reality platform suitable for training NTSs in BFA.

METHODS

First, using next-generation modeling technology and an animation synchronization system, a 10-person offensive battle drill was established. Decision-making training software addressing basic principles of tactical combat casualty care was constructed and integrated into the scenarios with Unreal Engine 4 (Epic Games). Large-space teamwork and virtual interaction systems that made sense in the proposed platform were developed. Unreal Engine 4 and software engineering technology were used to combine modules to establish a mixed-reality BFA training platform. A total of 20 Grade 4 medical students were recruited to accept BFA training with the platform. Pretraining and posttraining tests were carried out in 2 forms to evaluate the training effectiveness: one was knowledge acquisition regarding the NTS and the other was a real-world, scenario-based test. In addition, the students were asked to rate their agreement with a series of survey items on a 5-point Likert scale.

RESULTS

A battlefield geographic environment, tactical scenarios, scenario-based decision software, large-space teamwork, and virtual interaction system modules were successfully developed and combined to establish the mixed-reality training platform for BFA. The posttraining score of the students' knowledge acquisition was significantly higher than that of pretraining (t=-12.114; P≤.001). Furthermore, the NTS score and the total score that the students obtained in the real-world test were significantly higher than those before training (t=-17.756 and t=-21.354, respectively; P≤.001). However, there was no significant difference between the scores of technical skills that the students obtained before and after training. A posttraining survey revealed that the students found the platform helpful in improving NTSs for BFA, and they were confident in applying BFA skills after training. However, most trainees thought that the platform was not helpful for improving the technical skills of BFA, and 45% (9/20) of the trainees were not satisfied with the simulation effect.

CONCLUSIONS

A scenario-based, mixed-reality platform was constructed in this study. In this platform, interaction of the movement of multiple players in a large space and the interaction of decision-making by the trainees between the real world and the virtual world were accomplished. The platform could improve the NTSs of BFA. Future works, including improvement of the simulation effects and development of a training platform that could effectively improve both the technical skills and NTSs of BFA, will be carried out.

Telementoring of Open and Laparoscopic Knot Tying and Suturing Is Possible: A Randomized Controlled Study

AIM

 Several motor learning models have been used to teach highly complex procedural skills in medical education. The aim of this randomized controlled trial was to assess the efficiency of telementoring of open and laparoscopic suturing of medical students compared to conventional in-person teaching and training.

METHODS

 After randomization, 23 medical students were assigned to either the telementoring or the in-person training group. Both groups were taught by surgically trained residence with a student-teacher ratio of 1:1 (teacher-student). Open suturing was assessed in a model of congenital diaphragmatic hernia and laparoscopic suturing in a model of bowel anastomosis. All subjects were trained according to the spaced learning concept for 3 hours. Primary end points were time, knot quality, precision, knot strength, and overall knotting performance/competency. Furthermore, we utilized the Surgery Task Load Index to evaluate the cognitive load of both teaching techniques. Students' subjective progress regarding skill acquisitions and acceptance of telementoring was assessed using a nine-item questionnaire.

RESULTS

 All 23 trainees significantly improved after training in all knot attributes. More than 90% of all subjects reached proficiency in both groups. In-person training and telementoring were similarly practical, and no significant differences regarding speed, knot quality, precision, knot stability, and procedure performance/competency were found. Students perceived no difference in acquisition of factual or applicational knowledge between the two groups. General acceptance of telementoring was moderate in both groups before training, but increased during training in students actually assigned to this group, in comparison to students assigned to conventional teaching.

CONCLUSION

 The current study shows that telementoring of open and laparoscopic suturing is an ideal answer to the current coronavirus disease 2019 pandemic, ensuring continuous training. On-site training and telementoring are similarly effective, leading to substantial improvement in proficiency in intracorporeal suturing and knot tying. Likewise, students' subjective progress regarding skill acquisitions and cognitive load does not differ between teaching methods. Skepticism toward telementoring decreases after exposure to this learning method. Given our results, telementoring should be considered a highly effective and resource-saving educational approach even after the current pandemic.

Stone disease in low-middle income countries. Could augmented reality have a role in its management?

Urolithiasis is a global phenomenon. Cystolithiasis is common in parts of Africa due to low protein intake and dehydration from endemic diarrhoeal illnesses. Nephrolithiasis is less prevalent than in high income countries, probably due to a variety of lifestyle issues, such as a more elemental diet, higher physical activity and less obesity. Although renal stones are less common in low-middle income countries (LMICs), the social and economic impacts of nephrolithiasis are still considerable; many stones present late or with complications such as upper urinary tract obstruction or urosepsis. These may lead to the development of chronic kidney disease, or end-stage renal failure in a small proportion of cases, conditions for which there is very poor provision in most LMICs. Early treatment of nephrolithiasis by the least invasive method possible can, however, reduce the functional consequences of urinary stone disease. Although ESWL is uncommon, and endoscopic interventions for stone are not widespread in most of Africa, percutaneous nephrolithomy and ureteroscopic renal surgery are viable techniques in those regional centres with infrastructure to support them. Longitudinal mentoring has been shown to be a key step in the adoption of these minimally invasive procedures by local surgeons, something that has been difficult during the COVID-19 pandemic due to travel restriction. Augmented reality (AR) technology is an alternative means of providing remote mentoring, something that has been trialled by Urolink, the MediTech Trust and other global non-governmental organisations during this period. Our preliminary experience suggests that this is a viable technique for promulgating skills in LMICs where appropriate connectivity exists to support remote communication. AR may also have long term promise for decreasing the reliance upon short-term surgical visits to consolidate competence, thereby reducing the carbon footprint of global surgical education.

SIG-Former: monocular surgical instruction generation with transformers

PURPOSE

Automatic surgical instruction generation is a crucial part for intra-operative surgical assistance. However, understanding and translating surgical activities into human-like sentences are particularly challenging due to the complexity of surgical environment and the modal gap between images and natural languages. To this end, we introduce SIG-Former, a transformer-backboned generation network to predict surgical instructions from monocular RGB images.

METHODS

Taking a surgical image as input, we first extract its visual attentive feature map with a fine-tuned ResNet-101 model, followed by transformer attention blocks to correspondingly model its visual representation, text embedding and visual-textual relational feature. To tackle the loss-metric inconsistency between training and inference in sequence generation, we additionally apply a self-critical reinforcement learning approach to directly optimize the CIDEr score after regular training.

RESULTS

We validate our proposed method on DAISI dataset, which contains 290 clinical procedures from diverse medical subjects. Extensive experiments demonstrate that our method outperforms the baselines and achieves promising performance on both quantitative and qualitative evaluations.

CONCLUSION

Our experiments demonstrate that SIG-Former is capable of mapping dependencies between visual feature and textual information. Besides, surgical instruction generation is still at its preliminary stage. Future works include collecting large clinical dataset, annotating more reference instructions and preparing pre-trained models on medical images.

Telestration in the Teaching of Basic Surgical Skills: A Randomized Trial

OBJECTIVE

To evaluate how an affordable course using telestration with augmented reality can be compared to the traditional teaching of basic surgical skills.

DESIGN

Prospective, randomized and blinded study.

SETTING

Faculty of Medicine of Porto University.

PARTICIPANTS AND METHODS

Twenty medical students without any experience in basic surgical skills were randomized into two different learning groups: telestration and traditional teaching (on-site mentoring) groups. Five different types of sutures were taught: the single interrupted, the cruciate mattress, the horizontal mattress, the vertical mattress and the simple continuous sutures. Data was obtained on the time taken to learn each of the techniques and to perform each exercise without any support from the faculty, tension of the suture, quality of the procedure using a modified Objective Structured Assessment of Technical Skills and participants' answers to a Likert questionnaire in terms of their learning experience, confidence, and self-evaluation.

RESULTS

Trainees in the telestration group were globally faster when performing independently (1393.40 [SD 288.89] vs 1679.00 [SD 328.22] seconds, p = 0.04) particularly during the cruciate mattress suture (235.50 [SD 61.81] vs 290.00 [SD 68.77] seconds, p = 0.05) and the simple continuous suture (492.40 [SD 87.49] vs 630.30 [SD 132.34] seconds, p = 0.01).Time needed for students to learn the procedures was similar between the groups. There were also no statistically significant differences in terms of the quality of the surgical gesture, tension of the suture, self-evaluation or confidence.

CONCLUSIONS

A basic surgical skills course using telestration through a head-mounted device with augmented reality capabilities can be a viable alternative to traditional teaching, considering time and quality of the gesture. Though costs can discourage from using this technology in basic procedures, the use of free software may turn it into an affordable option in the context of distant learning.

Development of a robot-assisted thoracic surgery (RATS) program. Lessons learned after 2500 cases

Robotic surgery provides significant advantages in terms of an optimal three-dimensional and magnified view of the surgical field, superior maneuverability of surgical instruments, removal of surgeon's tremor and excellent ergonomics. Nonetheless, the adoption of this technology in thoracic surgery has been slower than in other specialties such as urology, gynecology or digestive surgery. In this article we describe our institution's experience in robotic-assisted thoracic surgery (RATS) in the span from 2012 to 2020. During this time the average annual growth of the program has been 55%. Among the most frequently procedures performed were lobectomies, wedge resection and segmentectomies. Surgical time and length of stay decreased as the number of procedures performed increased, relative to the learning curve. Additional important elements considered relevant to the success of the program are the resources available, leadership, motivation of the surgical team, adequate and stepwise training, as well as the collection of data for periodic analysis of results. All those initiatives have led to a relevant improvement of financial variables reflecting a cost reduction.

Effect of Artificial Intelligence Tutoring vs Expert Instruction on Learning Simulated Surgical Skills Among Medical Students: A Randomized Clinical Trial

IMPORTANCE

To better understand the emerging role of artificial intelligence (AI) in surgical training, efficacy of AI tutoring systems, such as the Virtual Operative Assistant (VOA), must be tested and compared with conventional approaches.

OBJECTIVE

To determine how VOA and remote expert instruction compare in learners' skill acquisition, affective, and cognitive outcomes during surgical simulation training.

DESIGN, SETTING, AND PARTICIPANTS

This instructor-blinded randomized clinical trial included medical students (undergraduate years 0-2) from 4 institutions in Canada during a single simulation training at McGill Neurosurgical Simulation and Artificial Intelligence Learning Centre, Montreal, Canada. Cross-sectional data were collected from January to April 2021. Analysis was conducted based on intention-to-treat. Data were analyzed from April to June 2021.

INTERVENTIONS

The interventions included 5 feedback sessions, 5 minutes each, during a single 75-minute training, including 5 practice sessions followed by 1 realistic virtual reality brain tumor resection. The 3 intervention arms included 2 treatment groups, AI audiovisual metric-based feedback (VOA group) and synchronous verbal scripted debriefing and instruction from a remote expert (instructor group), and a control group that received no feedback.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were change in procedural performance, quantified as Expertise Score by a validated assessment algorithm (Intelligent Continuous Expertise Monitoring System [ICEMS]; range, -1.00 to 1.00) for each practice resection, and learning and retention, measured from performance in realistic resections by ICEMS and blinded Objective Structured Assessment of Technical Skills (OSATS; range 1-7). Secondary outcomes included strength of emotions before, during, and after the intervention and cognitive load after intervention, measured in self-reports.

RESULTS

A total of 70 medical students (41 [59%] women and 29 [41%] men; mean [SD] age, 21.8 [2.3] years) from 4 institutions were randomized, including 23 students in the VOA group, 24 students in the instructor group, and 23 students in the control group. All participants were included in the final analysis. ICEMS assessed 350 practice resections, and ICEMS and OSATS evaluated 70 realistic resections. VOA significantly improved practice Expertise Scores by 0.66 (95% CI, 0.55 to 0.77) points compared with the instructor group and by 0.65 (95% CI, 0.54 to 0.77) points compared with the control group (P < .001). Realistic Expertise Scores were significantly higher for the VOA group compared with instructor (mean difference, 0.53 [95% CI, 0.40 to 0.67] points; P < .001) and control (mean difference. 0.49 [95% CI, 0.34 to 0.61] points; P < .001) groups. Mean global OSATS ratings were not statistically significant among the VOA (4.63 [95% CI, 4.06 to 5.20] points), instructor (4.40 [95% CI, 3.88-4.91] points), and control (3.86 [95% CI, 3.44 to 4.27] points) groups. However, on the OSATS subscores, VOA significantly enhanced the mean OSATS overall subscore compared with the control group (mean difference, 1.04 [95% CI, 0.13 to 1.96] points; P = .02), whereas expert instruction significantly improved OSATS subscores for instrument handling vs control (mean difference, 1.18 [95% CI, 0.22 to 2.14]; P = .01). No significant differences in cognitive load, positive activating, and negative emotions were found.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, VOA feedback demonstrated superior performance outcome and skill transfer, with equivalent OSATS ratings and cognitive and emotional responses compared with remote expert instruction, indicating advantages for its use in simulation training.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04700384.

Learning Process Effectiveness During the COVID-19 Pandemic: Teleproctoring Advanced Endoscopic Skills by Training Endoscopists in Endoscopic Sleeve Gastroplasty Procedure

Background and Aims

The COVID‐19 pandemic has led health institutions to cancel many of the activities including training in different fields. Most practices and training programs have been encouraged to use teleproctoring as an alternative method to enhance physician’s ability and assure training. We aimed to evaluate remote training program for endoscopy sleeve gastroplasty (ESG).

Methods

Ten consecutive patients underwent an endoscopic sleeve gastroplasty procedure guided by a proctor expert using an online platform. A stepwise approach was created to assure skill acquisition.

Results

All cases were safely performed with no serious adverse events under teleproctoring. The average surgical and suturing times significantly decreased during the training model. From the first 5 cases to the last 5 ones, the endoscopic procedure time decreased from 120 to 93.4 min while suturing time from 92.8 to 68.4 min. The effect size was large in both cases, and the changes were meaningful according to the fitted learning curves.

Conclusions

The proposed teleproctoring program was effective to deliver advanced endoscopic skills such as endosuturing for ESG, despite the restrictions imposed by the COVID-19 pandemic.

Graphical abstract

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method

BACKGROUND/PURPOSE

In an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure.

METHODS

A multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process.

RESULTS

After five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula.

CONCLUSIONS

A modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees.

TYPE OF STUDY

Diagnostic study LEVEL OF EVIDENCE: Level V (expert opinion).

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

INTRODUCTION

Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

METHODS

A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

RESULTS

Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

CONCLUSIONS

Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

The role of telemedicine in the postoperative home monitoring after robotic colo-rectal cancer surgery: a preliminary single center experience

The telemedicine studies, takes care and prevents diseases at distance basing on the interaction among physicians and patients remotely. Few data are available on its application to early postoperative after surgery. The endpoints of our preliminary experience were the detection, as primary, of feasibility and safety of home telemonitoring after robotic colo-rectal resection and, as secondary, perception and satisfaction of the patients. From December 2019 to March 2020, at the Division of Robotic Surgery of San Giovanni Hospital of Rome, 20 of 29 colorectal cancer patients, submitted to Robotic resection, were prospectively included in a program of postoperative home telemonitoring. Telemonitoring was considered feasible if at least 75% of data were available and safe if morbidity ≤ II by Clavien-Dindo classification. Perception and patients' satisfaction were evaluated through a dedicated questionnaire. Out of 20 patients, the median age was 68 years, overall postoperative morbidity was 30%, all events classified Clavien-Dindo Grade I or II. Only 2 patients were corresponded to surgical consult without readmission during home telemonitoring. Compliance of patients was > 80%, overall grade of satisfaction was very high: 4.2 as median (range 0-5). In this preliminary study, the procedures of postoperative home telemonitoring were feasible and safe and high rate of patients' satisfaction was observed. The telemedicine could enhance the role of robotic technique in decrease the hospital stay and improving postoperative recovery after surgery. Further structured prospective trial are needed to validate the routine application of telemedicine in healthcare.

Application of technology to educational needs in surgery

Innovations in surgical education follow advancing clinical technology. New surgical methods have prompted demand for systematic methods to leverage computing power and internet tools to achieve proficiency-based training goals. Virtual reality, high-fidelity patient simulation, web-based resources to facilitate performance assessment, and telementoring have become mainstream practices, although patient outcomes benefits are not well studied. Remote virtual meeting and mentoring have had transformative effects on resident experiences, the full effects of which remain to be seen.

Towards development of a tele-mentoring framework for minimally invasive surgeries

BACKGROUND

Tele-mentoring facilitates the transfer of surgical knowledge. The objective of this work is to develop a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon by transferring information in a form of surgical instruments' motion required during a minimally invasive surgery.

METHOD

A tele-mentoring framework is developed to transfer video stream of the surgical field, poses of the scope and port placement from the operating room to a remote location. From the remote location, the motion of virtual surgical instruments augmented onto the surgical field is sent to the operating room.

RESULTS

The proposed framework is suitable to be integrated with laparoscopic as well as robotic surgeries. It takes on average 1.56 s to send information from the operating room to the remote location and 0.089 s for vice versa over a local area network.

CONCLUSIONS

The work demonstrates a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon during a minimally invasive surgery.

Surgeon satisfaction and outcomes of tele-proctoring for robotic gynecologic surgery

Surgical proctoring requires increasing resources in growing healthcare systems. In addition, travel has become less safe in the era of COVID-19. This study demonstrates surgeon satisfaction and safety with tele-proctoring in robotic gynecologic surgery. This pilot study assesses surgeon satisfaction and operative outcomes with a novel operative tele-proctoring system with a continuous two-way video-audio feed that allows the off-site surgeon to see the operating room, surgical field, and hands of the robotic surgeon. After thorough system testing, two experienced surgeons underwent tele-proctoring for hospital credentialing, completing 7 total cases. Each completed pre- and post-surveys developed from the Michigan Standard Simulation Experience Scale. Surgical characteristics were compared between tele-proctored cases and 59 historical cases proctored in-person over the last 8 years. Surgeons reported unanimous high satisfaction with tele-proctoring (5 ± 0). There were no major technologic issues. Five of the tele-proctored cases and 35 of controls were hysterectomies. Mean age was 48.2 ± 1.4 years, mean BMI was 29.6 ± 0.9 kg/m², and mean uterine weight was 152 ± 112.3 g. Two-thirds had prior abdominal surgery (P > 0.1). Tele-proctored hysterectomies were 58 ± 6.5 min shorter than controls (P = 0.001). There were no differences in EBL or complication rates (P > 0.1). Tele-proctoring resulted in high surgeon satisfaction rates with no difference in EBL or complications. Tele-mentoring is a natural extension of tele-proctoring that could provide advanced surgical expertise far beyond where we can physically reach.

Preceptoring, proctoring, mentoring, and coaching in surgery

Contemporary models of surgical education that are founded on sound educational theories and constructs need to be used across the continuum of professional development of surgeons starting with the first day of medical school, through surgery residency and fellowship training, to the last day of surgical practice. The highly learner-centered and individually-focused special interventions of preceptoring, proctoring, mentoring, and coaching should be linked to innovative competency-based education models to address the educational needs of learners at all levels, and especially of surgeons in practice to continually improve their knowledge, skills, and performance, with the aspirational goal of achieving expertise and mastery. Each of these interventions is distinct with its own unique characteristics, applications, and anticipated impact, which must be clearly recognized for the interventions to be used most effectively. Broad acceptance and adoption of the aforementioned special interventions require recognition of the value each brings to the learner and the educational program. Professional organizations should play a key role in designing innovative educational programs that include these interventions, supporting their integration into surgical education and surgical practice, and influencing changes in the cultures in surgery to facilitate broad adoption of these interventions.

Intraoperative and postoperative complications in colorectal procedures: the role of continuous updating in medicine

Accepting surgical complications, especially those related to the learning curve, as unavoidable events in colorectal procedures, is like accepting to fly onboard an aircraft with a 10 to 20% chance of not arriving at final destination. Under this condition, it is very likely that the aviation industry and the concurrent reshaping of the world and of our lives would have not been possible in the absence of high reliability and reproducibility of safe flights. It's hard to imagine surgery without any intraoperative and/or postoperative complications. Nevertheless, there is a plenty of room for improvement by simply adopting what has been explicitly and scientifically demonstrated; training outside of the OR, usage of modern information technologies and application of evidence-based perioperative care protocols. Additionally, the possibility to objectively measure and monitor the technical and even non-technical skills and competencies of individual surgeons and even of OR teams through the application of structured and validated assessment tools can finally put an end to the self-referential, purely hierarchical, and indeed extremely unreliable process of being authorized or not to perform operations on patients. Last but not least, a wide range of new technologies spanning from augmented imaging modalities, virtual reality for intraoperative guidance, improved robotic manipulators, artificial intelligence to assist in preoperative patient specific risk assessment, and intraoperative decision-making has the potential to tackle several hidden roots of surgical complications.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

Telementoring of in-home real-time laparoscopy using whatsapp messenger: An innovative teaching tool during the COVID-19 pandemic. A cohort study

Background

COVID-19 pandemic has decreased worldwide surgical activity, thus impairing the training of surgical residents. As a coping strategy, we opted for laparoscopic simulation with endotrainer; however, due to social distancing rules, a face-to-face tutoring training method is unfeasible. In this context telementoring using WhatsApp® Messenger (owned by Facebook Inc., Menlo Park, CA) with a Smartphone aims to train surgical residents in laparoscopy from their homes during the pandemic.

Methods

Trainers and surgical residents who were at home participated in this study. They used endotrainers with Smartphone cameras and were trained by video calls using WhatsApp. The baseline and final score of intracorporeal knotting was measured, according to the Fundamentals of Laparoscopic Surgery (FLS) methodology, measuring the difference in means with the paired t-test. Recommendations for virtual surgical tutoring were followed and user satisfaction was measured using the Likert scale.

Results

40 surgical residents participated. The average distance between the mentor and the trainee was 12.87 km. Average bandwidth was 32.5 Megabits per second (Mbits/s), latency was 424.5 ms (ms), good quality image with immediate feedback was achieved. The statistically significant difference between basal and final measurement was 23.7 points (p < 0.001). All participants found telementoring a good educational tool.

Conclusion

Smartphone telementoring using WhatsApp® Messenger is an effective educational tool for acquiring laparoscopic skills with a statistically significant difference. This type of training represents a new teaching resource in the light of the recommendations of social distancing during a pandemic.

Surgical training 2.0: A systematic approach reviewing the literature focusing on oral maxillofacial surgery - Part I

PURPOSE

Many technologies are emerging in the medical field. Having an overview of the technological arsenal available to train new surgeons seems very interesting to guide subsequent surgical training protocols.

METHODS

This article is a systematic approach reviewing new technologies in surgical training, in particular in oral and maxillofacial surgery. This review explores what new technologies can do compared to traditional methods in the field of surgical education. A structured literature search of PubMed was performed in adherence to PRISMA guidelines. The articles were selected when they fell within predefined inclusion criteria while respecting the key objectives of this systematic review. We looked at medical students and more specifically in surgery and analysed whether exposure to new technologies improved their surgical skills compared to traditional methods. Each technology is reviewed by highlighting its advantages and disadvantages and studying the feasibility of integration into current practice.

RESULTS

The results are encouraging. Indeed, all of these technologies make it possible to reduce the learning time, the operating times, the operating complications and increase the enthusiasm of the students compared to more conventional methods. The start-up cost, the complexity to develop new models, and the openness of mind necessary for the integration of these technologies are all obstacles to immediate development. The main limitations of this review are that many of the studies have been carried out on small numbers, they are not interested in acquiring knowledge or skills over the long term and obviously there is a publication bias.

CONCLUSION

Surgical education methods will probably change in the years to come, integrating these new technologies into the curriculum seems essential so as not to remain on the side. This first part therefore reviews, open field camera, telemedicine and 3D printing. This systematic review is registered on PROSPERO.

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training

Context

The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence acquisition

This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence synthesis

There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions

Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient summary

Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.

Surgical Telementoring Without Encumbrance: A Comparative Study of See-through Augmented Reality-based Approaches

OBJECTIVE

This study investigates the benefits of a surgical telementoring system based on an augmented reality head-mounted display (ARHMD) that overlays surgical instructions directly onto the surgeon's view of the operating field, without workspace obstruction.

SUMMARY BACKGROUND DATA

In conventional telestrator-based telementoring, the surgeon views annotations of the surgical field by shifting focus to a nearby monitor, which substantially increases cognitive load. As an alternative, tablets have been used between the surgeon and the patient to display instructions; however, tablets impose additional obstructions of surgeon's motions.

METHODS

Twenty medical students performed anatomical marking (Task1) and abdominal incision (Task2) on a patient simulator, in 1 of 2 telementoring conditions: ARHMD and telestrator. The dependent variables were placement error, number of focus shifts, and completion time. Furthermore, workspace efficiency was quantified as the number and duration of potential surgeon-tablet collisions avoided by the ARHMD.

RESULTS

The ARHMD condition yielded smaller placement errors (Task1: 45%, P < 0.001; Task2: 14%, P = 0.01), fewer focus shifts (Task1: 93%, P < 0.001; Task2: 88%, P = 0.0039), and longer completion times (Task1: 31%, P < 0.001; Task2: 24%, P = 0.013). Furthermore, the ARHMD avoided potential tablet collisions (4.8 for 3.2 seconds in Task1; 3.8 for 1.3 seconds in Task2).

CONCLUSION

The ARHMD system promises to improve accuracy and to eliminate focus shifts in surgical telementoring. Because ARHMD participants were able to refine their execution of instructions, task completion time increased. Unlike a tablet system, the ARHMD does not require modifying natural motions to avoid collisions.

The System for Telementoring with Augmented Reality (STAR): A head-mounted display to improve surgical coaching and confidence in remote areas

BACKGROUND

The surgical workforce particularly in rural regions needs novel approaches to reinforce the skills and confidence of health practitioners. Although conventional telementoring systems have proven beneficial to address this gap, the benefits of platforms of augmented reality-based telementoring in the coaching and confidence of medical personnel are yet to be evaluated.

METHODS

A total of 20 participants were guided by remote expert surgeons to perform leg fasciotomies on cadavers under one of two conditions: (1) telementoring (with our System for Telementoring with Augmented Reality) or (2) independently reviewing the procedure beforehand. Using the Individual Performance Score and the Weighted Individual Performance Score, two on-site, expert surgeons evaluated the participants. Postexperiment metrics included number of errors, procedure completion time, and self-reported confidence scores. A total of six objective measurements were obtained to describe the self-reported confidence scores and the overall quality of the coaching. Additional analyses were performed based on the participants' expertise level.

RESULTS

Participants using the System for Telementoring with Augmented Reality received 10% greater Weighted Individual Performance Score (P = .03) and performed 67% fewer errors (P = .04). Moreover, participants with lower surgical expertise that used the System for Telementoring with Augmented Reality received 17% greater Individual Performance Score (P = .04), 32% greater Weighted Individual Performance Score (P < .01) and performed 92% fewer errors (P < .001). In addition, participants using the System for Telementoring with Augmented Reality reported 25% more confidence in all evaluated aspects (P < .03). On average, participants using the System for Telementoring with Augmented Reality received augmented reality guidance 19 times on average and received guidance for 47% of their total task completion time.

CONCLUSION

Participants using the System for Telementoring with Augmented Reality performed leg fasciotomies with fewer errors and received better performance scores. In addition, participants using the System for Telementoring with Augmented Reality reported being more confident when performing fasciotomies under telementoring. Augmented Reality Head-Mounted Display-based telementoring successfully provided confidence and coaching to medical personnel.

Augmented Reality as a Medium for Improved Telementoring

Combat trauma injuries require urgent and specialized care. When patient evacuation is infeasible, critical life-saving care must be given at the point of injury in real-time and under austere conditions associated to forward operating bases. Surgical telementoring allows local generalists to receive remote instruction from specialists thousands of miles away. However, current telementoring systems have limited annotation capabilities and lack of direct visualization of the future result of the surgical actions by the specialist. The System for Telementoring with Augmented Reality (STAR) is a surgical telementoring platform that improves the transfer of medical expertise by integrating a full-size interaction table for mentors to create graphical annotations, with augmented reality (AR) devices to display surgical annotations directly onto the generalist's field of view. Along with the explanation of the system's features, this paper provides results of user studies that validate STAR as a comprehensive AR surgical telementoring platform. In addition, potential future applications of STAR are discussed, which are desired features that state-of-the-art AR medical telementoring platforms should have when combat trauma scenarios are in the spotlight of such technologies.

Developing a Culture of Mentorship to Strengthen Academic Medical Centers

Mentorship is central to academic medicine and its missions, and it has long played a critical role in the training and career development of physicians and scientists. A growing body of literature has documented the positive impact of mentorship on various outcomes, including research productivity, academic promotion, faculty retention, and career satisfaction. These benefits span academic medical centers' missions and have the potential to enhance biomedical research, patient care, education, and faculty diversity and leadership.In this Invited Commentary, the authors argue that a dynamic culture of mentorship is essential to the success of academic medical centers and should be elevated to the level of a major strategic priority. This culture of mentorship would capitalize on an institution's intellectual resources and seek to develop leaders in biomedical discovery, patient care, and education. The bidirectional transmission of knowledge between mentors and mentees, through both formal programs and informal relationships, can foster the growth of faculty members needed to meet the complex challenges currently confronting medical schools and teaching hospitals.Developing a culture of mentorship requires a strong commitment by leaders at all levels to nurture the next generation of physicians and scientists as well as grassroots efforts by trainees and faculty to seek out and create mentorship opportunities. The authors conclude by outlining possible mechanisms and incentives for elevating mentorship to the level of a strategic priority to strengthen academic medical centers across their missions.

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.

A pilot study of surgical telementoring for leg fasciotomy

INTRODUCTION

Acute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research.

METHODS

Three anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications.

RESULTS

14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth.

CONCLUSIONS

This study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.