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The field of telemedicine has grown tremendously over the last decade. We present a systematic review of publications on telemedicine as it pertains to surgery, addressing six facets: 1) telerobotics, 2) telementoring, 3) teleconsulting, 4) telemedicine in post-operative follow-up, 5) tele-education, and 6) current technology. A search of relevant literature querying PubMed, Web of Science, and Science Direct was performed using the following keywords: telecommunication, telemedicine, telehealth, virtual health, virtual medicine, general surgery, surgery, surgical or surgical patients. Telemedicine is being used to care for patients in remote areas, to help expert surgeons assist other specialists in the office or novice surgeons in the operating room, as well as to help teach the next generation of surgeons. There are many opportunities for surgeons to utilize this technology to optimize their practice. •Telesurgery can help overcome geographic and resource constraints.•Telementoring is an effective method of transfering surgical knowledge and expertise.•Technologic advancements have facilitated education, consultation, and remote telesurgery. The use of telemedicine in surgical care has seen substantial growth over the last decade. This article provides a descriptive review of some significant innovations in the following areas pertaining to surgery: 1) telerobotics, 2) telementoring, 3) teleconsulting, 4) telemedicine in post-operative follow-up, 5) tele-education, and 6) current technology.

This paper reports a new type of augmented reality (AR) system that integrates a Microsoft HoloLens device with a three-dimensional (3D) point tracking module for medical training and telementored surgery. In this system, a stereo camera is used to track the 3D position of a scalpel and transfer its coordinates wirelessly to a HoloLens device. In the scenario of surgical training, a virtual surgical scene with pre-recorded surgical annotations is superimposed with the actual surgical scene so that the surgical trainee is able to operate following virtual instructions. In the scenario of telementored surgery, the virtual surgical scene is co-registered with the actual surgical scene so that the virtual scalpel remotely mentored by an experienced surgeon provides the AR guidance for the inexperienced on-site operator. The performance characteristics of the proposed AR telementoring system are verified by benchtop experiments. The clinical applicability of the proposed system in telementored skin grafting surgery and fasciotomy is validated in a New Zealand rabbit model. Our benchtop and in vivo experiments demonstrate the potential to improve surgical performance and reduce healthcare disparities in remote areas with limited resources.

IntroductionRobot-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.MethodsA 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.ResultsOverall, 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.ConclusionsImprovements 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.

Over the last decade, augmented reality (AR) has emerged in health care as a tool for visualizing data and enhancing simulation learning. AR, which has largely been explored for communication and collaboration in nonhealth contexts, could play a role in shaping future remote medical services and training. This review summarized existing studies implementing AR in real-time telemedicine and telementoring to create a foundation for health care providers and technology developers to understand future opportunities in remote care and education. This review described devices and platforms that use AR for real-time telemedicine and telementoring, the tasks for which AR was implemented, and the ways in which these implementations were evaluated to identify gaps in research that provide opportunities for further study. We searched PubMed, Scopus, Embase, and MEDLINE to identify English-language studies published between January 1, 2012, and October 18, 2022, implementing AR technology in a real-time interaction related to telemedicine or telementoring. The search terms were \"augmented reality\" OR \"AR\" AND \"remote\" OR \"telemedicine\" OR \"telehealth\" OR \"telementoring.\" Systematic reviews, meta-analyses, and discussion-based articles were excluded from analysis. A total of 39 articles met the inclusion criteria and were categorized into themes of patient evaluation, medical intervention, and education. In total, 20 devices and platforms using AR were identified, with common features being the ability for remote users to annotate, display graphics, and display their hands or tools in the local user's view. Common themes across the studies included consultation and procedural education, with surgery, emergency, and hospital medicine being the most represented specialties. Outcomes were most often measured using feedback surveys and interviews. The most common objective measures were time to task completion and performance. Long-term outcome and resource cost measurements were rare. Across the studies, user feedback was consistently positive for perceived efficacy, feasibility, and acceptability. Comparative trials demonstrated that AR-assisted conditions had noninferior reliability and performance and did not consistently extend procedure times compared with in-person controls. Studies implementing AR in telemedicine and telementoring demonstrated the technology's ability to enhance access to information and facilitate guidance in multiple health care settings. However, AR's role as an alternative to current telecommunication platforms or even in-person interactions remains to be validated, with many disciplines and provider-to-nonprovider uses still lacking robust investigation. Additional studies comparing existing methods may offer more insight into this intersection, but the early stage of technical development and the lack of standardized tools and adoption have hindered the conduct of larger longitudinal and randomized controlled trials. Overall, AR has the potential to complement and advance the capabilities of remote medical care and learning, creating unique opportunities for innovator, provider, and patient involvement.

BackgroundAlthough several studies on telesurgery have been reported globally, a clinically applicable technique has not yet been developed. As part of a telesurgical study series conducted by the Japan Surgical Society, this study describes the first application of a double-surgeon cockpit system to telesurgery.MethodsSurgeon cockpits were installed at a local site and a remote site 140 km away. Three healthy pigs weighing between 26 and 29 kg were selected for surgery. Non-specialized surgeons performed emergency hemostasis, cholecystectomy, and renal vein ligation with remote assistance using the double-surgeon cockpits and specialized surgeons performed actual telesurgery. Additionally, the impact of adding internet protocol security (IPsec) encryption to the internet protocol-virtual private network (IP-VPN) line on communication was evaluated to address clinical security concerns.ResultsThe average time required for remote emergency hemostasis with the double-surgeon cockpit system was 10.64 s. A non-specialized surgeon could safely perform cholecystectomy or renal vein ligation with remote assistance. Global Evaluative Assessment of Robotic Skills and System Usability Scale scores were higher for telesurgical support-assisted surgery by a non-specialized surgeon using the double-surgeon cockpits than for telesurgery performed by a specialized surgeon without the double-cockpit system. Adding IPsec encryption to the IP-VPN did not have a significant impact on communication.ConclusionTelesurgical support through our double-surgeon cockpit system is feasible as first step toward clinical telesurgery.

BackgroundLaparoscopic surgery is rapidly expanding in low-and middle-income countries (LMICs), yet many surgeons in LMICs have limited formal training in laparoscopy. In 2017, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) implemented Global Laparoscopic Advancement Program (GLAP), an in-person simulation-based laparoscopic training curriculum for surgeons in LMICs. In light of COVID-19, SAGES adapted GLAP to a virtual format with telesimulation. This study explores the feasibility and efficacy of virtual laparoscopic simulation training in resource-limited settings.MethodsParticipants from San Jose, Costa Rica, Leon, México, and Guadalajara, México enrolled in the virtual GLAP curriculum, meeting biweekly for 2-h didactic classes and 2-h hands-on live simulation practice. Surgical residents’ laparoscopic skills were evaluated using the five Fundamentals of Laparoscopic Surgery (FLS) tasks during the initial and final weeks of the program. Participants also completed pre-and post-program surveys assessing their perception of simulation-based training.ResultsThe study cohort consisted of 16 surgical attendings and 20 general surgery residents. A minimum 70% response rate was recorded across all surveys in the study. By the end of GLAP, residents completed all five tasks of the FLS exam within less time relative to their performance at the beginning of the training program (p < 0.05). Respondents (100%) reported that the program was a good use of their time and that education via telesimulation was easily reproduced. Participants indicated that the practice sessions, guidance, and feedback offered by mentors were their favorite elements of the training.ConclusionA virtual simulation-based curriculum can be an effective strategy for laparoscopic skills training. Participants demonstrated an improvement in laparoscopic skills, and they appreciated the mentorship and opportunity to practice laparoscopic skills. Future programs can expand on using a virtual platform as a low-cost, effective strategy for providing laparoscopic skills training to surgeons in LMICs.

BackgroundIn telementoring, differences in teaching methods affect local surgeons’ comprehension. Because the object to be operated on is a three-dimensional (3D) structure, voice or 2D annotation may not be sufficient to convey the instructor’s intention. In this study, we examined the usefulness of telementoring using 3D drawing annotations in robotic surgery.MethodsKyushu University and Beppu Hospital are located 140 km apart, and the study was conducted using a Saroa™ surgical robot by RIVERFIELD Inc. using a commercial guarantee network on optical fiber. Twenty medical students performed vertical mattress suturing using a swine intestinal tract under surgical guidance at the Center for Advanced Medical Innovation Kyushu University. Surgical guidance was provided by Beppu Hospital using voice, 2D, and 3D drawing annotations. All robot operations were performed using 3D images, and only the annotations were independently switched between voice and 2D and 3D images. The operation time, needle movement, and performance were also evaluated.ResultsThe 3D annotation group tended to have a shorter working time than the control group (25.6 ± 63.2 vs. − 36.7 ± 65.4 min, P = 0.06). The 3D annotation group had fewer retries than the control group (1.3 ± 1.7 vs. − 1.1 ± 0.7, P = 0.006), and there was a tendency for fewer needle drops (0.4 ± 0.7 vs. − 0.5 ± 0.9, P = 0.06). The 3D annotation group scored significantly higher than the control group on the Global Evaluate Assessment of Robot Skills (16.8 ± 2.0 vs. 22.8 ± 2.4, P = 0.04). The 3D annotation group also scored higher than the voice (13.4 ± 1.2) and 2D annotation (16.2 ± 1.8) groups (3D vs. voice: P = 0.03, 3D vs. 2D: P = 0.03).ConclusionTelementoring using 3D drawing annotation was shown to provide good comprehension and a smooth operation for local surgeons.

Telemedicine has the potential to overcome the unequal distribution of medical resources worldwide. In this study, we report the second-generation co-axial projective imaging (CPI-2) system featured with orthotopic image projection for augmented reality surgical telementoring. The CPI-2 system can acquire surgical scene images from the local site, transmit them wirelessly to the remote site, and project the virtual annotations drawn by a remote expert with great accuracy to the surgical field. The performance characteristics of the CPI-2 system are quantitatively verified in benchtop experiments. The ex vivo study that compares the CPI-2 system and a monitor-based telementoring system shows that the CPI-2 system can reduce the focus shift and avoid subjective mapping of the instructions from a monitor to the real-world scene, thereby saving operation time and achieving precise teleguidance. The clinical feasibility of the CPI-2 system is validated in teleguided skin cancer surgery. Our ex vivo and in vivo experiment results imply the improved performance of surgical telementoring, and the clinical utility of deploying the CPI-2 system for surgical interventions in resource-limited settings. The CPI-2 system has the potential to reduce healthcare disparities in remote areas with limited resources.

IntroductionSurgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic.MethodsThis course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method 1. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year.ResultsThe ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses.ConclusionsSAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.

IntroductionContinuing Professional Development opportunities for lifelong learning are fundamental to the acquisition of surgical expertise. However, few opportunities exist for longitudinal and structured learning to support the educational needs of surgeons in practice. While peer-to-peer coaching has been proposed as a potential solution, there remains significant logistical constraints and a lack of evidence to support its effectiveness. The purpose of this study is to determine whether the use of remote videoconferencing for video-based coaching improves operative performance.MethodsEarly career surgeon mentees participated in a remote coaching intervention with a surgeon coach of their choice and using a virtual telestration platform (Zoom Video Communications, San Jose, CA). Feedback was articulated through annotating videos. The coach evaluated mentee performance using a modified Intraoperative Performance Assessment Tool (IPAT). Participants completed a 5-point Likert scale on the educational value of the coaching program.ResultsEight surgeons were enrolled in the study, six of whom completed a total of two coaching sessions (baseline, 6-month). Subspecialties included endocrine, hepatopancreatobiliary, and surgical oncology. Mean age of participants was 39 (SD 3.3), with mean 5 (SD 4.1) years in independent practice. Total IPAT scores increased significantly from the first session (mean 47.0, SD 1.9) to the second session (mean 51.8, SD 2.1), p = 0.03. Sub-category analysis showed a significant improvement in the Advanced Cognitive Skills domain with a mean of 33.2 (SD 2.5) versus a mean of 37.0 (SD 2.4), p < 0.01. There was no improvement in the psychomotor skills category. Participants agreed or strongly agreed that the coaching programs can improve surgical performance and decision-making (coaches 85%; mentees 100%).ConclusionRemote surgical coaching is feasible and has educational value using ubiquitous commercially available virtual platforms. Logistical issues with scheduling and finding cases aligned with learning objectives continue to challenge program adoption and widespread dissemination.