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Google Glass for Remote Surgical Tele-proctoring in Low- and Middle-income Countries: A Feasibility Study from Mozambique

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Background: Untreated surgical conditions account for one-third of the total global burden of disease, and a lack of trained providers is a significant contributor to the paucity of surgical care in low- and middle-income countries (LMICs). Wearable technology with real-time tele-proctoring has been demonstrated in high-resource settings to be an innovative method of advancing surgical education and connecting providers, but application to LMICs has not been well-described. Methods: Google Glass with live-stream capability was utilized to facilitate teleproctoring between a surgeon in Mozambique and a reconstructive surgeon in the United States over a 6-month period. At the completion of the pilot period, a survey was administered regarding the acceptability of the image quality as well as the overall educational benefit of the technology in different surgical contexts. Results: Twelve surgical procedures were remotely proctored using the technology. No complications were experienced in any patients. Both participants reported moderate visual impairment due to image distortion and light over-exposure. Video-stream latency and connection disruption were also cited as limitations. Overall, both participants reported that the technology was highly useful as training tool in both the intraoperative and perioperative setting. Conclusions: Our experience in Mozambique demonstrates the feasibility of wearable technology to enhance the reach and availability of specialty surgical training in LMICs. Despite shortcomings in the technology and logistical challenges inherent to international collaborations, this educational model holds promise for connecting surgeons across the globe and introducing expanded access to education and mentorship in areas with limited opportunities for surgical trainees. Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
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www.PRSGlobalOpen.com 1
Copyright © 2018 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
BACKGROUND
There is a paucity of trained health care providers in
low- and middle-income countries (LMICs) contributing
to the large unmet burden of surgical disease. Two-thirds
of the world’s population are not currently able to access
basic surgical and anesthetic care, and greater than 46.6%
of countries have a density of skilled health professionals
less than 22.8 per 10,000 population, which is categorized
by the World Health Organization as a “medical workforce
crisis.”1 As a result of this gap, an estimated 2.2 million
additional skilled medical professionals are needed to
address the current global need for surgery.2,3 Ongoing
efforts are being made, by multiple organizations and in-
stitutions, to reduce this educational gap, but attempts at
training additional providers are complicated by the prac-
tical and logistical constraints of volunteer travel.2 Local
From the *Division of Plastic Surgery, Department of Surgery, Keck
School of Medicine of the University of Southern California, Los
Angeles, Calif.; †Ohana One, Los Angeles, Calif.; ‡Department of
Surgery, Matola Hospital, Matola, Mozambique; and §Department
of Plastic and Reconstructive Surgery, Cedars Sinai Hospital, Los
Angeles, Calif.
Received for publication June 19, 2018; accepted September 14, 2018.
Supported through a philanthropic donation from the Jay and
Sue Roach Foundation.
Background: Untreated surgical conditions account for one-third of the total global
burden of disease, and a lack of trained providers is a significant contributor to the
paucity of surgical care in low- and middle-income countries (LMICs). Wearable
technology with real-time tele-proctoring has been demonstrated in high-resource
settings to be an innovative method of advancing surgical education and connect-
ing providers, but application to LMICs has not been well-described.
Methods: Google Glass with live-stream capability was utilized to facilitate tele-
proctoring between a surgeon in Mozambique and a reconstructive surgeon in
the United States over a 6-month period. At the completion of the pilot period,
a survey was administered regarding the acceptability of the image quality as well
as the overall educational benefit of the technology in different surgical contexts.
Results: Twelve surgical procedures were remotely proctored using the technology.
No complications were experienced in any patients. Both participants reported
moderate visual impairment due to image distortion and light over-exposure. Vid-
eo-stream latency and connection disruption were also cited as limitations. Overall,
both participants reported that the technology was highly useful as training tool in
both the intraoperative and perioperative setting.
Conclusions: Our experience in Mozambique demonstrates the feasibility of wear-
able technology to enhance the reach and availability of specialty surgical train-
ing in LMICs. Despite shortcomings in the technology and logistical challenges
inherent to international collaborations, this educational model holds promise for
connecting surgeons across the globe and introducing expanded access to educa-
tion and mentorship in areas with limited opportunities for surgical trainees. (Plast
Reconstr Surg Glob Open 2018;6:e1999; doi: 10.1097/GOX.0000000000001999;
Published online 5 December 2018.)
Meghan C. McCullough,
MD, MS*
Louie Kulber†
Patrick Sammons, BS*
Pedro Santos, MD‡
David A. Kulber, MD*§
Google Glass for Remote Surgical Tele-proctoring
in Low- and Middle-income Countries: A Feasibility
Study from Mozambique
Disclosure: The authors have no financial interest to de-
clare in relation to the content of this article or products men-
tioned within it. The study and Article Processing Charge
were funded through a philanthropic donation from the Jay
and Sue Roach Foundation.
Supplemental digital content is available for this ar-
ticle. Clickable URL citations appear in the text.
DOI: 10.1097/GOX.0000000000001999
SPECIAL TOPIC
PRS Global Open 2018
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providers forced to seek medical training outside of their
countries due to lack of domestic opportunities often fuel
brain drain, a failure of the newly trained providers to
return to their countries to serve the communities most
in need, and strategies to build capacity and encourage
in-country retention are essential. If this problem is not
addressed and current educational methods are not up-
dated, it is estimated that there will be a global deficit of
about 12.9 million skilled health professionals by 2035.3
Tele-proctoring is an emerging technology where au-
dio and video interaction facilitates the virtual presence
of a teacher to provide real-time instruction and technical
assistance from a different geographic location. Similar to
traditional mentoring, it allows the educator to simulta-
neously provide training to the novice surgeon while ad-
ditionally providing care to the patient. In LMICs, where
training opportunities may be limited, tele-proctoring
avoids many of the logistic obstacles around distance, time
constraints and cost associated with volunteer educators
traveling to provide in-person training.4–7 In resource-lim-
ited settings, tele-proctoring serves the additional benefit
of providing access to surgical expertise for patients requir-
ing procedures in areas where specialty care might other-
wise not exist.6–9 Numerous studies have demonstrated its
feasibility and efficacy as a surgical training model since
the emergence of the technology in the mid 1990s,4,5,8,10
and additional studies have shown its applicability to inter-
national11 and low-resource settings.12–14
The majority of surgical tele-proctoring has developed
around laparoscopic or endoscopic procedures, given the
necessity of a surgical scope during operation. The van-
tage point of the transmitted image to the remote viewer is
the same as that seen by the surgeon on the screen in the
operating room, and while transmission speed and inter-
net bandwidth raise potential concerns for image clarity,
both the remote observer and operating surgeon share an
identical perspective. Open surgery, on the other hand,
poses a unique challenge for incorporating cameras into
the surgical field and ensuring that the camera can repli-
cate the surgeon’s point of view without interfering with
his ability to use his hands. Wearable technologies, such as
Google Glass (Google, Inc, Mountain View, Calif.), which
was first introduced in 2012, represent an opportunity to
expand tele-proctoring to a wider range of open surger-
ies. Sterility in the operating room is maintained by verbal
control of the wearable device, allowing both hands to op-
erate as normal, and the view of the operative field is unim-
peded by the peripherally positioned camera and prism.
The camera is capable of taking photographs or videos
to live-stream for teaching purposes, while the prism pro-
vides a semitransparent overlay on the wearer’s visual field
by projecting a computer-generated image directly onto
the wearer’s retina. Sound is recorded and transmitted by
means of a mastoid bone conductor and earpiece, allow-
ing dialogue between wearer and the remote viewer. The
feasibility of using Google Glass in the surgical setting was
first described in Germany in 2014,15 and since then the
technology has been successfully explored as a teaching
tool throughout perioperative care in an array of surgical
and procedural specialties in high resource settings.16–21
Though its use in educational training and mentoring
in LMICs has not been described extensively, wearable
technology tele-proctoring has been shown initial success
as an educational tool in rural areas of Brazil, Paraguay,
and Mongolia.14,22 These early examples demonstrate the
potential for the application of wearable technology and
live-stream tele-proctoring to other LMICs. One such
country is Mozambique, where the surgical capacity is se-
verity limited with only 0.25 surgical specialists available
per 10,000 citizens and less than 1 hospital bed per 1,000
people.23 Currently, there are only 61 surgeons for a to-
tal population of 30 million.24 Specialty surgical care is
even more limited, with only 3 registered reconstructive
surgeons for the entire country.24 We share our 6-month
experience with Google Glass in Mozambique and dem-
onstrate the feasibility of using wearable technology with
tele-proctoring to expand access to training opportunities
in reconstructive surgery in this low resource setting.
CASE STUDY
Participants
A senior plastic and reconstructive surgeon based in
Los Angeles, California, provided training to a Mozambi-
can surgeon. The 2 surgeons, hereafter referred to as the
mentor surgeon and field surgeon, respectively, were ac-
quainted and worked together over the course of a 1 week
visit in August 2017.
Setting
All preoperative screening, operative procedures, and
postoperative care was conducted at the Provincial Hospital
of Matola, in Matola, Mozambique. Mending Kids, a 501c(3)
organization providing surgical care in 12 LMICs, coordi-
nated the location and logistics in conjunction with the Mo-
zambican Ministry of Health and faculty of Matola Hospital.
Cases
Patients were recruited from those presenting to the
hospital with conditions amenable to plastic surgical inter-
vention. Cases were presented by the field surgeon to the
mentor surgeon, and after discussion, cases for tele-men-
toring were selected primarily based on the difficulty of
the procedure and educational value to the field surgeon.
Cases were chosen to represent common presentations
encountered by field surgeon, such as burn contracture,
but which could utilize reconstructive approaches that
would be novel to him, such as regional flaps. Operations
were performed while patients were under general or lo-
cal anesthesia, administered by a local anesthesiologist. All
services were provided at no cost to the patients.
Video Streaming
The Google Glass wearable technology was tested dur-
ing the 1-week period when both the mentor and field
surgeon were in Matola, and all hardware and software re-
quirements were ensured at that time. A portable modem
“hotspot” was placed in the hospital to increase transmis-
sion speed based on this initial testing and a wi-fi hotspot
McCullough et al. Google Glass for Tele-proctoring in Mozambique
3
from the field surgeon’s cell phone was additionally used
to improve connection.
The surgeon in Mozambique transmitted video and
picture data via Google Glass equipped with AMA Xpert-
Eye software suite (AMA XpertEye Inc., Woburn, Mass.)
to the mentor surgeon in the United States, who accessed
the live-stream via a web portal. Two-way audio was pro-
vided via a speaker, and a laptop computer in the oper-
ating room provided video feed of the mentor surgeon.
The mentor surgeon conducted preoperative screening
with the field surgeon via tele-proctoring, and during that
session, appropriate cases were selected and the opera-
tive approach discussed. The field surgeon was then re-
ferred to literature to assist in preparation for the case.
During the case, the mentor surgeon walked the field sur-
geon through the procedure in a step-by-step fashion (see
video, Supplemental Digital Content 1, which displays an
example video feed from mentor surgeon’s computer,
http://links.lww.com/PRSGO/A910).
Tele-proctoring Software
The XpertEye software suite was equipped with 5 ma-
jor functions including live streaming capability, a photo
function that allowed the mentor surgeon to take a pho-
tograph with higher resolution than provided on the live
stream, a drawing function that allowed the mentor sur-
geon to “tele-strate” or annotate images captured from the
live stream and project them back onto the field surgeon’s
visual field via the Google Glass prism (Fig. 1), and a zoom
function that allowed the mentor surgeon to zoom into
the center of the live stream video display.
Data Collection
Twelve bimonthly surgical proctoring sessions were
held over the course of a 6-month period following the
initial visit during which surgeries were live streamed with
2-way audio and video communication to the mentor sur-
geon in the United States. Figure 2 demonstrates an exam-
ple case of a patient undergoing resection of a giant cell
tumor of third digit. Images were screen-captured from
the mentor surgeon’s remote computer. A log was used
to record all procedures performed utilizing the Google
Glass technology, as well as preoperative screenings and
postoperative evaluations. Notes were taken on any inter-
ruptions in the stream and any complications experienced
by the patient were recorded for both the intraoperative
and postoperative setting.
At the conclusion of the 6-month pilot phase, an on-
line, 10-question survey was administered to both the
field surgeon and mentor surgeon. The questionnaire was
adapted from prior work by Hashimoto et al.25 on assess-
ing acceptability of video platforms in surgical settings and
evaluated both functionality of the Google Glass as well as
the quality of video from the livestream. Additional narra-
tive interviews were conducted with both participants to
gain further insight into potential challenges and limita-
tions of the program.
RESULTS
Over the course of the pilot period, 12 surgeries
were completed using Google Glass and XpertEye tele-
proctoring (Table 1). None of the patients experienced
any complications either intraoperatively or postop-
eratively. Among the 12 operations, all were successfully
livestreamed in real time. As previously discussed, the
majority of procedures performed were unfamiliar to the
field surgeon. Specifically, all rotational and pedicle flaps
were new approaches for him. For techniques in which
Video Graphic 1. See video, Supplemental Digital Content 1, which
displays an example video feed from mentor surgeon’s computer,
http://links.lww.com/PRSGO/A910.
Fig. 1. Remote “tele-stration.”
Fig. 2. Excision of a giant cell tumor of the third digit using Google
Glass tele-proctoring.
PRS Global Open 2018
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the field surgeon had previous experience, for example
skin grafting and z-plasty, nuances in technique in skin
marking or bolster dressings were emphasized.
Survey results demonstrate the biggest limitations to the
experience, from the perspective of both the mentor sur-
geon and the field surgeon, were issues related to image dis-
tortion. Image quality was sufficient for the mentor surgeon
to perceive and to comment on pertinent anatomical struc-
tures, instrument handling, positioning and technique, but
distortion due to light overexposure, motion artifact, and
image resolution were rated as moderate to significant im-
pairments (Fig. 3). The field surgeon rated the overall video
quality as good while the mentor surgeon rated it as fair.
Despite image distortion, both surgeons found the
technology to be helpful as a teaching instrument.
Figure 4 demonstrates the perceived usefulness of the
technology by both the mentor surgeon and the field sur-
geon in various surgical contexts.
DISCUSSION
Overall, both the mentor surgeon and field surgeon re-
ported that the technology was very helpful for surgical train-
ing in both the preoperative and intraoperative context. The
seeming discrepancy between reported rates of impairment
from image distortion and the still high subjective satisfac-
tion with the experience may be attributed to a higher toler-
ance for technologic shortcomings in low resource settings
coupled with the strong desire for educational opportunities.
While the technology was imperfect, tele-mentoring repre-
sented the only source for instruction for the field surgeon in
this setting, apart from once yearly visits from the mentor sur-
geon and his team. In contrast to those far-spaced, in-person
interactions, tele-mentoring provided a constant line of com-
munication and a virtual presence of the mentor to provide
continuity to the field surgeon’s learning experience. This
benefit was felt by both the mentor and the field surgeon to
far outweigh the shortcomings of the visual display.
Table 1. Case Log of Tele-proctored Sessions Including Patient Information and Technical Specications
Case Date
Patient
Age Presentation Procedure
Connection
Speed Technologic Issues
1 August 30 2 Post burn contracture to
palm of right hand
Contracture release with multiple
z-plasties
Not
documented
Connectivity issues,
audio distortion
2 August 30 2 Post burn contracture
to lateral aspect of left
popliteal fossa
Contracture excision and reconstruc-
tion with multiple z-plasties
Not
documented
Connectivity issues,
audio distortion
3 September 1 2 Skin graft failure post pre-
vious burn contracture
release on dorsum of
right hand
Full-thickness skin graft Not
documented
Connectivity issues,
audio distortion
4 September 22 5 Ectropion of the right
lower eyelid and epi-
canthus, widened scars
across the face
Pentagonal scar excision on lower eye-
lid with eyelid margin eversion, and
w-plasty revision of right cheek scar
and excision of left eyebrow scar
Not
documented
Not documented
5 September 22 1 3rd degree flame burn to
7% BSA on right lower
limb with exposed heel
bone
Reverse sural flap for soft-tissue defect
of heel and split-thickness skin graft
for remaining wounds
Not
documented
Not documented
6 September 29 19 Giant cell tumor of right
3rd digit
Excision and local tissue rearrange-
ment
12.01 mbps Connectivity issues,
audio distortion
7 November 15 6 Posterior ankle avulsion
wound with Achilles
tendon rupture
Debridement, tendon lengthening and
coverage with posterior tibial artery
perforator propeller flap and small
split-thickness skin graft for donor
area
Not
documented
Connectivity issues,
audio distortion
8 December 22 8 3rd degree electrical burn
to 1st, 2nd, 3rd and 5th
digits of right hand
Finger reconstruction with multiple
random cross finger flaps (proximal
phalanx crossed volar flap from
2nd to 1st digit, reversed crossed
adipofascial flap from dorsum of
middle phalanx of 2nd to 3rd digit)
and full-thickness skin grafts
Not
documented
Not documented
9 January 14 24 3rd degree electrical burn
to 5th digit of left hand
Reconstruction of 5th digit with staged
cross thoracic to digit random flap
Not
documented
Not documented
10 January 31 20 Heel avulsion wound Soft-tissue coverage with antegrade
cross leg sural flap
13.92 mbps Connectivity issues,
audio distortion
11 February 2 9 3rd degree electrical burn
to 1st and 3rd left hand
Finger reconstruction first dorsal
metacarpal artery flap for thumb
and reversed crossed adipofascial
flap from 2nd to 3rd digit plus full-
thickness skin grafts
8.50 mbps No connection
issues
12 February 9 32 3rd degree electrical burn
to 2nd and 3rd digits of
left hand
reconstruction of 3rd digit by excision
of burn and primary closure and
of 2nd digit with staged cross digit
random flap
Not
documented
Not documented
BSA, body surface area.
McCullough et al. Google Glass for Tele-proctoring in Mozambique
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Although objective measures of technical proficiency
were not undertaken during this pilot period, the field sur-
geon did subjectively feel that his proficiency in the spe-
cialty had increased through the tele-mentoring. Toward
the end of the pilot phase, the field surgeon passed the
College of Surgeons of East, Central and Southern Africa
boards after having twice previously not passed. Although
causation cannot be inferred, in his narrative interview,
the field surgeon did feel that the tele-mentoring experi-
ence, specifically as it facilitated conversations around sur-
gical planning, intraoperative problem solving and critical
thinking, was critical to his exam preparation.
Although both participants reported the technology to
be very helpful for surgical education and desired to con-
tinuing using it, several limitations and challenges experi-
enced during the pilot phase warrant further discussion.
Fig. 3. Perceived degree of impairment due to various image distortions.
Fig. 4. Perceived education value in various surgical contexts.
PRS Global Open 2018
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First, the logistical requirements for tele-proctoring were sig-
nificant. The software suite required a powerful and reliable
wireless internet connection in the hospital, which, given
the large bandwidth required for video and audio stream-
ing, was frequently insufficient resulting in interruptions in
connectivity. Even with the addition of internet “hotspots” in
the hospital to improve bandwidth and transmission speed,
disruptions occurred in nearly every case. Additionally, la-
tency in the video stream lead to poor reproducibility of mo-
tion, which was cited as a moderate impairment.
Time zone differences posed another logistical diffi-
culty for live-streaming, and the 10-hour time difference
between the Los Angeles, California, and Matola, Mozam-
bique meant that the mentor surgeon often had to proctor
cases in the middle of the night. Another practical consid-
eration was the fitting of the Google Glass headset onto
surgical loupes. Surgical loupes are used in the majority of
reconstructive surgical procedures, which, depending on
the style of the loupes, may interfere with the surgeon’s
ability to wear the Google Glass headset. Our field surgeon
was able to accommodate the headset due to the design of
his loupes (Fig. 5), but the ability to adapt the headset to
accommodate surgical loupes must be considered.
Image quality, as cited in other studies, was also a signif-
icant limitation.21,25 One of the most common distortions
was due to overexposure of the image from the operating
room lights. Figure 6 demonstrates light overexposure on
a case of full-thickness skin graft to the dorsal hand (A)
and correction of the image after light adjustment (B).
We have since trialed a neutral density gel coating (Lee In-
ternational, Burbank, Calif.) over the camera to minimize
glare and have found promising results in initial testing in
the United States, but field testing with remote tele-proc-
toring has not yet been undertaken.
Other challenges noted in the narrative interviews in-
clude difficulties with the zoom function of the software
and the potential for parallax, or a displacement in what
the surgeon sees and what the camera captures when the
surgeon moves their head when operating (Fig. 7). While
the zoom function could target the center of the screen,
the inability to direct the zoom to other areas of the visual
field led to occasional difficulty centering on the point of
interest.
Another limitation of the platform is its cost. A yearly
contract for the wearable hardware and Expert Eye operat-
ing platform is $6,990 USD. Although this is significantly
less than the cost of importing a team of high-income coun-
try volunteers for a short-term surgical trip, the price is not
insignificant, especially for low-resource settings. The exact
costs for short-term surgical trips are varied based on the
specific requirements of the setting, number of volunteers,
and types of surgeries undertaken, but numerous studies
in the literature have demonstrated the cost effectiveness
of the model with respect to disability-adjusted life years
for a variety of surgical conditions.27–29 To our knowledge,
no similar studies have been undertaken on the cost-effec-
tiveness of tele-mentoring in LMICs, but given the com-
paratively low cost of the hardware and software relative
to the organization of an international volunteer trip, the
cost-benefit ratio should be even greater.
Finally, limitations to the study design include a low
number of cases, the short time frame of the pilot phase
and the experience of a single field surgeon and mentor
surgeon. Further data will need to be collected to follow
long-term patient outcomes and determine skill retention.
Expanding to include additional cases and surgeons will
also be essential for proving the generalizability of our ex-
perience and findings. Additionally, objectively assessing
surgeon technical skill will be critical for understanding
the impact of tele-proctoring with wearable technology on
skill acquisition and maintenance, and future work with
our collaboration will plan to utilize competency-based in-
struments such as the Objective Structured Assessment of
Technical Skills.26
Since the pilot experience, improvements in infra-
structure and equipment have been made, which should
benefit future iterations of the project. Increased wireless
access in the hospital, for example, should help mitigate
connectivity issues. Still, disruptions in the connection were
less frequently cited as concerns than image distortion and
resolution. To address these hardware-specific limitations,
and because active development of Google Glass hardware
has been ceased, a next generation device called the Vuzix
(Vuzix Corp, Rochester, N.Y.) will be utilized starting on the
next trip in August 2018. Compared with Google Glass, it
can run both iOS and Android operating systems, is more
break resistant, and has batteries that can be exchanged
without interrupting the video stream, allowing for up to
Fig. 5. Fitting the Google Glass headset over surgical loupes.
McCullough et al. Google Glass for Tele-proctoring in Mozambique
7
12 hours of continuous use. Additionally, increased random
access memory (RAM) and video processing capabilities
allow the camera to stream higher quality images while
auto-focus features, image stabilization and scene illumi-
nation help to mitigate image distortion errors. Improved
gyroscopes and compass systems also improve head track-
ing for increased fidelity to the wearer’s visual field. Finally,
the headpiece can be worn without lenses to easily accom-
modate surgical loupes. There is no existing literature
evaluating the Vuzix in the surgical setting, but its techni-
cal specifications hold promise for improving many of the
technical challenges experienced during our pilot phase.
CONCLUSIONS
The global surgical community must urgently decide
on how to train a vast workforce of future surgeons, how
to motivate them to remain within LMICs, and how to sup-
port these surgeons to provide sustainable, high-quality
care. Surgical aid to LMICs has long been dominated by
short-term trips by high-income country volunteers, and
creative solutions are needed to refocus efforts on surgi-
cal education and prioritize the development of local sur-
geons within their countries and local practice settings.
Although the present tele-mentoring platform has short-
comings, constant development will continue to refine the
technologic limitations and we believe will be driven, in
part, by interest in and application of the technology to
novel settings and problems.
Our experience in Mozambique demonstrates the fea-
sibility of tele-proctoring with wearable technology as an
educational model to enhance the reach and availability
of specialty surgical training in a resource-limited setting,
Fig. 6. Light-over exposure (A) and correction (B).
Fig. 7. Image parallax and displacement of point of interest within remote viewer’s screen.
PRS Global Open 2018
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and its user acceptability for both trainee and educator.
Despite shortcomings in the present technology and logis-
tical challenges inherent to international collaborations,
this educational model holds promise for connecting
surgeons across the globe, introducing expanded access
to education and mentorship in areas with limited oppor-
tunities for surgical trainees and generating discussion
around the potential for innovative technologies to ad-
dress needs in training and care delivery in LMICs.
Meghan McCullough, MD, MS
Division of Plastic Surgery
Department of Surgery
Keck School of Medicine of the University
of Southern California
1510 San Pablo Street, Suite 415 Los Angeles, CA 90033
E-mail: Meghan.McCullough@med.usc.edu
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... Alternatively, teleproctoring has long been employed in surgical training and allows virtual real-time instructions through video and audio interaction from a distant location. In this sense, the proctor may train a fellow in a clinical environment [5,6]. ...
... According to McCullough et al., it is a "technology where audio and video interaction facilitate the virtual presence of a teacher to provide real-time instruction and technical assistance from a different geographic location." Similar to the traditional approach, this method allows the proctor to provide training to the surgery fellow amid clinical setting [6]. However, it mitigates logistic obstacles concerning distance, time constraints, and costs [11]. ...
... However, it mitigates logistic obstacles concerning distance, time constraints, and costs [11]. Teleproctoring was a success as an educational tool in different countries [6,12,13]. ...
Article
Full-text available
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
... Compared to other devices like smartphones, smart glasses allow a hands-free audiovisual communication and, not long after its introduction, attempts were made to implement this technology for telemedical support. [7][8][9] The results were promising but did not meet requirements for standardized implementation for telemedical support in LMICs. Especially under challenging lighting conditions in the operating room (OR) and at the surgical site, Google Glass did not meet the requirements that are needed for proper identification of surgical landmarks and anatomical structures to provide remotely reliable surgical support. ...
... This problem has already been described in the literature and should be considered. 7 Another major difficulty was establishing and maintaining a stable and sufficiently fast internet connection in the African study center. Even though the software requirements for internet speed are relatively low, the internet connection must not drop below the required value. ...
... This phenomenon was also described in the literature during a field test with the Google Glass and significantly limited the imaging quality. 7 In our study the intraoperative imaging resolution was limited due to the restricted 3D visualization of the surgical field. However, the main problem was the clipped white effect, which made assessment of the surgical site in all cases not possible. ...
Article
Full-text available
OBJECTIVE Telemedicine technology has been developed to allow surgeons in countries with limited resources to access expert technical guidance during surgical procedures. The authors report their initial experience using state-of-the-art wearable smart glasses with wireless capability to transmit intraoperative video content during spine surgery from sub-Saharan Africa to experts in the US. METHODS A novel smart glasses system with integrated camera and microphone was worn by a spine surgeon in Dar es Salaam, Tanzania, during 3 scoliosis correction surgeries. The images were transmitted wirelessly through a compatible software system to a computer viewed by a group of fellowship-trained spine surgeons in New York City. Visual clarity was determined using a modified Snellen chart, and a percentage score was determined on the smallest line that could be read from the 8-line chart on white and black backgrounds. A 1- to 5-point scale (from 1 = unrecognizable to 5 = optimal clarity) was used to score other visual metrics assessed using a color test card including hue, contrast, and brightness. The same scoring system was used by the group to reach a consensus on visual quality of 3 intraoperative points including instruments, radiographs (ability to see pedicle screws relative to bony anatomy), and intraoperative surgical field (ability to identify bony landmarks such as transverse processes, pedicle screw starting point, laminar edge). RESULTS All surgeries accomplished the defined goals safely with no intraoperative complications. The average download and upload connection speeds achieved in Dar es Salaam were 45.21 and 58.89 Mbps, respectively. Visual clarity with the modified white and black Snellen chart was 70.8% and 62.5%, respectively. The average scores for hue, contrast, and brightness were 2.67, 3.33, and 2.67, respectively. Visualization quality of instruments, radiographs, and intraoperative surgical field were 3.67, 1, and 1, respectively. CONCLUSIONS Application of smart glasses for telemedicine offers a promising tool for surgical education and remote training, especially in low- and middle-income countries. However, this study highlights some limitations of this technology, including optical resolution, intraoperative lighting, and internet connection challenges. With continued collaboration between clinicians and industry, future iterations of smart glasses technology will need to address these issues to stimulate robust clinical utilization.
... Humanitarian trips and partnership programs between low-and high-income hospitals are essential to provide initial training of local surgeons, enabling a continuity of surgical care that lasts well beyond the mission trip. Where such trips are not feasible, global web meetings, 17 live surgery viewings, 18 and remote mentoring 18 are also beneficial to the training of surgeons in low-income countries. ...
... Humanitarian trips and partnership programs between low-and high-income hospitals are essential to provide initial training of local surgeons, enabling a continuity of surgical care that lasts well beyond the mission trip. Where such trips are not feasible, global web meetings, 17 live surgery viewings, 18 and remote mentoring 18 are also beneficial to the training of surgeons in low-income countries. ...
Article
Full-text available
Introduction: There is a significant unmet need for cleft repair in low-income countries. The procedure is challenging due to limited access, small fragile flaps, and the depth at which sutures need to be placed. The aim of this analysis is to review available literature pertaining to cleft lip and palate repair training, with a focus on those applicable to low-income countries. Methodology: Literature searches of Medline and EMBase were performed to identify studies of cleft lip and/or palate training. Terms including "cleft," "lip," "palate," and "training" were searched. Literature published in English from inception to May 2021 in which the full text was available was considered for inclusion. Studies were included on the basis that they included interventions such as virtual/online training, simulation training, courses, fellowships, and/or hospital-based training. Studies that met this criterion were further assessed using a validated scoring tool then the applicability of each training strategy for low-income countries reviewed. Results: Nineteen studies were included in this analysis. Of these 4 studies pertained to online training, 11 studies illustrated cleft models and simulation training, while 4 studies highlighted the role of charity led training achieved through direct hospital teaching and fellowship programs. The training strategies described have been summarised and presented herein in a narrative format. The simplicity, fidelity, and training benefit of palatoplasty models has also been described. Conclusions: Cleft lip and palate repair training should be accessible to surgeons in low-income countries. Direct practical experience has an important role in training to perform cleft procedures. Affordable, simple simulation models that resemble human tissue are essential so that surgeons can safely practice skills between initial training and operating on a living child.
... A large number of commercially available smartglasses feature video streaming functionality [7,30,66]. Applications for smartglasses have a wide addressability, among which applications to improve the quality of life for people with visual impairments [42,131,135], receiving information about one's surroundings [110], streaming the wearer's firstperson video to remote viewers [3,72,105], consuming media projected on see-through lenses [52,89,90], and lifelogging [4,5]. For example, Stearns et al. [131] introduced a system that used the HoloLens HMD to render video captured by the smartphone: on HoloLens, users with low vision were able to see a magnified version of the visual reality. ...
... Tanuwidjaja et al. [135] developed a smartglasses-based system for color substitution to assist colorblind people to distinguish color information. Rio and McCullough [72,105] discussed telementoring and teleproctoring applications. Other systems employed video streaming to provide access to remote events rendered via HMDs [90], view favorite parts from videos recorded in 360 • [89], end-to-end VR streaming [52], and super-multi view 3-D content delivered from an autostereoscopic device to a web browser [117]. ...
Article
Full-text available
We address in this work the topic of broadcasting one’s visual reality, captured by the video cameras embedded in mobile and wearable devices, to a remote audience. We discuss several designs of such life broadcasting systems, which we position at the intersection of lifelogging, Alternate Reality, and Cross-Reality technology. To this end, we introduce the “Alternate Reality Broadcast-Time” matrix for the broadcasting and consumption of alternate realities, in which designs of systems that implement sharing and consumption of personal visual realities can be positioned, characterized, and compared. These design options range from simple video streaming over the web using conventional video protocols to mediated and augmented reality, to audio narration and vibrotactile rendering of concepts automatically detected from video captured by wearable cameras. To demonstrate the usefulness of our broadcast-time matrix, we describe three prototypes implementing lifelogging, concept recognition from video, augmented and mediated vision, and vibrotactile feedback. Our contributions open the way toward new applications that blend lifelogging, consumption of multimedia alternate realities, and XR technology to empower users with richer opportunities for self-expression and new means to connect with the followers of events in their lives.
... Twenty-five (13.7%) studies reported limitations to telemedicine for surgical care in LMICs. These included Internet bandwidth, network instability and coverage [69,78,82,[122][123][124], high costs of technology set-up [55,125], and safety, privacy and confidentiality concerns [117,118,126]. Poor image quality for asynchronous (where information transmission and response do not take place in real-time) telemedicine [127], inability to confirm delivery of information by SMS recipients [128,129], and time zone differences for international collaborations and mentoring [31] were additional limitations that were reported. ...
Article
Background: Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking. Aim: To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs. Methods: This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021. Results: A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes. Conclusion: Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes.
... Similar models have been used in teleproctoring for peer teaching across surgical specialty centres on both a national and international level (12). With a myriad of potential benefits derived from the integration of telemedicine into every facet of clinical environments in the wake of the COVID pandemic; this randomised control trial aimed to evaluate the perceived benefit of surgical bedside teaching sessions using common surgical conditions on a virtual platform. ...
Article
Background The social distancing recommendations from the WHO during the pandemic has resulted in a pivot point in the delivery of medical education. With the medical student clinical experience constantly under threat; novel methods to maintain adequate surgical patient exposure and student interaction on a platform amenable to the interactive format required were devised using a virtual platform to compliment current pedagogical approaches. Methods A parallel randomised control trial evaluated the perceived use of remote learning in place of bedside teaching. Participants were randomised to undergo surgical bedside teaching in person or virtually. Feedback questionnaires and exit interviews carried out following each session. Content analysis of transcripts was performed to evaluate the presence and quality of perceived learning, benefits and limitations to each modality. Results Feedback demonstrated greater engagement, satisfaction, involvement and learning (p<0.001) in the bedside teaching group. Content analysis yielded three main themes; Technological, Interpersonal Component, Provision of Content. Participants in the virtual group reported a limited ability to elicit clinically relevant findings in surgical patients. Students however reported the virtual teaching was an acceptable method of learning with 90% satisfaction reported for learning via the virtual platform. Discussion The pandemic posed challenges to adequate student-patient exposure. Delivering surgical bedside teaching remotely is a method amenable to learning for students, with advantages including convenience, fewer reports of information fatigue, and decreased perceived pressure identified with this learning modality.
Article
Durante la pandemia COVID-19 se ha incrementado el uso de la telemedicina y de plataformas virtuales en el campo de la medicina, por ello en nuestra institución contamos con un sistema multicámara que permite la visualización en vivo de procedimientos endovasculares. Se realizaron once casos de aneurismas, malformaciones arteriovenosas y hematomas subdurales crónicos que fueron tratados y transmitidos en vivo sin problemas técnicos a través de la plataforma Zoom®. El tiempo promedio de transmisión y del número de participantes fue de 2.5 horas y 6 participantes, respectivamente. En todos los casos se discutió la técnica empleada y las complicaciones ocurridas. El aprendizaje remoto con plataformas en línea es hoy en día una herramienta importante, pero no un sustituto del aprendizaje práctico para procedimientos endovasculares. Recomendamos su implementación durante la pandemia de COVID-19 como un sustituto temporal, especialmente para los médicos en entrenamiento que no tienen acceso a intervenciones endovasculares avanzadas.
Chapter
Rapid expansion of internet access and mobile technologies in low-and middle-income countries has accelerated interest in digital health strategies to improve cardiac surgery outcomes in resource-constrained areas. Several pilot studies of wearable and portable health monitoring devices, virtual reality, and telehealth platforms have shown great promise as governments strategically invest in information and communication technology expansion and costs continue to decline for internet-assisted devices. However, future research directions on digital health systems and interventions must focus on overcoming key challenges in achieving interoperability with existing health care infrastructures, ensuring coverage across diverse socio-economic regions, and user-centric design approaches that incorporate the local cultural context to increase adoption and usability.
Article
Virtual education is a promising tool for expanding surgical training and continuing education. The authors present their preferred platforms for virtual surgical education, and discuss security and privacy concerns. Maintaining communication and keeping sessions engaging require special consideration when education is done virtually. The limitations to virtual education may soon be mitigated by new technologies. In this article, the authors aim to describe the benefits, current modalities, tips for use, and future directions for virtual education as it pertains to plastic surgeons and trainees during the current coronavirus pandemic.
Article
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Objective This systematic review aims to provide a summary of the use of real-time telementoring, telesurgical consultation and telesurgery in surgical procedures in patients in low/middle-income countries (LMICs). Design A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Collaboration published guidelines. Data sources EMBASE, MEDLINE, Cochrane, PubMed and Google Scholar were searched for original articles and case reports that discussed telementoring, telesurgery or telesurgical consultation in countries defined as low-income or middle-income (as per the World Banks’s 2021–2022 classifications) from inception to August 2021. Eligibility criteria for selecting studies All original articles and case reports were included if they reported the use of telemedicine, telesurgery or telesurgical consultation in procedures conducted on patients in LMICs. Results There were 12 studies which discussed the use of telementoring in 55 patients in LMICs and included a variety of surgical specialities. There was one study that discussed the use of telesurgical consultation in 15 patients in LMICs and one study that discussed the use of telesurgery in one patient. Conclusion The presence of intraoperative telemedicine in LMICs represents a principal move towards improving access to specialist surgical care for patients in resource-poor settings. Not only do several studies demonstrate that it facilitates training and educational opportunities, but it remains a relatively frugal and efficient method of doing so, through empowering local surgeons in LMICs towards offering optimal care while remaining in their respective communities.
Article
Full-text available
Background: With the increased efforts to adopt health information technology in the healthcare field, many innovative devices have emerged to improve patient care, increase efficiency, and decrease healthcare costs. A recent addition is smart glasses: web-connected glasses that can present data onto the lenses and record images or videos through a front-facing camera. OBJECTIVE: In this article, we review the most salient uses of smart glasses in healthcare, while also denoting their limitations including practical capabilities and patient confidentiality. METHODS: Using keywords including, but not limited to, "smart glasses", "healthcare", "evaluation", "privacy", and "development", we conducted a search on Ovid-MEDLINE, PubMed, and Google Scholar. A total of 71 studies were included in this review. RESULTS: Smart glasses have been adopted into the healthcare setting with several useful applications including, hands-free photo and video documentation, telemedicine, Electronic Health Record retrieval and input, rapid diagnostic test analysis, education, and live broadcasting. CONCLUSIONS: In order for the device to gain acceptance by medical professionals, smart glasses will need to be tailored to fit the needs of medical and surgical sub-specialties. Future studies will need to qualitatively assess the benefits of smart glasses as an adjunct to the current health information technology infrastructure.
Article
Background: In recent years, wearable devices have become increasingly attractive and the health care industry has been especially drawn to Google Glass because of its ability to serve as a head-mounted wearable device. The use of Google Glass in surgical settings is of particular interest due to the hands-free device potential to streamline workflow and maintain sterile conditions in an operating room environment. Objective: The aim is to conduct a systematic evaluation of the literature on the feasibility and acceptability of using Google Glass in surgical settings and to assess the potential benefits and limitations of its application. Methods: The literature was searched for articles published between January 2013 and May 2017. The search included the following databases: PubMed MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO (EBSCO), and IEEE Xplore. Two reviewers independently screened titles and abstracts and assessed full-text articles. Original research articles that evaluated the feasibility, usability, or acceptability of using Google Glass in surgical settings were included. This review was completed following the Preferred Reporting Results of Systematic Reviews and Meta-Analyses guidelines. Results: Of the 520 records obtained, 31 met all predefined criteria and were included in this review. Google Glass was used in various surgical specialties. Most studies were in the United States (23/31, 74%) and all were conducted in hospital settings: 29 in adult hospitals (29/31, 94%) and two in children's hospitals (2/31, 7%). Sample sizes of participants who wore Google Glass ranged from 1 to 40. Of the 31 studies, 25 (81%) were conducted under real-time conditions or actual clinical care settings, whereas the other six (19%) were conducted under simulated environment. Twenty-six studies were pilot or feasibility studies (84%), three were case studies (10%), and two were randomized controlled trials (6%). The majority of studies examined the potential use of Google Glass as an intraoperative intervention (27/31, 87%), whereas others observed its potential use in preoperative (4/31, 13%) and postoperative settings (5/31, 16%). Google Glass was utilized as a videography and photography device (21/31, 68%), a vital sign monitor (6/31, 19%), a surgical navigation display (5/31, 16%), and as a videoconferencing tool to communicate with remote surgeons intraoperatively (5/31, 16%). Most studies reported moderate or high acceptability of using Google Glass in surgical settings. The main reported limitations of using Google Glass utilization were short battery life (8/31, 26%) and difficulty with hands-free features (5/31, 16%). Conclusions: There are promising feasibility and usability data of using Google Glass in surgical settings with particular benefits for surgical education and training. Despite existing technical limitations, Google Glass was generally well received and several studies in surgical settings acknowledged its potential for training, consultation, patient monitoring, and audiovisual recording.
Article
Objectives We aimed to explore the potential benefits of using smart glasses – wearable computer optical devices with touch-less command features – in the surgery room and in outpatient care settings in urology. Materials and methods Between April and November 2015, 80 urologists were invited to use Google Glass in their daily surgical and clinical practice, and to share them with other urologists. Participants rated the usefulness of smart glasses on a 10-point scale, and provided insights on their potential benefits in a telephone interview. Results During the testing period, 240 urologists used smart glasses, and the 80 initially invited rated their usefulness. Mean scores for usefulness in the surgery room and in outpatient clinics were 7.4 and 5.4, respectively. The interview revealed that the applications of smart glasses considered most promising in surgery were live video streaming and static image playback, augmented reality, laparoscopic navigation, and digital checklist for safety verification. In outpatient settings, participants considered the glasses useful as a viewing platform for sharing test results, for browsing digital vademecum, and for checking medical records in emergency situations. Conclusions Urologists engaged in our experience identified various uses of smart glasses with potential benefits for physician's daily practice, particularly in the urological surgery setting. Further quantitative studies are needed to exploit the actual possibilities of smart glasses and address the technical limitations for their safe use in clinical and surgical practice.
Article
Objectives: We aimed to explore the potential benefits of using smart glasses - wearable computer optical devices with touch-less command features - in the surgery room and in outpatient care settings in urology. Materials and methods: Between April and November 2015, 80 urologists were invited to use Google Glass in their daily surgical and clinical practice, and to share them with other urologists. Participants rated the usefulness of smart glasses on a 10-point scale, and provided insights on their potential benefits in a telephone interview. Results: During the testing period, 240 urologists used smart glasses, and the 80 initially invited rated their usefulness. Mean scores for usefulness in the surgery room and in outpatient clinics were 7.4 and 5.4, respectively. The interview revealed that the applications of smart glasses considered most promising in surgery were live video streaming and static image playback, augmented reality, laparoscopic navigation, and digital checklist for safety verification. In outpatient settings, participants considered the glasses useful as a viewing platform for sharing test results, for browsing digital vademecum, and for checking medical records in emergency situations. Conclusions: Urologists engaged in our experience identified various uses of smart glasses with potential benefits for physician's daily practice, particularly in the urological surgery setting. Further quantitative studies are needed to exploit the actual possibilities of smart glasses and address the technical limitations for their safe use in clinical and surgical practice.
Article
Observation of surgical procedures performed by experts is extremely important for acquisition and improvement of surgical skills. Smart glasses are small computers, which comprise a head-mounted monitor and video camera, and can be connected to the internet. They can be used for remote observation of surgeries by video streaming. Although Google Glass is the most commonly used smart glasses for medical purposes, it is still unavailable commercially and has some limitations. This article reports the use of a different type of smart glasses, InfoLinker, for surgical video streaming. InfoLinker has been commercially available in Japan for industrial purposes for more than 2 years. It is connected to a video server via wireless internet directly, and streaming video can be seen anywhere an internet connection is available. We have attempted live video streaming of knee arthroplasty operations that were viewed at several different locations, including foreign countries, on a common web browser. Although the quality of video images depended on the resolution and dynamic range of the video camera, speed of internet connection, and the wearer's attention to minimize image shaking, video streaming could be easily performed throughout the procedure. The wearer could confirm the quality of the video as the video was being shot by the head-mounted display. The time and cost for observation of surgical procedures can be reduced by InfoLinker, and further improvement of hardware as well as the wearer's video shooting technique is expected. We believe that this can be used in other medical settings.
Article
Background The relatively decreased time spent in the operating room and overall reduction in cases performed by neurosurgical trainees as a result of duty-hour restrictions demands that the pedagogical content within each surgical encounter be maximized and crafted toward the specific talents and shortcomings of the individual. It is imperative to future generations that the quality of training adapts to the changing administrative infrastructures and compensates for anything that may compromise the technical abilities of trainees. Neurosurgeons in teaching hospitals continue to experiment with various emerging technologies—such as simulators and virtual presence—to supplement and improve surgical training. Methods The authors participated in the Google Glass Explorer Program in order to assess the applicability of Google Glass as a tool to enhance the operative education of neurosurgical residents. Google Glass is a type of wearable technology in the form of eyeglasses that employs a high-definition camera and allows the user to interact using voice commands. Results Google Glass was able to effectively capture video segments of various lengths for residents to review in a variety of clinical settings within a large, tertiary care university hospital, as well as during a surgical mission to a developing country. The resolution and quality of the video were adequate to review and use as a teaching tool. Conclusion While Google Glass harbors the potential to dramatically improve both neurosurgical education and practice in a variety of ways, certain technical drawbacks of the current model limit its effectiveness as a teaching tool.
Article
Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.
Article
New technologies and innovations are common in the delivery of modern health care. Google Glass is one such device gaining increased attention in medical specialties. The authors surveyed residents and attending physicians in the Department of Plastic Surgery, MedStar Georgetown University Hospital, on their experience using Google Glass in the operating room. Ease of use, quality of images, gaze disruption, and distraction during surgery were measured. Overall, subjects found the device to be comfortable and satisfying to wear and use during surgery to capture images of good quality. Despite some identified weaknesses, Google Glass is a unique technology with a promising plastic surgical application in the operating room.
Article
Google Glass is, in essence, a smartphone in the form of a pair of spectacles. It has a display system, a bone conduction “speaker,” video camera, and connectivity via WiFi or Bluetooth technologies. It can also be controlled by voice command. Seizing Google Glass’ capabilities as windows of opportunity, surgeons have been the first group of doctors trying to incorporate the technology into their daily practices. Experiences from different groups have demonstrated Google Glass’ potential in improving perioperative care, intraoperative communication and documentation, surgical outcome as well as surgical training. On the other hand, the device has technical limitations, notably suboptimal image qualities and a short battery life. Its operational functions also bring forth concerns on the protection of patient privacy. Nonetheless, the technological advances that this device embodies hold promises in surgical innovations. Further studies are required, and surgeons should explore, investigate, and embrace similar technologies with keen and informed anticipation.
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Telementoring as a subset of telemedicine has evolved over the past few years, but it is yet to be utilized to its full potential. The technology holds promise in bridging divides of distance and enables far-flung areas to be mentored in operative advances. It thus has a special bearing in countries like India where health care is short staffed and many areas lack availability of quality care. We describe the setting up of a telementoring facility at our centre. As against a ‘routine’ facility with dedicated equipments which cost heavily, our facility was set up using mostly equipments commonly available in an operating room. The facility is presently functional and allows telementoring through an encrypted Web-based service. Our set-up design can be emulated in centres with financial constraint and can help raise the standard of surgical care.