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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
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,
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.
PRS Global Open • 2018
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.
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.
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.
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.
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
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,
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.
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.
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,
Fig. 1. Remote “tele-stration.”
Fig. 2. Excision of a giant cell tumor of the third digit using Google
PRS Global Open • 2018
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.
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 Specications
Age Presentation Procedure
Speed Technologic Issues
1 August 30 2 Post burn contracture to
palm of right hand
Contracture release with multiple
2 August 30 2 Post burn contracture
to lateral aspect of left
Contracture excision and reconstruc-
tion with multiple z-plasties
3 September 1 2 Skin graft failure post pre-
vious burn contracture
release on dorsum of
Full-thickness skin graft Not
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
5 September 22 1 3rd degree ﬂame burn to
7% BSA on right lower
limb with exposed heel
Reverse sural ﬂap for soft-tissue defect
of heel and split-thickness skin graft
for remaining wounds
6 September 29 19 Giant cell tumor of right
Excision and local tissue rearrange-
12.01 mbps Connectivity issues,
7 November 15 6 Posterior ankle avulsion
wound with Achilles
Debridement, tendon lengthening and
coverage with posterior tibial artery
perforator propeller ﬂap and small
split-thickness skin graft for donor
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
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
10 January 31 20 Heel avulsion wound Soft-tissue coverage with antegrade
cross leg sural ﬂap
13.92 mbps Connectivity issues,
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
12 February 9 32 3rd degree electrical burn
to 2nd and 3rd digits of
reconstruction of 3rd digit by excision
of burn and primary closure and
of 2nd digit with staged cross digit
BSA, body surface area.
McCullough et al. • Google Glass for Tele-proctoring in Mozambique
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
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
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
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
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.
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
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
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