Secondly, mentored over long distances. Teleproctoring: Video-based analysis is



Secondly, the device must be “surgical
grade”. It must have the ability to be wiped clean without damage and the unit
must work to precision without breaking down or heating up. The battery life
must be improved where it can easily record a long operation without powering
down. It should also carry out the main functions with voice control so as to
avoid the need to touch the device while performing surgery.


The first hurdle to overcome will be to
make the device compliant with data privacy laws. The streaming must occur over
a secure server and the device should be blocked from uploading to pictures and
videos to non-secure databases.

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to overcome:


As demonstrated by Grosmann et al (ref) and
Datta et al (ref), another way this device can revolutionise surgical teaching,
is teleproctoring. This is especially of benefit to low-income countries where
trainees can be taught a certain skill and mentored over long distances.




Video-based analysis is a powerful tool to
improve performance. It was rapidly adopted by the sports world to improve
performance where every inch and every millisecond matter. Surgeons, in a way,
are athletes as well. The specialty demands precision and efficiency. They
constantly practice to improve and maintain their skills. Head-mounted wearable
devices provide a way to record first person videos which they can then review
with their trainer. These videos can be saved for future review so that the
surgeons can constantly learn from their past experiences.






The invention of head-mounted wearable
computers like the Google Glass has the potential to update and augment the
current surgical teaching model. It is unobtrusive, easy to use and provides a
way to record the field of view of the operating surgeon. When Rafael Grossman
collaborated with ____ to perform the world’s first surgery with remote
consultation in 2013, he showed how Google glass can disrupt the current method
of teaching by putting the trainee in the “driver’s seat” and the trainer
assisting remotely. (reference here). It has since been used by various
surgeons to livestream surgeries with viewers interacting live with the
operating surgeon(Shafi reference here).


Google glass explorer edition was released in
2013 and promptly found it’s way into operating theaters across the world.
Unfortunately, it did suffer from quite a few significant issues mostly around
battery life and CPU heating up and google ceased production in ___. They have
since released an updated version called Google Glass 2.0 Enterprise Edition
and released it to various businesses through it’s partners. A comparison of
the two devices is given in the table.


Technology is advancing at a breakneck
speed. It has already become a significant part of our everyday lives to the
extent that some have advocated classifying them into a “Seventh Kingdom”
called “Techium” (reference here). Since it’s brutal beginnings two centuries
ago, surgery has become far more refined and safer than it used to be.
Technology has allowed us to perform major surgery through tiny incisions. With
all the specialisation has come a lot of demand on the time of surgeons. With
European working time directive and ever increasing paperwork to be done,
trainees have seen their surgical exposure shrink considerably. Even though
most of surgery is very different from what it was in the beginning, the
teaching methods are still the same.






Dickey et al (ref 8) used Google Glass to
train urology residents in correctly placing an inflatable penile prosthesis. The
participants were stratified into urology trainees and urology faculty. The
team developed an application to not only demonstrate steps of the procedure
but also to recognise points of interest in the operating field for
teleproctors to interact with the surgeon during prosthesis placement. A
questionnaire was completed after the procedure. The results were positive with
faculty and trainees finding the device educationally useful and easy to use.


Iqbal et al (ref 7) explored the efficacy
of Google glass as a vital signs monitor during urological surgery. They
recruited medical students (novices), urology trainees (intermediates) and
urology consultants (experts) for this study. They found a correlation between
Google Glass use and detection of deteriorating vital signs which was
statistically relevant (p = 0.0267). There was also no statistically
significant effect of Google glass use on technical skills of the participants.
The majority of participants (75.7% 95%CI 58.8, 88.2) agreed that Google
Glass increased their awareness of vital signs during surgery and that they
would like to use it again on a different surgical procedure at a later stage.
The drawbacks they reported pertained to poor device fit and dismal battery


Urology has always been one of the first
surgical specialties to embrace new technology. A similar trend is seen with
the Google Glass. Borgmann et al (7) utilised the glass to perform augmented
reality assisted surgery in 10 different types of procedures for a total of 31
procedures. They found it a safe and useful device for urological surgeons with
43% rating its overall usefulness very high and 29% as high. They also reported
no technical difficultes with the device.



One of the earliest exploratory studies on
google glass in the surgical workplace were conducted by Muensterer et al (ref
6) in 2014. They wore the google glass daily for four weeks and kept a log of
the Glass’s performance in various applications like coding for procedures,
photodocumentation and filming a mock paediatric trauma. In the mock
telementoring and teleproctoring session, google glass proved useful but was
limited by lag time, occasional dropped calls and freeze-frames. They also ran
into issues with data privacy, poor battery life and sub-par image quality in
low light.

Paediatric Surgery:


Brewer et al (ref 5) performed a small study
with 11 surgery residents in the department of cardiothoracic surgery to look
at the usefulness of google glass in improving surgical performance. Trainees
and the trainer wore the device. Trainees were instructed to perform simple
tasks in a simulated surgical environment and time to task completion was
measured. A questionnaire was filled at the end of the task. Results were equivocal
but did show promise in operative teaching.

Cardiothoracic Surgery:


Nakhla et al (ref 4) conducted a proof of
concept study on enhancing the surgical education of their neurosurgical
residents using the google glass. The attending surgeon wore the google glass
and demonstrated to the residents, proper position and localization in
minimally invasive lumbar disckectomy. Then he observed and assisted a trainee
while wearing the google glass and thirdly, a physician wore the device to
record post-operative status of neurosurgical patients during a surgical
mission in Mongolia. In a survey, the residents found it to be an easy to use
device with potential to use it to build a library of surgical procedures.
However, only 50% felt it’s image quality was good enough for telementoring.



Libert et al (ref number 3) explored the
usefulness of Google glass as a real-time wireless sign monitoring device
during surgical procedures.  14 General
surgery residents were randomised into a group using google glass with
real-time stream of vital signs and a control group using traditional bedside
digital monitor. Scenarios were conducted in the simulation lab on a mannequin
with pre-programmed vital sign deterioration to occur before task completion.
Trainees were not made aware of this. Procedures were thoracostomy tube
placement and a bronchoscopy. A survey was conducted after the procedure.
Majority of the participants checked “agree” or “strongly agree” that Google
glass was useful in periprocedural vital signs surveillance (86%), heightened
their situational awareness (64%) and was simple to use while performing the
procedure (93%). 85% felt it could potentially improve patient safety. 86% felt
that Google glass did not impair their ability to perform the procedure.   


Evans et al (ref number 2) compared first
person recording using google glass to assess bedside procedural skills to a
traditional third person video. Seven trainees performed a simulated internal
jugular vein catheterisation while wearing the google glass while observes
simultaneously recorded this wearing a head-mounted camera. They found the
first person recording captured more complete steps than the third person recording.
They did however run into trouble with poor battery life, increased device
temperature, frequent shutdown and loose fit of the device.


Datta et al (ref paper 1) conducted a study
using google glass and a performance rating tool to evaluate the feasibility of
global surgical teleproctoring. They used the Lichtenstein inguinal hernia
repair as the surgical procedure and the Lichtenstein-specific Operative
Performance Rating Scale for remote evaluation of procedure. Mentors were
experienced general surgeons from the Hernia Repair for Underserved non-profit,
non-governmental organisation. They were based in Germany, Brazil and the
United States. One local surgeon from Brazil and Paraguay each were taken
through one surgery by the mentor and then performed the operation
themselves.  The local surgeon wore
Google glass to stream the operation to a web-based streaming platform accessed
by mentors in New York and Germany. They observed and commented on the surgery
using a web-based forum which was visible on the Google glass in real-time.
Each case was followed by evaluation using the OPRS. Both trainees showed
improvement as they went through each case and found this to be a very valuable
training method. There were some issues with wireless internet connectivity
during the cases with three video stream interruptions requiring a
reconnection. Even though the image quality varied with connection speed, it
was deemed adequate for purpose by the remote teleproctors.


General Surgery:


Google glass has been tested in
various surgical departments which we have summarised in Table 1. These are
discussed below:








Google Glass

General Surgery

Bedside procedural skill assessment

First person video assessment advantageous for behaviourally anchored

GG heats up, frequent shutdowns, poor battery life, difficult to
record procedures on close distances, GG fell into sterile drape a few times

Evans et al 2015


General Surgery

Vital sign monitoring during surgical procedures

Significant decreased time in looking away from procedural field,
early recognition of vital sign deterioration

Difficulty for residents wearing corrective glasses, increased
learning curve

Liebert et al 2016


General Surgery

Remote teleproctoring

Handsfree recording, adequate image quality for video streaming

Issues mainly with hospital wifi rather than device

Datta et al 2015

Google Glass


Recording of cases by trainer/mentor and post op review of patients

Handsfree recording, good tool for making a video library of

Poor battery life, camera focus disrupted by operating lights,
inability to zoom, cannot record >10s handsfree, camera view slightly off
of surgeon’s field of view

Nakhla et al


Cardiothoracic surgery

Streaming of trainee field of view to trainer for real-time task

Unobtrusive device, good for communication, helpful in learning
operations, easy to operate

Poor battery life, low image resolution, slow CPU speed.

Brewer et al


Paediatric surgery

Paediatric mock trauma simulation

Hands-free photodocumentation, clinical coding, calling, recording
and  searching conditions.

Poor battery life and audio quality, bad video in low light, data
privacy issues

Muensterer et al 2014



AR-assisted surgery (31 procedures)

Hands-free video, safe to use

No technical difficulties encountered

Borgmann et al



Peri-operative vital signs monitoring

Useful handsfree display, unobtrusive

Poor fit and battery life

Iqbal et al



AR-assisted inflatable penile prosthesis placement

Hands-free, easy to use, voice control.

Overheating, poor battery life, cumbersome software integration

Dickey et al




We did a literature review on Pubmed using the search terms
“Google Glass” and “Surgical training”. Articles on google glass used during surgery
but not for teaching purposes were rejected. Case reports, oral and poster
presentations as well as articles not in English were rejected as well.



Surgery is a craft specialty and surgical training has long
followed the apprentice model of teaching whereby a skilled surgeon mentors an
inexperienced trainee. The advent of head-mounted wearable devices like Google
glass in 2013 (Google Glass, Mountain View, California) has taken this
apprenticeship model into the technological realm. From merging the field of
view of mentor and trainee(1) to allowing a surgeon to remotely assist from
thousands of miles away(1), this technology is proving to be a useful tool.
Google Glass is a head mounted wearable computer that has a prism for display,
a CPU, a touch based sensor and a gyroscope on an eye-frame. Since 2013, there
have been various studies on it’s use in the surgical setting. In this literature
review, we aim to review all the studies pertaining to the use of google glass
in surgical training.