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

  Secondly, the device must be “surgicalgrade”. It must have the ability to be wiped clean without damage and the unitmust work to precision without breaking down or heating up. The battery lifemust be improved where it can easily record a long operation without poweringdown.

It should also carry out the main functions with voice control so as toavoid the need to touch the device while performing surgery.  The first hurdle to overcome will be tomake the device compliant with data privacy laws. The streaming must occur overa secure server and the device should be blocked from uploading to pictures andvideos to non-secure databases.  Challengesto overcome: As demonstrated by Grosmann et al (ref) andDatta et al (ref), another way this device can revolutionise surgical teaching,is teleproctoring.

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This is especially of benefit to low-income countries wheretrainees can be taught a certain skill and mentored over long distances.  Teleproctoring: Video-based analysis is a powerful tool toimprove performance. It was rapidly adopted by the sports world to improveperformance where every inch and every millisecond matter. Surgeons, in a way,are athletes as well.

The specialty demands precision and efficiency. Theyconstantly practice to improve and maintain their skills. Head-mounted wearabledevices provide a way to record first person videos which they can then reviewwith their trainer.

These videos can be saved for future review so that thesurgeons can constantly learn from their past experiences.  Videologbook: PotentialUses: The invention of head-mounted wearablecomputers like the Google Glass has the potential to update and augment thecurrent surgical teaching model. It is unobtrusive, easy to use and provides away to record the field of view of the operating surgeon.

When Rafael Grossmancollaborated with ____ to perform the world’s first surgery with remoteconsultation in 2013, he showed how Google glass can disrupt the current methodof teaching by putting the trainee in the “driver’s seat” and the trainerassisting remotely. (reference here). It has since been used by varioussurgeons to livestream surgeries with viewers interacting live with theoperating surgeon(Shafi reference here).  Google glass explorer edition was released in2013 and promptly found it’s way into operating theaters across the world.Unfortunately, it did suffer from quite a few significant issues mostly aroundbattery life and CPU heating up and google ceased production in ___. They havesince released an updated version called Google Glass 2.0 Enterprise Editionand released it to various businesses through it’s partners. A comparison ofthe two devices is given in the table.

 Technology is advancing at a breakneckspeed. It has already become a significant part of our everyday lives to theextent that some have advocated classifying them into a “Seventh Kingdom”called “Techium” (reference here). Since it’s brutal beginnings two centuriesago, surgery has become far more refined and safer than it used to be.Technology has allowed us to perform major surgery through tiny incisions. Withall the specialisation has come a lot of demand on the time of surgeons.

WithEuropean working time directive and ever increasing paperwork to be done,trainees have seen their surgical exposure shrink considerably. Even thoughmost of surgery is very different from what it was in the beginning, theteaching methods are still the same. Discussion:  Orthopaedics: Dickey et al (ref 8) used Google Glass totrain urology residents in correctly placing an inflatable penile prosthesis. Theparticipants were stratified into urology trainees and urology faculty. Theteam developed an application to not only demonstrate steps of the procedurebut also to recognise points of interest in the operating field forteleproctors to interact with the surgeon during prosthesis placement. Aquestionnaire was completed after the procedure. The results were positive withfaculty and trainees finding the device educationally useful and easy to use.  Iqbal et al (ref 7) explored the efficacyof Google glass as a vital signs monitor during urological surgery.

Theyrecruited medical students (novices), urology trainees (intermediates) andurology consultants (experts) for this study. They found a correlation betweenGoogle Glass use and detection of deteriorating vital signs which wasstatistically relevant (p = 0.0267). There was also no statisticallysignificant 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 GoogleGlass increased their awareness of vital signs during surgery and that theywould 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 batterylife. Urology has always been one of the firstsurgical specialties to embrace new technology.

A similar trend is seen withthe Google Glass. Borgmann et al (7) utilised the glass to perform augmentedreality assisted surgery in 10 different types of procedures for a total of 31procedures. They found it a safe and useful device for urological surgeons with43% rating its overall usefulness very high and 29% as high. They also reportedno technical difficultes with the device.

5.      Urology: One of the earliest exploratory studies ongoogle glass in the surgical workplace were conducted by Muensterer et al (ref6) in 2014. They wore the google glass daily for four weeks and kept a log ofthe Glass’s performance in various applications like coding for procedures,photodocumentation and filming a mock paediatric trauma. In the mocktelementoring and teleproctoring session, google glass proved useful but waslimited by lag time, occasional dropped calls and freeze-frames. They also raninto issues with data privacy, poor battery life and sub-par image quality inlow light.

4.      Paediatric Surgery: Brewer et al (ref 5) performed a small studywith 11 surgery residents in the department of cardiothoracic surgery to lookat the usefulness of google glass in improving surgical performance. Traineesand the trainer wore the device. Trainees were instructed to perform simpletasks in a simulated surgical environment and time to task completion wasmeasured. A questionnaire was filled at the end of the task. Results were equivocalbut did show promise in operative teaching.

3.      Cardiothoracic Surgery: Nakhla et al (ref 4) conducted a proof ofconcept study on enhancing the surgical education of their neurosurgicalresidents using the google glass. The attending surgeon wore the google glassand demonstrated to the residents, proper position and localization inminimally invasive lumbar disckectomy.

Then he observed and assisted a traineewhile wearing the google glass and thirdly, a physician wore the device torecord post-operative status of neurosurgical patients during a surgicalmission in Mongolia. In a survey, the residents found it to be an easy to usedevice 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. 2.      Neurosurgery: Libert et al (ref number 3) explored theusefulness of Google glass as a real-time wireless sign monitoring deviceduring surgical procedures.  14 Generalsurgery residents were randomised into a group using google glass withreal-time stream of vital signs and a control group using traditional bedsidedigital monitor.

Scenarios were conducted in the simulation lab on a mannequinwith pre-programmed vital sign deterioration to occur before task completion.Trainees were not made aware of this. Procedures were thoracostomy tubeplacement and a bronchoscopy. A survey was conducted after the procedure.Majority of the participants checked “agree” or “strongly agree” that Googleglass was useful in periprocedural vital signs surveillance (86%), heightenedtheir situational awareness (64%) and was simple to use while performing theprocedure (93%). 85% felt it could potentially improve patient safety.

86% feltthat Google glass did not impair their ability to perform the procedure.    Evans et al (ref number 2) compared firstperson recording using google glass to assess bedside procedural skills to atraditional third person video. Seven trainees performed a simulated internaljugular vein catheterisation while wearing the google glass while observessimultaneously recorded this wearing a head-mounted camera. They found thefirst person recording captured more complete steps than the third person recording.

They did however run into trouble with poor battery life, increased devicetemperature, frequent shutdown and loose fit of the device.  Datta et al (ref paper 1) conducted a studyusing google glass and a performance rating tool to evaluate the feasibility ofglobal surgical teleproctoring. They used the Lichtenstein inguinal herniarepair as the surgical procedure and the Lichtenstein-specific OperativePerformance Rating Scale for remote evaluation of procedure.

Mentors wereexperienced general surgeons from the Hernia Repair for Underserved non-profit,non-governmental organisation. They were based in Germany, Brazil and theUnited States. One local surgeon from Brazil and Paraguay each were takenthrough one surgery by the mentor and then performed the operationthemselves.

  The local surgeon woreGoogle glass to stream the operation to a web-based streaming platform accessedby mentors in New York and Germany. They observed and commented on the surgeryusing 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 showedimprovement as they went through each case and found this to be a very valuabletraining method. There were some issues with wireless internet connectivityduring the cases with three video stream interruptions requiring areconnection. Even though the image quality varied with connection speed, itwas deemed adequate for purpose by the remote teleproctors.  1.      General Surgery: Google glass has been tested invarious surgical departments which we have summarised in Table 1.

These arediscussed below:  Device Specialty Use Benefits Drawbacks Authors Google Glass General Surgery Bedside procedural skill assessment First person video assessment advantageous for behaviourally anchored checklists. 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 Neurosurgery Recording of cases by trainer/mentor and post op review of patients Handsfree recording, good tool for making a video library of procedures. 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 assessment 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   Urology AR-assisted surgery (31 procedures) Hands-free video, safe to use No technical difficulties encountered Borgmann et al   Urology Peri-operative vital signs monitoring Useful handsfree display, unobtrusive Poor fit and battery life Iqbal et al   Urology 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 surgerybut not for teaching purposes were rejected.

Case reports, oral and posterpresentations as well as articles not in English were rejected as well. Methods:  Surgery is a craft specialty and surgical training has longfollowed the apprentice model of teaching whereby a skilled surgeon mentors aninexperienced trainee. The advent of head-mounted wearable devices like Googleglass in 2013 (Google Glass, Mountain View, California) has taken thisapprenticeship model into the technological realm. From merging the field ofview of mentor and trainee(1) to allowing a surgeon to remotely assist fromthousands 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, therehave been various studies on it’s use in the surgical setting. In this literaturereview, we aim to review all the studies pertaining to the use of google glassin surgical training.   Introduction: