Educational value of surgical telementoring

Abstract Educating surgeons is a time‐consuming process. In addition to theoretical knowledge, the practical tasks of surgical procedures must be mastered. Translation of such knowledge from mentor to mentee may be efficiently done by surgical telementoring (ST). This is a review on surgical telementoring. Recent technological advances have made this tool in surgical education more available and applicable but future applications of ST have to be wisely guided by high‐quality trials.


| INTRODUCTION
Telementoring reports for educational purposes can be traced back to the 1960s with DeBakey performing the first open-heart surgery.
Originally, there were only a few interested contributors to surgical telementoring, and the technique and hardware were not available. Advances in telecommunication technology made possible the development of low-cost and reliable solutions for distant telementoring. 1,2 Emerging challenges, including the expanding world population and the time and resources needed for educating the surgical workforce, 3 have foreseen surgical telementoring as a possible solution to enhance and improve surgical education. Development in the field of surgery has evolved toward minimally invasive surgery where live camera image represents the surgeon's view of the surgical field. Because ST allows the mentor to guide the mentee by live transfer of video and audio feeds of the surgical field, it has been proposed as a natural fit for surgery. 4 The traditional Halstadian approach to surgical teaching 5 has been challenged over the recent decades. Restrictions in allowed working hours for residents in addition to recent restrictions in international travel caused by the ongoing pandemic, has limited hands-on sharing of surgical experience between mentors and mentees. These are some of the factors which have contributed to a paradigm shift regarding surgical teaching and education. 6,7 Video-based surgical coaching 8 including telementoring in surgical education holds promise in regard to improved surgical education and may efficiently allow acquisition of surgical skills. 9 Despite numerous evaluating surveys assessing surgical telementoring over the last decades, there is still a lack of widespread application of this tool in surgical education. experience by the involved mentor (i.e., clinical experience, teaching capabilities, LapCo experience/TT-course). Of note is that surgical telementoring requires additional communication skills (i.e., predefined communication protocol) from both mentor and mentee due to the time lag experienced during present 4G wireless network used to transmit the video-audio signals.

| Mentee-telementee
A surgeon with appropriate knowledge and experience seeking individual training in a specific procedure he or she is lacking experience in. The goal is acquisition of surgical knowledge/skills and the medium used for this purpose may be telementoring.
There have also been defined prerequisites for the mentee (i.e., board eligibility and enrollment in an educational pathway in the specialty in question). 10

| Live video feed
It allows continuous images from the surgical site to be shown during laparoscopic or robotic surgery. With this technological capability, surgical telementoring is considered a natural fit for the teaching process in minimal invasive surgery. The mentor is able to switch between the live video feed of the laparoscopic or robotic camera and a view provided by an external camera which might be placed at specific sites in the operating room (OR). This enables the mentor to provide a more comprehensive evaluation of the procedure, taking into account external positioning of trocars or robotic arms in addition to the positioning of the assistant surgeon and nurse.

| Live audio feed
It allows continuous instructional verbal interaction between mentor and mentee during the procedure. The verbal communication may be provided by a headset worn by the operating mentee, or the voice of the mentor may be provided through loudspeakers in the OR. The latter may give disturbance in communication but has the advantages of including the whole staff in the OR into the ongoing communication. The verbal communication should follow some rules of conduct agreed upon by the mentor and mentee. The number of verbal interactions or corrections could be regarded as a measure for the mentee´s degree of needed support.

| Telestration
It allows the mentor to give instructions by freehand sketches made on a still picture taken from the continuous video-feed. Identification of anatomical landmarks and planes of dissection might be clarified and warnings of anatomical danger zones may be given. The instructional session with telestration requires a pause in the ongoing surgery. The still picture is taken by the mentor who then may ask the mentee to stop the ongoing procedure for a telestrational session. The telestrational instructions as well as verbal feedback are shown to enhance the educational value of surgical telementoring and may reduce the telementoring session by more than 30%. 11 The telestrational session has an inherent weakness in that it may exclusively be carried out on a still picture of the live video feed, but possible future solutions to the problem have been discussed by Budrionis et al. 12

| Educational frameworks in surgical telementoring
It is helpful to adapt and have knowledge about conceptual frameworks in educational surgical telementoring programs. These frameworks assist the mentor and place the telementoring curriculum into a broader context and are useful in the planning and fulfilling of an effective surgical telementoring curriculum. 9,13-17 2.4.5 | Video technology and education: tasktechnology fit model The "task-technology fit model" is defined by Maruping 16,17 as "the degree to which technology assists a group in performing its portfolio or task." The "task-technology fit model" applies to surgical telementoring in several ways 1) High immediacy in feedback: surgical telementoring enables high immediacy in feedback to the surgical trainees as communication is live.
2) High symbol variety: video coaching offers high symbol variety in communications where live video, audio, and telestration are applied simultaneously.
3) Communication with multiple participants simultaneously. 4) High richness: richness is the ability of information to change perception within a time interval for tasks requiring social presence.
High richness is seen in surgical telementoring as mentors provide immediate feedback to the mentees to check interpretation and task performance during the surgical procedure.

| IDEAL framework in surgical telementoring
The IDEAL framework provides five stages for development and evaluation and is recommended when introducing surgical innovations (i.e., surgical telementoring). 18 The IDEAL framework is of importance when the faculty is planning a surgical telementoring curriculum, and consists of the following stages: Idea, Development, Exploration, Assessment, and Long term study (IDEAL): 1) Idea: case reports to present the idea and background describing the need for the product or innovation in question.

| Methods of assessment in surgical telementoring
Surgical telementoring is a process in which a mentor gives constant support, enabling the mentee to adopt proficient, effectivite, and safe-conduct during a specific surgical procedure. Several tools for assessment of the quality of the surgery have been developed.

Video coaching
Video coaching involves the assessment of recorded videos of the surgery carried out by the mentee without intraoperative involvement of the mentor. These recorded videos may retrospectively be used for educational purposes to examine surgical performance, including technical, cognitive, and interpersonal skills. The coaches then identify individualized performance goals, evaluate current performance, and design an action plan to advance toward those goals. Video coaching might be used as an adjunct during the process of surgical telementoring. Reviews of procedures might be a particularly efficient method of assessing telementoring sessions. Video coaching might hence be regarded as an advanced part of the telementoring educational process where the mentee is first mentored by surgical telementoring with verbal and telestrational guidance during surgery and then video coaching would be utilized as a gradual part of achieving independence.

Scoring scales for surgical skills
The effectiveness of surgical mentoring/telementoring can be measured and qualitative feedback can be given to the surgical mentee in an educational setting. Several validated scoring scales for specific purposes have been proposed. The scoring scales are designed to give optimal evaluation for open, laparoscopic or robotic surgery.
There is a strong association between video-scored surgical performance and surgical complications. Scoring scales have been matched with quality registry, and surgical skills measured by these scales have shown significant association with the rate of complications. 19 Application of the scoring scales for assessment of surgical skills has been shown to be reliable in the hands of experts (surgeons), nonexperts (crowdsourcing), 20 and by automated software programs. 21 There is an emerging trend for crowdsourcing as a quick and cheap method for assessment of technical skills. A recent systematic review and meta-analysis of video-based coaching in surgical education 8 identified 13 different validated scoring scale instruments utilized in the included studies that might be feasible to use in telementoring studies. (Table 1)  Utilizing multisource feedback (MSF) as a method of assessment of a surgeon´s abilities has been incorporated into the recertification process in several countries. 24 This method of assessment gathers feedback from multiple individuals occupying a variety of roles in the surgeons working environment. 25 MSF, also referred to as 360-degree of feedback, aims to give a more comprehensive perspective on performance where peers, superiors, and subordinates give structured feedback on the surgeon´s abilities. 26 The surgeon´s own opinion about his or her performance scored by the review may also be taken into account in such a global assessment.
Information gathered from such surveys of an individuals' performance can be used to enhance or achieve the required code of excellence within a unit. 27 The industry has gained interest in developing a software network for providing individual assessment of surgeons by peer-topeer discussions and assessment of video-recorded surgical procedures by expert surgeons. An example of such an industry-driven platform is C-SATS©.

| Mentor assessment
Assessment of the competency of the mentor has been the focus in several studies. 28 2) Bandwidth and latency: availability and quality of network connection should fulfill requirements of bandwidth and latency. The minimum bandwidth for telementoring is advised to be 40 Mb/s.
Telementoring may be achieved with lower bandwidth but highquality audio and video might lag and be choppy. 33 3) Image quality: ideal resolution for image quality in sophisticated telementoring applications is recommended to be 1080 progressive scan (1080 p) at 30 frames per second.

| Examples of ongoing telementoring initiatives
Resent research in the field of surgical telementoring has highlighted the need of randomized controlled trials exploring educational outcomes. 9 A structured educational curriculum utilizing surgical telementoring is required in these trials. The authors present two ongoing trials that assess a predefined and stepwise surgical telementoring curriculum (Figure 1).

| Robotic ventral mesh rectopexy (RVMR) initiative
This initiative was born because of the need of surgical experience in RVMR in a medium-sized hospital, in Norway located in the north of the country where the patient population is relatively scarce. Developing experience in the technique of RVMR in such a setting was challenging as the learning curve might be prolonged because of reduced patient access. In addition, access to an on-site mentor was difficult as no existing surgeon at the hospital had experience with laparoscopic or RVMR, and the hospital location was remote.
The solution for the author, being a colorectal surgeon with sufficient experience in laparoscopic and robotic colorectal cancer surgery, was to seek experienced mastery from another institution.
After  Figure 2A shows the setup and Figure 2B shows the setup and telestrational annotations during the telementored RVMR-initiative. The objective of the pilot study is to obtaining a "proof of concept" before conducting the randomized controlled trial, enabling us to anticipate pitfalls.

| Experience of the Medprescence© laparoscopy initiative
The skill-enhancing benefits of a telementor-guided procedure involving the above-mentioned telementoring technology will be evaluated in the pilot study. There will be an emphasis on benefits and drawbacks with the technology utilized for this purpose. We The pilot will be conducted by letting two mentees (general surgical registrars) perform five consecutive telementor-guided LCs involving two telementors. Primary outcomes will be GOALS scores of the mentees to assess skill development and secondary outcomes will be satisfaction scores of the mentees and the mentors The pilot study has been approved by the national ethical committee and is due to initiate patient inclusion by summer 2021. Figure 3 shows the setup in the planned laparoscopic initiative. In the future, there will be a more and better information-transfer in near real-time. Given the increasing availability of surgical robots in combination with 5G technology, telesurgery is no longer a futuristic thought but a current and practical application. 36 Telementoring applications have been described as technology driven 28  areas of implementation should be in accordance with the IDEAL framework. 18 Adherence to the mentioned principles is crucial to further development of this novel educational tool.

ACKNOWLEDGMENTS
The authors would like to thank Intuitive Surgical© and MedPresence© for allowing use of product pictures.

CONFLICT OF INTERESTS
Khayam Butt has received equipment and software from Intuitive Surgical© and MedPrescence© in relation to the presented trials.
The other author declares that there is no conflict of interest.

DATA AVAILABILITY STATEMENT
The data which is stated in this article are available from the corresponding author upon reasonable request.