The American Journal of Surgery 218 (2019) 760e766

Contents lists available at ScienceDirect

The American Journal of Surgery

journal homepage: www.americanjournalofsurgery.com

Telemedicine and telementoring in the surgical specialties: A narrative

review
Eunice Y. Huang a, Samantha Knight b, Camila Roginski Guetter c,
Catherine Hambleton Davis d, Mecker Moller e, Eliza Slama f, Marie Crandall g, *
a
Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 49 N. Dunlap St.,
Second Floor, Memphis, TN, 38105, USA
b
Southern Illinois School of Medicine, 701 N. First Street, PO Box 19638, Springfield, IL, 62702, USA
c
Federal University of Parana, Medical School. Rua Padre Camargo, 285. Alto da Glo ria, Curitiba, PR, 80060-240, Brazil
d
Department of Surgery, Houston Methodist Hospital, 6550 Fannin Suite 1600, Houston, TX, 77030, USA
e
Division of Surgical Oncology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB C232, Miami, Fl, 33131, USA
f
Department of Surgery, St. Agnes Hospital, 900 S. Caton Avenue, Baltimore, MD, 21229, USA
g
University of Florida College of Medicine, Jacksonville 655 W. 8th Street Jacksonville, FL, 32209, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: The field of telemedicine has grown tremendously over the last decade. We present a
Received 26 February 2019 systematic review of publications on telemedicine as it pertains to surgery, addressing six facets: 1)
Received in revised form telerobotics, 2) telementoring, 3) teleconsulting, 4) telemedicine in post-operative follow-up, 5) tele-
28 May 2019
education, and 6) current technology.
Accepted 16 July 2019
Data sources: A search of relevant literature querying PubMed, Web of Science, and Science Direct was
performed using the following keywords: telecommunication, telemedicine, telehealth, virtual health,
Keywords:
virtual medicine, general surgery, surgery, surgical or surgical patients.
Telementoring
Telemedicine
Conclusions: Telemedicine is being used to care for patients in remote areas, to help expert surgeons
Teleconsulting assist other specialists in the office or novice surgeons in the operating room, as well as to help teach the
Technology next generation of surgeons. There are many opportunities for surgeons to utilize this technology to
optimize their practice.
© 2019 Elsevier Inc. All rights reserved.

Introduction knowledge with consultants to direct patient care as well as to

educate trainees.
Telemedicine is the field of utilizing telecommunications for the Telementoring in surgery promises to address some of the field's
purpose of diagnosing and treating patients in remote locations. most pressing issues, such as the growing disparity of access to
This technology has gained increased popularity in recent years, surgical care, rapid knowledge transfer of innovative surgical
both in medicine and surgery. With the advancement of computer techniques, and fostering resident autonomy and career readiness.
science and engineering, telemedicine now affords surgeons even Surgical telementoring utilizes technology to facilitate the distri-
greater opportunities for patient care, mentoring, collaboration and bution of surgical knowledge by means of both technical assistance
teaching without being limited by geographic boundaries. and real-time guidance between an experienced surgeon and a
Telesurgery and telerobotics, including pre- and post-operative novice in a different geographical location. Telementoring has been
video telecommunication, offer opportunities for surgical proce- shown to be comparable to onsite mentorship when knowledge
dural care on patients in remote areas. It also allows sharing and skill acquisition are analyzed, thereby reinforcing it to be a
cost-effective and reliable educational tool.1,2,3 These reports are
especially encouraging with present day challenges of providing
* Corresponding author. subspecialized surgical care and mentorship in geographically
E-mail addresses: [email protected] (E.Y. Huang), [email protected] remote locations.
(S. Knight), [email protected] (C.R. Guetter), [email protected] Herein, we present a systematic review of publications on
(C.H. Davis), [email protected] (M. Moller), [email protected]
telemedicine as it pertains to surgery, specifically discussing six
(E. Slama), [email protected]fl.edu (M. Crandall).

https://doi.org/10.1016/j.amjsurg.2019.07.018
0002-9610/© 2019 Elsevier Inc. All rights reserved.
 E.Y. Huang et al. / The American Journal of Surgery 218 (2019) 760e766 761

facets relevant to surgeons, namely: 1) telerobotics or direct sur- Latency rates were between 450 and 900 ms and found to be
gical intervention, 2) telementoring (surgeon to surgeon), 3) tele- significantly cumbersome at 900 ms. In the Nguan et al. study,8 six
consulting (surgeon to other specialists or primary care physicians), pyeloplasties were performed, and no network failures were noted.
4) telemedicine for post-operative follow-up, 5) tele-education, Latency rates of 350 ms were seen, which did not appear to affect
especially in resource-limited regions, and finally, 6) current tele- physical-visual asynchrony. Nevertheless, real-time Da Vinci
medicine technology. continued to outperform telesurgical Da Vinci, with regards to
speed (10.9 ± 1.1 min. vs. 20.7 ± 4.7 min, P < 0.01).
Materials and methods Three studies reporting telesurgery in patients were identified.
The first described the establishment of a telerobotic remote sur-
An experienced research librarian performed a search of the gical service, which was based in Hamilton, Ontario.9 Using the
relevant literature in October 2017, querying PubMed, Web of Sci- Zeus TS microjoint system, the author performed 21 telerobotic
ence, and Science Direct using the following search strategy: cases in North Bay, Ontario. The local environment required a sur-
((telecommunication[tiab] OR telemedicine[mh] OR telemedicine geon trained in laparoscopy but did not require experience in
[tiab] OR telehealth[tiab] OR virtual health[tiab] OR virtual medi- advanced laparoscopy. Cases included laparoscopic Nissen fundo-
cine[tiab])) AND (general surgery[mh] OR general surgery[tiab] OR plication, laparoscopic inguinal hernia repair and laparoscopic
surgery[tiab] OR surgical[tiab] OR surgical patients[tiab]). A total of colectomies and were performed collaboratively with both the
551 citations were found. The abstracts and titles were screened for remote and local surgeon. The overall latency rate was 135e140 ms
relevance and consideration for quantitative review with meta- and was noticeable for the telerobotic surgeon. A temporary
analysis or qualitative systematic review. We excluded 436 arti- disturbance in signal transmission occurred during the first colec-
cles for lack of relevance to our topic; these included opinion pa- tomy, but a switch to a second telecommunication line solved this
pers, editorials, and user surveys unrelated to telemedicine. The problem with a less than 1 s delay. The second publication,1 re-
remaining 115 full-text articles were examined and their references ported the work of the Centre for Minimal Access Surgery (CMAS)
scanned to determine if other articles should be included or if, upon with two community hospitals. The Zeus TS microjoint system was
review, these articles were not relevant to our inquiry. No used, and 18 cases were performed (7 telerobotic, 11 tele-
comparative data were found; most published papers were case mentoring) with good outcomes. The last publication reporting
studies and case series. For this reason, we proceeded with a telesurgery in patients was a case report of a telesurgical fetoscopy
narrative review of the most informative and illustrative articles performed from Tampa, FL to Santiago, Chile on a female with a
(n ¼ 54), to provide an overview of the state of the science on this twin pregnancy with an acardiac twin.10 This patient successfully
topic and identify areas for future research. underwent ultrasound and laser photocoagulation under the
guidance of the Tampa-based expert in order to occlude blood flow
Results to the acardiac twin.
These studies show that with current technology, remote tele-
Telerobotics or direct surgical intervention surgery is a highly attainable feat. However, network performance
continues to pose an area of concern as latency rates affect the
There were nine primary publications in the area of telerobotics accuracy and speed of surgery. Furthermore, lost audio or visual
identified in our search. Five articles discussed telesurgery utilizing input could disrupt care. Higher grade networks and system
animal models or trainers. Three publications reported results from redundancy may help protect against this risk. Lastly, additional
telesurgery in patients. Of the publications on telesurgery in non- improvements in 3D visualization, refining of robotic instrument
humans, the first was published in 1998 by Bowersox et al.4 The movements and decrease in unsteadiness will also assist in
authors assessed a telemanipulator system which allowed a sur- improvement of telerobotic surgery.
geon to see, hear and manipulate a remote operative field, which, in
this study, was 5 m away. Several procedures, such as gastric repair, Telementoring, surgeon to surgeon
cholecystectomy, liver laceration repairs and enterotomy repairs
were performed by trained surgeons on swine. The authors Telementoring facilitates the safe transfer of knowledge from an
concluded that surgical procedures could be completed using this experienced surgeon to a novice and allows the expert to guide the
technology; however, a significantly longer length of time, specif- novice through a procedure in which they previously had minimal
ically 2.7 times, was needed. Fabrizio et al.5 utilized the Aesop experience.3 Telementoring has, and continues to be, utilized
1000 TS robot to examine the effect of time delay on telesurgical within a wide range of surgical subspecialties, including but not
performance using the game Operation. They found that the time limited to neurosurgery, urology, vascular surgery, ophthalmology,
needed to complete each task, as well as the error rate, correlated otolaryngology, and subspecialties of general surgery such as pe-
with increased time delays. Challacombe et al.6 studied human diatric, transplant, endocrine, and trauma surgery. In fact, in a 2010
versus robotic needle access of a percutaneous kidney trainer in review of clinical outcomes and educational benefits of tele-
order to examine the usability of telerobotics for accessing the mentoring, 33 telementored surgical procedures spanning 11 sub-
kidney for percutaneous nephrolithotomy. They found that the specialties were reported to have been documented in the
robotic insertion was slower but more accurate than human literature.11,12
insertion, and it performed equally well locally and trans- Telementoring intra-operatively facilitates an experienced sur-
Atlantically. geon unfamiliar or with limited practice in a particular operation, to
In 2008, two studies were published which assessed the be guided through the procedure by an expert surgeon. Tele-
viability of utilizing the Da Vinci telesurgery-enabled surgical robot consultation (also referred to as teleconferencing and tele-
for remote surgery.7,8 Utilizing porcine models, both studies suc- assistance) on the other hand takes on a more collaborative
cessfully performed surgeries remotely, one from California to Ohio dynamic, whereby two surgeons both experienced in a procedure,
and the other had data routed from London, Ontario to Halifax, work together through a complex case.13,14
Nova Scotia. In the study by Sterbis et al.,7 four nephrectomies were Should surgeons wish to acquire new skills, the traditional
performed; in one case, loss of the visual packet occurred which approach was, and for the large part remains, on-site mentoring in
required the local surgeon to complete the bulk of the procedure. conjunction with hands-on course training and conferences.
762 E.Y. Huang et al. / The American Journal of Surgery 218 (2019) 760e766

However this can be challenging for two main reasons: dispro- participated in a telemedicine program to supply care to a rural area
portion between the number of trained experts and the number of within Georgia.23 The Department arranged a monthly clinic using
surgeons in need of training, and significant time and resources audiovisual telemedicine equipment to connect with patients and
required when surgeons are travelling from remote locations. Tel- parents in Georgia, which was facilitated by trained nurses.
ementoring is an innovative strategy to overcome these challenges. Through the program they were able to order adequate diagnostic
It should come as no surprise that the countries that are leading the tests for the patients and provide appropriate care and referrals.
way in both telementoring and telerobotics are those with signifi- Not only is telemedicine being applied within the boundaries of
cant geographical spread. Canada, for example, has utilized tele- one's country, it has also been applied transcontinentally. The Japan
mentoring to facilitate both simple and complex laparoscopic Antarctic Research Expedition has been present in Antarctica since
surgeries in remote rural communities since 1999.1,15 In the United 1956, although medical care to the expeditioners has not always
States, individual hospital systems have developed mentoring been as robust as it is today. With the increasing popularity of
systems with resource limited institutions or those lacking signif- telemedicine and telecommunication, they have updated their
icant exposure to complex subspecialized case load, including technology to include weekly consultations where specialists can
South America, United Kingdom, Europe and beyond.10,16e22 communicate in real-time with the Antarctic-based physician and
Numerous case reports have been published outlining the utility patients.24 This is especially paramount for critical injuries where
and successes of telementoring, allowing patients to receive sub- any lag in communication could increase morbidity. In addition,
specialized care, in fields such as fetal, bariatric, and endocrine they have upgraded their system so medical photos can be shared.
surgery, without leaving home.10,16e21 Feedback from surgical Other applicable areas where telemedicine has been shown to
mentees involved in such cross-continental and trans-oceanic op- be beneficial in distant areas are war zones and correctional in-
erations has been positive, reporting increased confidence in per- stitutions. The military showed decreased resource utilization
forming procedures and, most vitally, learning the choreography of including aeromedical evacuations, costs, and duty time and
operations, including the positioning of the patient and assistant, decreased time to treatment through the use of orthopedic tele-
identifying planes of dissection, and the chronological steps. Some medicine consultations to soldiers deployed in Afghanistan, Iraq,
of the most interesting outcomes of these mentorship models have and Navy Afloats.25 The military has also shown successful appli-
been the development of collegial relationships between academic cation of telemedicine for relief efforts both within Africa and
and community surgeons, thereby reducing the sense of profes- Pakistan.26 Virginia Commonwealth University Health System
sional isolation that surgeons operating in remote communities collaborated with the Department of Corrections in Virginia to
would report.1,15 provide improved perioperative care to their patients. Facilitated by
The investment into developing telementoring programs also a nurse at the correctional facility, they were able to use electronic
reduces the need for patients to migrate to larger centres, meaning stethoscopes/dermascopes in addition to real-time video to
that, not only can they undergo procedures in their communities, perform physical exams, obtain informed consent, and provide
but they can also ensure follow-up with the same surgeon. appropriate preoperative care.27 With improvements in technol-
The term teleproctoring describes a situation where an experi- ogy, telemedicine will become more accessible to rural areas and
enced surgeon strictly observes the surgeon performing the oper- other locations where medical care is not easily accessed; in addi-
ation in order to assess adequacy of skills and, in some cases, to help tion, the quality of healthcare provided in these locations should
confer privileges to perform the procedure independently.14 Tele- also increase with improved technology.
mentoring in the setting of laparoscopic surgery in particular has
been studied thoroughly, as not only are these skills paramount in Telemedicine for post-operative follow-up
today's surgical practice, but they also lend themselves well to
remote mentoring. In traditional surgical care, patients are not continuously fol-
lowed up after hospital discharge except for a few pre-scheduled
Teleconsulting, surgeon to other specialists or primary care time-limited outpatient visits. Moreover, the period following a
physicians surgical intervention presents increased risk for complications,
which are often diagnosed late as patients and caregivers are not
Patient care is increasingly being addressed in a cross- formally trained to look for early signs of problems. As a result, the
disciplinary approach, especially with the trend away from gen- risk of hospital readmissions and mortality also tend to increase in a
eral practitioners and towards subspecialists. At major institutions similar manner.28
across the world, numerous teams work towards the care of the A systematic review conducted by Gunter et al.29 investigated
patient, including but not limited to primary care physicians, sub- the current role of telemedicine in facilitating postoperative re-
specialists of all disciplines, dieticians, physical therapists, etc. covery after hospital discharge in the United States. In this review,
While this strategy strives to provide a comprehensive approach for telemedicine showed a wide variety of uses in postoperative care
patient care at these institutions, many care centers around the across different specialties including, but not limited to, endocrine
world, in particular rural areas, lack the trained personnel or surgery, orthopedics, ENT, colorectal surgery, vascular surgery,
equipment to approach care in such a manner. The emergence of neurosurgery, transplant, oncologic surgery, urology and plastic
telemedicine and telecommunication has created opportunity for surgery. In the literature, there are also references to the use of
these care centers, lacking resources, to offer their patients such telemedicine for stoma care,30 in which a specialized nurse
comprehensive and multidisciplinary care. remotely examines the stoma and advises a local nurse on how to
change dressings and provide follow up care.
Long distance: rural, military medicine, and more In respect to the benefits associated with the use of post-
discharge telemedicine, it allows for access to specialty care in ru-
A major barrier to adequate healthcare both domestically and ral or medical shortage areas as well as reduces costs, both to the
internationally is lack of proximity to major facilities, particularly in patient and the healthcare system.28e31 For patients, telemedicine
rural areas and zones of conflict. Steps have been taken in the past presents a convenient alternative, which reduces the need for
using telemedicine as an approach to overcome such barriers. The taking time off work for outpatient consults. In one study, tele-
University of Florida Pediatric Neurosurgery Department medicine reduced costs up to US$176 by reducing average miles
 E.Y. Huang et al. / The American Journal of Surgery 218 (2019) 760e766 763

traveled (from 79.6 miles to 367.2 miles), and saved time Tele-education also has important implications in surgical
(77.5 mine317 min).29 Hence, telemedicine may present a good training and education. Several studies have been performed
alternative to the management of an aging population with limited demonstrating the equivalence of in person versus virtual training
mobility. of simple surgical techniques to medical students, more complex
For the healthcare system, postoperative telemedicine can laparoscopic procedures to residents, and even competence-based
reduce costs as it can liberate clinic appointments for other use, assessment of residents performing laparoscopic procedures.39e41
help decrease unnecessary hospital transfers as well as decrease Potentially even more important, tele-education allows for prac-
need for hospital readmission.28,29 ticing surgeons to learn new surgical techniques and procedures
Telemedicine has also been implemented using smartphone after their formal years of training, especially for those working in
applications for postoperative follow up. In one study,28 the institutions or locations that lack available mentors. In performing
application was used in vascular surgery patients for monitoring complex surgeries with telecommunication, local surgeons
wounds and surveillance for surgical site infections (SSI). This was perceived improved surgical exposure, more complete tumor re-
accomplished by having patients photograph incisions and answer sections, and shorter operating room time.42 Given the potential
simple questions on the quality of fluid leakage. These would then benefits of tele-education for the use of surgical training and
be reviewed and interpreted by a designated team of healthcare guiding, one group has even developed a structured surgical tele-
providers. Among 40 patients that completed the full study pro- education curriculum with several formal models for training and
tocol, there were 8 SSIs, 7 of which were detected through visual even a program to “train the trainer”.11,12
and written information from the application. There was one false
negative SSI that was detected at an early follow-up visit, and there Current technology
were no false positives.
In France, Teot and colleagues created a telemedicine wound Smart phones and gadgets
care system called Home Hospital Wound Healing Network (CICAT) A picture is worth a thousand words and a video can tell a story.
in 2005.31 Similarly, they use self-photographing by the patient to The ubiquotous presence of smart phones in every physician's life
obtain information and analyze wounds, which were mostly pres- has changed the way we communicate with each other when
sure ulcers (44%), arterial/venous/mixed leg ulcers (24%), and taking care of patients. In the surgical teaching environment it has
trauma wounds (10%). Results from 10 years of experience of CICAT proven of great relevance when making important decisions for
showed a 75% rate of improved or healed wounds, a 72% decline in surgical intervention. The on-call intern who may struggle for
the number of hospitalizations and a 56% reduction in ambulance words to describe complex computer tomography findings may
transfers to wound healing centers. send a video of the scan to the supervising senior resident or
Overall, studies on the use of telemedicine for postoperative attending, facilitating a treatment discussion. A picture can provide
care and follow-up have demonstrated high levels of satisfaction by detailed characteristics of an infected wound, breast abscess, exo-
both patients and physicians.28,29 phytic tumor or x-ray study that can expedite work up or decision
making.
Tele-educating, especially in resource-limited regions Most of us agree with the benefits provided by sharing these
images; however, the issue of how to transmit sensitive patient
Tele-educating, or the act of receiving instruction, guaidnace, or information while abiding by privacy guidelines is raised. Different
teaching by means of telecommunication, has the potential to be of institutions have different regulations when it comes to sharing
particular value in serving populations with limited resources or in patient's images. Some institutions may provide approved devices
remote areas. Many have piloted programs to connect expert spe- to their physicians and clinical staff, while others may provide
cialists often in large academic centers with smaller surgical cen- encrypted software to be used on smart phones to facilitate such
ters both for teaching purposes and for diagnostic purposes. Tele- ommunication, while others may ban the practice all together. But
education allows more remote centers to offer a greater breadth one way or the other the technology is at hand and is being used
of medical services as well as a higher standard of care.15 At the frequently in medical practice, changing paradigms in training and
same time, it saves time for both the trainee and the surgeon, de- communication among clinicians and in their patients as well.
creases costs involved with taking time out of practice and trav- There have been different studies showing the benefits of using
eling, and avoids cumbersome privileging issues.10e12 Furthermore, smart phone technology to aid in clinical diagnosis and treatment,
the technology has been validated using remote tele-education of for example, the use of smart phones with a thermal camera (FLIR
general surgery residents, demonstrating objective improvement ONE IRT) to diagnose diabetic ulcers. The complete system's
in specific surgical skills.3 Remote web-based audiovisual tele- implementation comprises three major steps: image acquisition,
education has been widely explored in laparoscopic and robotic image processing, and results display (image interpretation)43 or
urological procedures18,19,21,32,33 and to a lesser extent in robotic the ability of a smart phone pulse pressure variation and cardiac
neurosurgical procedures.34 There are several specific examples of output application to predict fluid responsiveness in patients un-
tele-education allowing for complex surgical care in remote loca- dergoing cardiac surgery.44
tions that would otherwise require extensive travel or inability to High definition smart-phone-adaptable dermatoscospes can be
treat patients optimally. Datta et al.35 piloted a model to train and used to provide tele-consultation for malignant lesions among not
empower local rural international surgeons to perform inguinal only trainees and regional colleagues, but at the international level
hernia repair using wearable technology, American pediatric sur- where access to subspecialties may not be readily available. Fig. 1A,
gery specialists used tele-education to perform cases with pediatric B and 1C show a dermatoscope that could be mounted on a smart
surgeons in France,36 and an orbital specialist in Hawaii was able to phone.
use real-time telecommunication to guide a general ophthalmol- A pilot study simulating medical emergencies in 11 different
ogist in the removal of an orbital tumor over 200 miles away on countries using smart phone GPS (global positioning system), Wi-Fi
another island.37 In perhaps the most extreme example, Cubano (wireless LAN network) and LBS (location based system) found
et al.38 describe using telecommunication in order to successfully significant acceleration of emergency response by 2 or more hours
perform laparoscopic inguinal hernia repairs on a military aircraft with use of geolocation data and a worldwide emergency call
carrier in the Pacific Ocean, obviating the need for a shore visit. support system.45
764 E.Y. Huang et al. / The American Journal of Surgery 218 (2019) 760e766

in different countries to control and discuss diagnosis and

treatment.49
A study of robot-assisted surgical ward rounds (ASWRs) for a
three-month period in Dublin, Ireland showed this to be technically
feasible (>90% completed without technical difficulty) and a ma-
jority of patients (96.08%, n ¼ 25) agreed that RASWR was a satis-
factory alternative when an attending consultant's physical
presence was not possible.50

Virtual reality
Virtual Interactive Presence and Augmented Reality (VIPAR) is a
recently developed technology that allows surgeons to deliver real-
time virtual assistance and training in locations where standard
internet connection is available. The technology provides a com-
bined perspective of local and remote video feeds, allowing the
remote surgeon to be able to digitally reach into the operating field,
with delineation of the anatomy and providing a visual demon-
stration of complex surgical techniques.51
VIPAR has been used in neurosurgery and in orthopedic surgery
for training of resident surgeons and has been shown to be feasible
for long-distance and international telecollaboration in neurosur-
gical procedures in locations where highly skilled surgeons are not
readily available. This technology has been successfully used
among surgeons in Alabama USA and surgeons in Ho Chi Minh City
in Vietnan. Their financial investment of establishing an interna-
tional telecollaboration system for one year was calculated at
$14,930.39, which included expenses for the visiting team, local
station hardware, distant station hardware, proprietary software,
internet connection, and technical support.51
In neurosurgey, VIPAR has been studied for remote surgical
Fig. 1. A: Dermatoscope and lens adapter to smart phone camera. B: Device ensemble. assistance of residents. It is a novel platform that could be used for
C: Picture of suspicious mole is uploaded into smart phone and ready to be
remote expert assistance and surgical training. The system is
transmitted.
composed of local and remote stations, one station located over a
surgical field and the other over a blue screen. Cameras for ster-
Applications eotatic capture are used as well as a high definition viewer to
In a review by Kulendran et al.46 on surgical smart phone appli- display the virtual field, along with digital renderings from volu-
cations across different platforms in 2014, there were 621 surgical metric MRI, which help with spatial guidance for both the
applications for Apple iPhone iOS and 97 identified on Android's attending and the resident performing the cadaveric carotid end-
Google Play. Of those 126 were dedicated to plastic surgery, 79 to arterectomy and pterional crianiotomy.52
orthopedics, 41 to neurosurgery, 180 to general surgery, 36 to cardiac Combined floating autostereoscopic three-dimensional (3D)
surgery, 121 to ophthalmology, and 44 to urology. The applications display approach in telesurgical visualization has been shown to
ranged from simple flashcard review to virtual surgery applications reproduce live surgical scene in a realistic and intuitive manner. The
that provided surgical exposure and familiarization with common floating autostereoscopic display presents 2D and 3D fusion im-
operative procedures. The authors concluded that despite the sur- ages. These are presented floatingly around the center of the
plus of surgical applications available for smart phones, there was no display device through reflection of semitransparent mirrors. Intra-
taxonomy for medical application and only 12% of those were affil- operative surgery information is fused and updated in the 3D
iated or associated with an academic institution highlighting the display, so that telesurgical visualization could be enhanced
need for greater regulation of surgical applications. remotely. The glasses-free IV 3D display have full parallax and can
be observed by multiple people from surrounding areas at the same
Robotics and telesurgery time. It has been proposed as a tool to enhance operative cooper-
Telesurgery was a pivotal motivation in the early development ation and efficiency during surgery.53
of surgical robots. In 2001 the first transatlantic laparoscopic cho- Virtual reality (VR) smart phone game applications have been
lecystectomy was performed in a 68-year-old female who was in shown to improve laparoscopic skills in a study of 45 medical
Strasbourg and the surgeons in New York.47 students. Participants were asked to play a different smart phone
Since then there have been many more robotic telesurgery application game daily for two months between the two laparo-
procedures, including a laparoscopic cholecystectomy on pigs be- scopic sessions. They were divided into gamers (previous VR game
tween Korea and Japan, ablation of an atrial fibrillation between experience), non-gamers and controls. There was significant
Boston and Milan, and even a demonstration using a robot on the improvement in the laparoscopic skills of non-gamers independent
ocean floor by a surgeon on land and the first remote telesurgery of the type of game practiced.54
experiment involving tentacle-like concentric tube manipulators
done by a surgeon in Nashville, Tennessee, controlling a robot Telemedicine billing
located approximately 800 km away in Chapel Hill, North Carolina.48
Robotic remote controlled slit lamp biomicroscope allows three Even though a virtual visit isn't the same as an in-person visit,
dimensional stereo viewing and recording of patient's examination most insurances are required by law to cover telemedicine visits at
using local area internet and satellite, allowing multiple examiners a comparable rate to in-person visit. Nonetheless these visits must
 E.Y. Huang et al. / The American Journal of Surgery 218 (2019) 760e766 765

be coded in a different manner as insurances may have distinctive within the field of telesurgery that are not yet clearly defined
requirements for how you log the visit. Before submitting a claim it include, if it were to present, the need to convert a remote tele-
is important to make sure the physician is adhering to the insurance surgical case into an open procedure, regulation of pre-/post-oper-
company's specific guidelines for the service, such as the type of tive care, informed consent when intraoperative telementoring/
services covered, type of provider, limitations on the number of teleconsulting is used, and the medico-legal aspect of telesurgery..
telemedicine consultations that can be claimed and any other Currenty there is no qualitative measure regarding patient safety
specific conditions.55 and risk versus benefit, and this poses a field of needed research in
Generally, the CPT code that the office would use for an in- the future. In addition, to promote optimal patient safety, improved
person visit can be used for a telemedicine visit, but there are telemedicine/telesurgical training, and a multifaceted telemedical
some exceptions. Outpatient codes 99201 to 99215 can be used for guidance to practicing surgeons, it may be of benefit to create a
telemedicine, but they need to meet two of the three following governing body, potentially within the American College of Sur-
requirements: 1) the visit has to be a low complexity medical- geons or other leading surgical organizations.
decision-making visit; 2) an expanded, problem-focused exam The future for telemedicine and surgery is bright. Advances in
must be documented; and 3) an expanded, problem-focused technology will allow for capture of a greater variety of data useful
medical history must be documented and the physician must for patient care, such as video and physiologic data captured by
have spent at least 15 min face-to-face with the patient.55 sensors. Development of new mobile applications may also change
Medicare has defined a specific CPT codes 99444 for telethealth how we capture and utilize data for patient care and education.
that specifies the visit was an "online evaluative and management Future visualization capabilities such as three dimensional tele-
service”. But different from private insurances, Medicare requires surgical viewing can enhance the viewing experience for operating
the call to originate from a hospital setting, a physician's office, a surgeons, and virtual interactive presence and augmented reality
critical access hospitals or rural health clinics.55,56 can allow teaching surgeons to digitally reach into operating fields
Using the appropriate CPT code or calling from a medical facitly to help and direct a surgery in progress. There will continue to be
is not enough, modifiers GT or GQ are required. Their use depends opportunities to optimize the work we do as surgeons with the
on the type of service provided. GT modifier is used for interactive advancement of technology.
audio and telecommunications system visits. GQ modifier is used for
asynchronous telecommunication system visits.55,56 For more re- Conclusions
sources visit the center for Medicare and Medical services webpage:
https://www.cms.gov/Medicare/Medicare-General-Information/ Telemedicine has grown tremendously over the course of the
Telehealth/ last decade. This technology has been used successfully to care for
patients in remote areas, to help expert surgeons assist other spe-
Discussion cialists in the office or novice surgeons in the operating room, as
well as to help teach the next generation of surgeons.
This narrative review provides the most current state of tele-
medicine and telecommunications for surgical care and surgical Conflicts of interest
education. These data can help practicing surgeons make more
educated decisions when they choose to invest in technology to The authors have no conflicts of interest to declare.
support their professional work.
Our review showed that teleconsultation and telementoring Funding
have been successfully used by many different surgical sub-
specialities, in many different environments (both for clinical This research did not receive any specific grant from funding
evaluation as well as operative assistance), in several different agencies in the public, commercial, or not-for-profit sectors.
countries crossing different continents, and in the military as well
as private/public sectors. Tele-education as a field has also grown
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