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Ferrari et al. Art Int Surg 2022;2:177-85 https://dx.doi.org/10.20517/ais.2022.16 Page 181

conclusion that this methodology is equivalent to on-site mentoring in regard to clinical and educational
outcomes [35-37] .

Telementoring in surgery is a novel methodology developed in response to a need to expand technical skills
for surgeons not having the possibility to attend courses or workshops in person. While telementoring has
been present for over two decades, social distancing required during the Covid-19 pandemic has
[35]
implemented its use . Telementoring can be defined as a technique through which an experienced
physician guides a less experienced physician in a remote location . If this occurs intra-operatively, it is
[38]
termed telesurgical telementoring and the main purpose is to improve the surgical skill of a mentee.

A variety of technologies might be used for surgical telementoring models. These include incorporated two-
[39]
way audio and real-time video images and telestration , which the mentor could use to guide the mentee
visually through the surgery. Telestration is a specific type of telementoring in which the mentor adds lines,
objects or text to the screen through which the mentee receives instruction. The mentor might also remotely
control electrocautery laser pointers and surgical devices [35-37] . New virtual reality technology, like the System
for Telementoring with Augmented Reality (STAR), has been used to provide instruction within the
mentee’s visual field [40,41] , while the coaxial projective imaging system can be used to project 3D images .
[42]

The outcome and efficacy of telementoring have been assessed in literature by comparing distance-
mentored groups to in-person mentoring and no mentoring. Telementored surgeons have been reported to
perform significantly better in skill assessments than non-mentored groups and improve their technical
skills after telementored training . Telementoring has also been proven to be an important instrument
[43]
during surgical training. In a study by Ereso et al. surgical residents using telementoring performed
significantly higher on overall performance (4.30 +/- 0.25 vs. 2.43 +/- 0.20; P < 0.001) and on individual
metrics, including tissue and instrument handling, procedure speed, and anatomy knowledge (P < 0.001) .
[44]
Okrainec et al. also demonstrated that surgeons learning laparoscopic skills through telementoring scored
significantly higher in skill assessments (440 +/- 56 vs. 272 +/- 95, P = 0.001) and were more likely to get a
passing score on the laparoscopic simulator than those not utilizing it .
[45]

The advantages of telementoring are various. Firstly, rural and community-based physicians might have
equal opportunities to access surgical specialist guidance [35,36] . Furthermore, telementoring reduces the costs
related to traveling and course enrollment. Moreover, this form of training allows the operating surgeon to
operate in its own environment, with collateral teaching of the whole theatre group, including scrub nurses
and technicians, rather than only the single operator [35-37] .

The main concern related to distance mentoring is related to patients’ confidentiality, because technology
leaves an inevitable digital record of information [35,37] . Unfortunately, the most commonly used software,
such as Skype and WhatsApp, are also less safe in terms of privacy. For data protection, de-identification of
information, use of phone calls and password protection devices should be implemented .
[46]

[37]
Other potential disadvantages of telementoring are high costs and technical requirements . Further
possible barriers to the adoption of distance mentoring for technical skills are poor video signal due to
bandwidth or latency, loss or delay of transmission and poor audio quality [47,48] . Moreover, hospital licensing
and credentialing might be required, creating an additional limitation to the introduction of this specific
form of teaching [33-35] .