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Telementoring Surgery-May 10, 2019

Real-time interactive telementoring between Ethiopia and the United States

1) Julia L. Kerolus, M.D.*

Clinical Assistant Professor

Department of Otolaryngology-Head and Neck Surgery

University of Illinois at Chicago

1855 West Taylor St - Suite 2.42

Chicago, IL 60612

Phone: (312) 996-6582

Fax: (312) 996-1283

2) Bilen Korra, MD

Chair ENT

St. Peter's Hospital

Addis Ababa, Ethiopia

Phone: +251 911 41 28 64

3) Talal Ali Ahmad

Co-founder & CEO

Proximie, Inc

143 Great Road

Bedford, MA 01730

Phone: +1617 3916824

4) Antonio Moukhtafi, MCS

Technical Support Lead

Proximie, Inc

Floor 8, BDD 1243, Nassif El Yaziji St, Bachoura

Beirut, Lebanon

Phone: 00961 81 856587

5) Miriam Redleaf, MD FACS

Louis J. Mayer Professor of Otolaryngology

Director of Otology/Neurotology

Department of Otolaryngology-Head and Neck Surgery

University of Illinois at Chicago

1855 West Taylor St - Suite 2.42

Chicago, IL 60612

Phone: (312) 996-6582

Fax: (312) 996-1283

*corresponding author

Word Count: 577

Ethiopia has few Otolaryngologists, resulting in a shortage of qualified experts to educate the next generation of surgeons. The current model for otologic training of Otolaryngologists in Ethiopia consists of periodic surgical campaigns in which surgeries are clustered into single weeks supervised by foreign experts.1 Surgical instruction has therefore been limited to short intermittent periods when foreign teachers are available. We therefore embarked on a program to incorporate telementoring2 as an additional tool for surgical education in Ethiopia.

Telementoring involves two-way audio and video streaming in which the teaching surgeon has the capability to use augmented reality3 to guide operative trainees during their operations. Proximie ®4 was our chosen augmented reality platform, because it is HIPAA-compliant and enables healthcare professionals in both countries to view the operative field in real time, converse, and even annotate the surgical image.5 On May 10, 2019 the first operation with telementoring was performed in Ethiopia to the United States after 18 months of trouble-shooting. We present all the factors which needed to be aligned before this real-time transmission was possible.

The patient

A 21-year-old male presented to the Otolaryngology clinic at Black Lion Hospital of Addis Ababa University with long-standing recurrent right otorrhea and decreased hearing. Otoscopic exam found a holo-tympanic membrane perforation, with a pure tone average of 55 decibels (dB).


The teaching surgeon at the University of Illinois at Chicago (MR) was able to guide the operating surgeon at Addis Ababa University during key portions of the operation (Figure 2b). The patient underwent right tympanoplasty with removal of tympanosclerotic plaque and cleaning of the stapes footplate. The incus remnant was then used as an interposition columellar graft from the stapes footplate and to the neotympanum. Video and audio connections were of high quality and maintained throughout the procedure. The teaching surgeon’s annotations on the screen were clear to all involved and there was no perceptible time delay.

Required equipment configuration

Equipment required for otologic surgery in the primary country include an operating microscope, a beam splitter, a teaching arm with a universal video adaptor, C-mount camera, cable connecting the video out on the camera to the AVIO capture card (HDMI- or S1- compatible), a cable from the AVIO capture card to the laptop’s USB port. Internet requirements are 4 megabits per second (Mbps) or higher, with 8 Mbps recommended for optimal communication. Figure 1 demonstrates the minimum and recommended system requirements for the operative surgeon’s laptop/webcam and the teaching surgeon’s laptop/webcam. Team viewer ® is essential for both laptops for real time trouble-shooting. In this first Ethiopian transmission, there was successful two-way video and audio communication once all connections were achieved (Figure 2a).

Required personnel

The operative site in the primary country needs motivated hospital administration, surgeons, hospital staff, and information technology (IT) support personnel - since the many initial obstacles are time-consuming and discouraging. Easy access to the operating room, ability to select appropriate patients, and patient informed consent for broadcast are also essential. For the first few transmission attempts, an IT expert who is conversant with the Proximie ® platform should be “on-call” to trouble-shoot on either laptop using Team Viewer.


Many essential features must be in place for successful telementoring. However, the technology is reliable once set-up is complete. It allows surgical trainees to operate under expert supervision, while preserving patient safety and treating patients in a timely manner. Telementoring is an accessible inexpensive modality for surgical education in areas with sparse local expertise.


  1. Girma B, Bitew A, Kiros N, Redleaf M. High-density otologic camps in regions of sparse expertise. Ann Otol Rhinol Laryngol. 2018;127(5):327-330. doi 10.1177/0003489418761961.

  1. Snyderman CH, Gardner PA, Lanisnik B, Ravnik J. Surgical telementoring: a new model for surgical training. Laryngoscope. 2016;126(6):1334-1338. doi 10.1002/lary.25753.

  1. Khor WS, Baker B, Amin K, Chan A, Patel K, Wong J. Augmented and virtual reality in surgery-the digital surgical environment: applications, limitation and legal pitfalls. Ann Transl Med. 2016;4(23):454. doi:10.21037/atm.2016.12.23.

  1. Ahmad, TA. (2014). United States Patent No. US 9,298,884 B1.

  1. Greenfield MJ, Luck J, Billingsley ML, Heyer R, Smith OJ, Mosahebi A, Khoussa A, Abu-Sittah G, Hachach-Haram N. Demonstration of the effectiveness of augmented reality telesurgery in complex hand reconstruction in Gaza. Plast Reconstr Surg Glob Open. 2018;6(3):e1708 doi 10.1097/GOX.0000000000001708. eCollection 2018 Mar.

Figure Legends

Figure 1

Proximie ® platform system requirements

Central processing unit (CPU); gigabyte (GB); random access memory (RAM); video graphics array (VGA); megabyte (MB); megabits per second (Mbps); Web Camera (WebCam)

Figure 2a

Ethiopian surgeon gives “thumbs up” to remote surgeon in Chicago once it is confirmed that all is functioning appropriately

Figure 1b

The remote surgeon’s split screen showing the local surgeon (left) and operative field through the microscope (right)

Fig. 2a

OR of first telementoring surgery

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