Using Virtual Augmented Reality to Remotely Proctor Overseas Surgical Outreach: Building Long-Term International Capacity and Sustainability

Background: Cleft lip affects one in 700 children globally, and the prevalence far surpasses capacity to deliver cleft care in underresourced and endemic regions. A hands-on educational presence is needed to promote overseas surgical autonomy, build overseas capacity, and ensure a sustained clinical and educational infrastructure. The goal of this study was to build and assess an augmented reality educational platform that allows a remote yet virtual interactive presence to transfer cleft surgery knowledge/skills to overseas colleagues. Methods: A prospective study assessing a 13-month overseas augmented reality-based cleft surgery curriculum was conducted. Three semiannual site visits engaged two Peruvian surgeons in evidence-based didactics, on-site cleft surgery, and familiarization with the augmented reality platform. During 10 remote augmented reality visits, a surgeon stationed in United States guided the same Peruvian surgeons through cleft surgery. Quarterly assessments of the Peruvian surgeons were performed using visual analogue scale questionnaires. Results: Visual analogue scale scores by both the remote and overseas surgeons demonstrated significant, progressive improvement in all facets of cleft lip repair throughout the curriculum. Site visits preferentially built capacity for cleft diagnosis and preoperative counseling (p < 0.001), principles of repair (p < 0.001), repair technique (p < 0.02) and intraoperative decision-making (p < 0.001). Remote sessions preferentially developed understanding of cleft operative design/anthropometry (p < 0.04), cleft anatomy (p < 0.01), and operative efficiency (p < 0.001). At 30-month follow-up, no children with cleft lip required transfer to tertiary care centers. Conclusion: A curriculum that combines on-site training and augmented reality-based hands-on remote teaching can build sustained capacity of comprehensive cleft care in underresourced areas.