Challenges in Surgical Training- Exploring the role of virtual and augmented reality

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Rehan Ahmed Khan


In the field of surgery major changes that have occurred

include advent of minimally invasive surgery and realization of

importance of the ‘systems’ in the surgical care of the patient

(Pierorazio & Allaf, 2009).Challenges in surgical training are

twofold: (i) to train the surgical residents to manage a patient

clinically (ii) to train them in operative skills (Singh & Darzi,

2013). In Pakistan, another issue with the surgical training is

that we have the shortest duration of surgical training in general

surgery of four years only, compared to six to eight years in

Europe and America (Zafar & Rana, 2013). Along with it, the

smaller number of patients to surgical residents’ ratio is also an

issue in surgical training. This warrants a formal training outside

the operation room. It has been reported by many authors that

changes are required in the current surgical training system

due to the significant deficiencies in the graduating surgeon

(Carlsen et al., 2014; Jarman et al., 2009; Parsons, Blencowe,

Hollowood, & Grant, 2011). Considering surgical training, it is

imperative that a surgeon is competent in clinical management

and operative skills at the end of the surgical training. To achieve

this outcome in this challenging scenario, a resident surgeon

should be provided with the opportunities of training outside

the operation theatre, before s/he can perform procedures on

a real patient. The need of this training was felt more when

the Institute of Medicine in USA published a report, ‘To Err is

Human’ (Stelfox, Palmisani, Scurlock, Orav, & Bates, 2006) , with

an aim to reduce the medical errors. This is required for better

training and objective assessment of the surgical residents. The

options for this training include but are not limited to use of

mannequins, virtual patients, virtual simulators, virtual reality,

augmented reality, and mixed reality.

Simulation is a technique to substitute or add to real experiences

with guided ones, often immersive in nature, that reproduce

substantial aspects of the real world in a fully interactive way.

Mannequins, virtual simulators are in use for a long time now.

They are available in low fidelity to high fidelity mannequins

and virtual simulators and help residents understand the

surgical anatomy, operative site and practice their skills. Virtual

patients can be discussed with students in simple format of text,

pictures and videos as case files available online, or in the form

of customised software applications based on algorithms. In a

study done by Courtielle et al, they reported that knowledge

retention is increased in residents when it is delivered though

virtual patients as compared to lecturing (Courteille et al., 2018).

But learning the skills component requires hand on practice. This

gap can be bridged with virtual, augmented, or mixed reality.

There are three types of virtual reality (VR) technologies:

(i) non-immersive, (ii) semi-immersive, and (iiii) fully

immersive. Non-immersive (VR) involves the use of software

and computers. In semi-immersive and immersive VR, the

virtual image is presented through the head mounted display

(HMD), the difference being that in fully immersive type, the

virtual image is completely obscured from the actual world.

Using handheld devices with haptic feedback the trainee can

perform a procedure in the virtual environment (Douglas,

Wilke, Gibson, Petricoin, & Liotta, 2017).

Augmented reality (AR) can be divided into complete AR or

mixed reality (MR). Through AR and MR, a trainee can see a

virtual and a real-world image at the same time, making it easy

for the supervisor to explain the steps of the surgery. Similar to

VR, in AR and MR the user wears an HMD that shows both

images. In AR, the virtual image is transparent whereas in MR,

it appears solid (Douglas et al., 2017).

Virtual, augmented and mixed reality have more potential to train

surgeons as they provide a fidelity very close to the real situation

and require fewer physical resources and space compared to the

simulators. But they are costlier, and affordability is an issue. To

overcome this, low-cost solutions to virtual reality have been

developed. It is high time that we also start thinking on the

same lines and develop this means of training our surgeons at

an affordable cost.

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