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

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Rehan Ahmed Khan

Abstract

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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Editorials