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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.