Virtual reality simulation of robotic transsphenoidal brain tumor resection: Evaluating dynamic motion scaling in a master-slave system

Augmented and Virtual Reality Applications in Rhinology: A Scoping Review

OBJECTIVES

Virtual reality (VR) and augmented reality (AR) are innovative technologies that have a wide range of potential applications in the health care industry. The aim of this study was to investigate the body of research on AR and VR applications in rhinology by performing a scoping review.

DATA SOURCES

PubMed, Scopus, and Embase.

REVIEW METHODS

According to PRISM-ScR guidelines, a scoping review of literature on the application of AR and/or VR in the context of Rhinology was conducted using PubMed, Scopus, and Embase.

RESULTS

Forty-nine articles from 1996 to 2023 met the criteria for review. Five broad types of AR and/or VR applications were found: preoperative, intraoperative, training/education, feasibility, and technical. The subsequent clinical domains were recognized: craniovertebral surgery, nasal endoscopy, transsphenoidal surgery, skull base surgery, endoscopic sinus surgery, and sinonasal malignancies.

CONCLUSION

AR and VR have comprehensive applications in Rhinology. AR for surgical navigation may have the most emerging potential in skull base surgery and endoscopic sinus surgery. VR can be utilized as an engaging training tool for surgeons and residents and as a distraction analgesia for patients undergoing office-based procedures. Additional research is essential to further understand the tangible effects of these technologies on measurable clinical results. Laryngoscope, 2024.

Virtual reality-based surgical planning simulator for tumorous resection in FreeForm Modeling: an illustrative case of clinical teaching

The importance of virtual reality (VR) has been emphasized by many medical studies, yet it has been relatively under-applied to surgical operation. This study characterized how VR has been applied in clinical education and evaluated its tutorial utility by designing a surgical model of tumorous resection as a simulator for preoperative planning and medical tutorial. A 36-year-old male patient with a femoral tumor who was admitted to the Affiliated Jiangmen Traditional Chinese Medicine Hospital was randomly selected and scanned by computed tomography (CT). The data in digital imaging and communications in medicine (*.DICOM) format were imported into Mimics to reconstruct a femoral model, and were generated to the format of *.stl executing in the computer-aided design (CAD) software SenSable FreeForm Modeling (SFM). A bony tumor was simulated by adding clay to the femur, the procedure of tumorous resection was virtually performed with a toolkit called Phantom, and its bony defect was filled with virtual cement. A 3D workspace was created to enable the individual multimodality manipulation, and a virtual operation of tumorous excision was successfully carried out with indefinitely repeated running. The precise delineation of surgical margins was shown to be achieved with expert proficiency and inexperienced hands among 43 of 50 participants. This simulative educator presented an imitation of high definition, those trained by VR models achieved a higher success rate of 86% than the rate of 74% achieved by those trained by conventional methods. This tumorous resection was repeatably handled by SFM, including the establishment of surgical strategy, whereby participants felt that respondent force feedback was beneficial to surgical teaching programs, enabling engagement of learning experiences by immersive events which mimic real-world circumstances to reinforce didactic and clinical concepts.

Neurosurgical simulation models developed in Latin America and the Caribbean: a scoping review

Simulation training is an educational tool that provides technical and cognitive proficiency in a risk-free environment. Several models have recently been presented in Latin America and the Caribbean (LAC). However, many of them were presented in non-indexed literature and not included in international reviews. This scoping review aims to describe the simulation models developed in LAC for neurosurgery training. Specifically, it focuses on assessing the models developed in LAC, the simulated neurosurgical procedures, the model's manufacturing costs, and the translational outcomes. Simulation models developed in LAC were considered, with no language or time restriction. Cadaveric, ex vivo, animal, synthetic, and virtual/augmented reality models were included for cranial and spinal procedures. We conducted a review according to the PRISMA-ScR, including international and regional reports from indexed and non-indexed literature. Two independent reviewers screened articles. Conflicts were resolved by a third reviewer using Covidence software. We collected data regarding the country of origin, recreated procedure, type of model, model validity, and manufacturing costs. Upon screening 917 studies, 69 models were developed in LAC. Most of them were developed in Brazil (49.28%). The most common procedures were related to general neurosurgery (20.29%), spine (17.39%), and ventricular neuroendoscopy and cerebrovascular (15.94% both). Synthetic models were the most frequent ones (38.98%). The manufacturing cost ranged from 4.00 to 2005.00 US Dollars. To our knowledge, this is the first scoping review about simulation models in LAC, setting the basis for future research studies. It depicts an increasing number of simulation models in the region, allowing a wide range of neurosurgical training in a resource-limited setting.

Training models and simulators for endoscopic transsphenoidal surgery: a systematic review

Endoscopic transsphenoidal surgery is a novel surgical technique requiring specific training. Different models and simulators have been recently suggested for it, but no systematic review is available. To provide a systematic and critical literature review and up-to-date description of the training models or simulators dedicated to endoscopic transsphenoidal surgery. A search was performed on PubMed and Scopus databases for articles published until February 2023; Google was also searched to document commercially available. For each model, the following features were recorded: training performed, tumor/arachnoid reproduction, assessment and validation, and cost. Of the 1199 retrieved articles, 101 were included in the final analysis. The described models can be subdivided into 5 major categories: (1) enhanced cadaveric heads; (2) animal models; (3) training artificial solutions, with increasing complexity (from "box-trainers" to multi-material, ct-based models); (4) training simulators, based on virtual or augmented reality; (5) Pre-operative planning models and simulators. Each available training model has specific advantages and limitations. Costs are high for cadaver-based solutions and vary significantly for the other solutions. Cheaper solutions seem useful only for the first stages of training. Most models do not provide a simulation of the sellar tumor, and a realistic simulation of the suprasellar arachnoid. Most artificial models do not provide a realistic and cost-efficient simulation of the most delicate and relatively common phase of surgery, i.e., tumor removal with arachnoid preservation; current research should optimize this to train future neurosurgical generations efficiently and safely.

Creation of low cost, simple, and easy-to-use training kit for the dura mater suturing in endoscopic transnasal pituitary/skull base surgery

Training kits for laparoscopes for deep suturing under endoscopes are commercially available; however, previously reported training kits for endoscopic transnasal transsphenoidal pituitary/skull base surgery (eTSS) were not available in the market. Moreover, the previously reported low cost, self-made kit has the drawback of being unrealistic. This study aimed to create a low cost training kit for eTSS dura mater suturing that was as close to real as possible. Most necessary items were obtained from the 100-yen store ($1 store) or from everyday supplies. As an alternative to the endoscope, a stick-type camera was used. Through the assembly of the materials, a simple and easy-to-use training kit was created, which is almost identical to the actual dural suturing situation. In eTSS, a simple and easy-to-use training kit for dural suturing was successfully created at a low cost. This kit is expected to be used for deep suture operations and the development of surgical instruments for training.

Virtual reality and surgical oncology

More than 80% of people diagnosed with cancer will require surgery. However, less than 5% have access to safe, affordable and timely surgery in low- and middle-income countries (LMICs) settings mostly due to the lack of trained workforce. Since its creation, virtual reality (VR) has been heralded as a viable adjunct to surgical training, but its adoption in surgical oncology to date is poorly understood. We undertook a systematic review to determine the application of VR across different surgical specialties, modalities and cancer pathway globally between January 2011 and 2021. We reviewed their characteristics and respective methods of validation of 24 articles. The results revealed gaps in application and accessibility of VR with a proclivity for high-income countries and high-risk, complex oncological surgeries. There is a lack of standardisation of clinical evaluation of VR, both in terms of clinical trials and implementation science. While all VR illustrated face and content validity, only around two-third exhibited construct validity and predictive validity was lacking overall. In conclusion, the asynchrony between VR development and actual global cancer surgery demand means the technology is not effectively, efficiently and equitably utilised to realise its surgical capacity-building potential. Future research should prioritise cost-effective VR technologies with predictive validity for high demand, open cancer surgeries required in LMICs.

Force-Sensorless Identification and Classification of Tissue Biomechanical Parameters for Robot-Assisted Palpation

The implementation of robotic systems for minimally invasive surgery and medical procedures is an active topic of research in recent years. One of the most common procedures is the palpation of soft tissues to identify their mechanical characteristics. In particular, it is very useful to identify the tissue's stiffness or equivalently its elasticity coefficient. However, this identification relies on the existence of a force sensor or a tactile sensor mounted at the tip of the robot, as well as on measuring the robot velocity. For some applications it would be desirable to identify the biomechanical characteristics of soft tissues without the need for a force/tactile nor velocity sensors. An estimation of such quantities can be obtained by a model-based state observer for which the inputs are only the robot joint positions and its commanded joint torques. The estimated velocities and forces can then be employed for closed-loop force control, force reflection, and mechanical parameters estimation. In this work, a closed-loop force control is proposed based on the estimated contact forces to avoid any tissue damage. Then, the information from the estimated forces and velocities is used in a least squares estimator of the mechanical parameters. Moreover, the estimated biomechanical parameters are employed in a Bayesian classifier to provide further help for the physician to make a diagnosis. We have found that a combination of the parameters of both linear and nonlinear viscoelastic models provide better classification results: 0% misclassifications against 50% when using a linear model, and 3.12% when using only a nonlinear model, for the case in which the samples have very similar mechanical properties.

Development and assessment of an educational application for the proper use of ceiling-suspended radiation shielding screens in angiography rooms using augmented reality technology

PURPOSE

An augmented reality (AR) application to help medical staff involved in interventional radiology (IR) learn how to properly use ceiling-suspended radiation shielding screens was created, and its utility was tested from the perspective of learner motivation.

METHOD

The distribution of scattered radiation in an angiography room was visualized with an AR application in three settings: when a ceiling-suspended radiation shielding screen is not used (incorrect); when there is a gap between the bottom edge of the shielding screen and the patient's torso (incorrect); and when there is no gap between the bottom edge of the shielding screen and the patient's torso (correct). This AR application was used by 33 medical staff, after which an Instructional Materials Motivation Survey (IMMS) based on the John Keller's ARCS (four categories of Attention, Relevance, Confidence, and Satisfaction) Motivation Model, consisting of 36-items with responses on a 5-point (1-5) Likert scale, was conducted.

RESULTS

The overall score was a high 4.67 ± 0.30 (mean ± standard deviation). Physician's scores tended to be lower than those of other medical staff in the categories of Attention, Relevance, and Satisfaction (not statistically significant).

CONCLUSIONS

The AR application to learn how to properly use ceiling-suspended radiation shielding screens was highly rated from the perspective of learner motivation.

A High-Fidelity Hybrid Virtual Reality Simulator of Aneurysm Clipping Repair With Brain Sylvian Fissure Exploration for Vascular Neurosurgery Training

INTRODUCTION

Microsurgery clipping is one of the most challenging surgical interventions in neurosurgery. The opportunities to train residents are scarce, but the need for accumulating practice is mandatory. New simulating tools are needed for skill learning.

METHODS

The design, implementation, and assessment of a new hybrid aneurysm clipping simulator are presented. It consists of an ergonomic workstation with a patient head mannequin and a physics-based virtual reality simulation with bimanual haptic feedback. The simulator recreates scenarios of microsurgery from the patient fixation and the exploration of the brain lobes through Sylvian fissure and vascular structures to the aneurysm clipping. Skill metrics were introduced, including monitoring of gestures movements, exerted forces, tissue displacements, and precision in clipping.

RESULTS

Two experimental conditions were tested: (1) simple clipping without brain tissue exploration and (2) clipping the aneurysm with brain Sylvian fissure exploration. Differences in the bimanual gestures were observed between both conditions. The quantitative measurements of tissue displacement of the brain lobes exhibited more tissue retrieval for the surgical gestures of neurosurgeons. Appraisal with questionnaires showed positive scores by neurosurgeons in all items evaluating the usability and realism of the simulator.

CONCLUSIONS

The simulator was well accepted and feasible for training purposes. The analysis of the interactions with virtual tissues offers information to establish differential and common patterns between tested groups and thus useful metrics for skill evaluation of practitioners. Future work can lead to other tasks during the intervention and the inclusion of more clinical cases.

A systematic review of virtual reality for the assessment of technical skills in neurosurgery

OBJECTIVE

Virtual reality (VR) and augmented reality (AR) systems are increasingly available to neurosurgeons. These systems may provide opportunities for technical rehearsal and assessments of surgeon performance. The assessment of neurosurgeon skill in VR and AR environments and the validity of VR and AR feedback has not been systematically reviewed.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted through MEDLINE and PubMed. Studies published in English between January 1990 and February 2021 describing the use of VR or AR to quantify surgical technical performance of neurosurgeons without the use of human raters were included. The types and categories of automated performance metrics (APMs) from each of these studies were recorded.

RESULTS

Thirty-three VR studies were included in the review; no AR studies met inclusion criteria. VR APMs were categorized as either distance to target, force, kinematics, time, blood loss, or volume of resection. Distance and time were the most well-studied APM domains, although all domains were effective at differentiating surgeon experience levels. Distance was successfully used to track improvements with practice. Examining volume of resection demonstrated that attending surgeons removed less simulated tumor but preserved more normal tissue than trainees. More recently, APMs have been used in machine learning algorithms to predict level of training with a high degree of accuracy. Key limitations to enhanced-reality systems include limited AR usage for automated surgical assessment and lack of external and longitudinal validation of VR systems.

CONCLUSIONS

VR has been used to assess surgeon performance across a wide spectrum of domains. The VR environment can be used to quantify surgeon performance, assess surgeon proficiency, and track training progression. AR systems have not yet been used to provide metrics for surgeon performance assessment despite potential for intraoperative integration. VR-based APMs may be especially useful for metrics that are difficult to assess intraoperatively, including blood loss and extent of resection.

A Physics-based Virtual Reality Simulation Framework for Neonatal Endotracheal Intubation

Neonatal endotracheal intubation (ETI) is a complex procedure. Low intubation success rates for pediatric residents indicate the current training regimen is inadequate for achieving positive patient out-comes. Computer-based training systems in this field have been limited due to the complex nature of simulating in real-time, the anatomical structures, soft tissue deformations and frequent tool interactions with large forces which occur during actual patient intubation. This paper addresses the issues of neonatal ETI training in an attempt to bridge the gap left by traditional training methods. We propose a fully interactive physics-based virtual reality (VR) simulation framework for neonatal ETI that converts the training of this medical procedure to a completely immersive virtual environment where both visual and physical realism were achieved. Our system embeds independent dynamics models and interaction devices in separate modules while allowing them to interact with each other within the same environment, which offers a flexible solution for multi-modal medical simulation scenarios. The virtual model was extracted from CT scans of a neonatal patient, which provides realistic anatomical structures and was parameterized to allow variations in a range of features that affect the level of difficulty. Moreover, with this manikin-free VR system, we can capture and visualize an even larger set of performance parameters in relation to the internal geometric change of the virtual model for real-time guidance and post-trial assessment. Lastly, validation study results from a group of neonatologists are presented demonstrating that VR is a promising platform to train medical professionals effectively for this procedure.

Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint

The evolution of technology has given practitioners and educators more tools to better treat, manage, and educate both patients and future pharmacists. The objective of this viewpoint publication is to describe the current use of extended reality (XR) in pharmacy and propose ways in which pharmacy practice and education may benefit from incorporation of this technology. While these tools have been used for decades by many other professions, pharmacy is starting to adopt XR in professional and educational practice. XR (virtual reality, mixed reality, and augmented reality) is being used in various aspects of pharmacy care and education, such as pain management, diabetes self-care, cross-checking of prescriptions, treatments for addiction, and (in limited ways) patient and pharmacy education. There is great potential for further integration of XR into pharmacy practice and pharmacy education to ultimately improve patient care and education as well as pharmacy education.

SlicerVR for Medical Intervention Training and Planning in Immersive Virtual Reality

Virtual reality (VR) provides immersive visualization that has proved to be useful in a variety of medical applications. Currently, however, no free open-source software platform exists that would provide comprehensive support for translational clinical researchers in prototyping experimental VR scenarios in training, planning or guiding medical interventions. By integrating VR functions in 3D Slicer, an established medical image analysis and visualization platform, SlicerVR enables virtual reality experience by a single click. It provides functions to navigate and manipulate the virtual scene, as well as various settings to abate the feeling of motion sickness. SlicerVR allows for shared collaborative VR experience both locally and remotely. We present illustrative scenarios created with SlicerVR in a wide spectrum of applications, including echocardiography, neurosurgery, spine surgery, brachytherapy, intervention training and personalized patient education. SlicerVR is freely available under BSD type license as an extension to 3D Slicer and it has been downloaded over 7,800 times at the time of writing this article.

SmartArm: Integration and validation of a versatile surgical robotic system for constrained workspaces

BACKGROUND

With the increasing presence of surgical robots minimally invasive surgery, there is a growing necessity of a versatile surgical system for deep and narrow workspaces.

METHODS

We developed a versatile system for constrained workspaces called SmartArm. It has two industrial-type robotic arms with flexible tools attached to its distal tip, with a total of nine active degrees-of-freedom. The system has a control algorithm based on constrained optimization that allows the safe generation of task constraints and intuitive teleoperation.

RESULTS

The SmartArm system is evaluated in a master-slave experiment in which a medically untrained user operates the robot to suture the dura mater membrane at the skull base of a realistic head phantom. Our results show that the user could accomplish the task proficiently, with speed and accuracy comparable to manual suturing by surgeons. Conclusions We demonstrated the integration and validation of the SmartArm.

Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint

The evolution of technology has given practitioners and educators more tools to better treat, manage, and educate both patients and future pharmacists. The objective of this viewpoint publication is to describe the current use of extended reality (XR) in pharmacy and propose ways in which pharmacy practice and education may benefit from incorporation of this technology. While these tools have been used for decades by many other professions, pharmacy is starting to adopt XR in professional and educational practice. XR (virtual reality, mixed reality, and augmented reality) is being used in various aspects of pharmacy care and education, such as pain management, diabetes self-care, cross-checking of prescriptions, treatments for addiction, and (in limited ways) patient and pharmacy education. There is great potential for further integration of XR into pharmacy practice and pharmacy education to ultimately improve patient care and education as well as pharmacy education.

Implementing Virtual and Augmented Reality Tools for Radiology Education and Training, Communication, and Clinical Care

Advances in virtual immersive and augmented reality technology, commercially available for the entertainment and gaming industry, hold potential for education and clinical use in medicine and the field of medical imaging. Radiology departments have begun exploring the use of these technologies to help with radiology education and clinical care. The purpose of this review article is to summarize how three institutions have explored using virtual and augmented reality for radiology.

Virtual reality simulation of robotic transsphenoidal brain tumor resection: Evaluating dynamic motion scaling in a master-slave system

Background

Integrating simulators with robotic surgical procedures could assist in designing and testing of novel robotic control algorithms and further enhance patient‐specific pre‐operative planning and training for robotic surgeries.

Methods

A virtual reality simulator, developed to perform the transsphenoidal resection of pituitary gland tumours, tested the usability of robotic interfaces and control algorithms. It used position‐based dynamics to allow soft‐tissue deformation and resection with haptic feedback; dynamic motion scaling control was also incorporated into the simulator.

Results

Neurosurgeons and residents performed the surgery under constant and dynamic motion scaling conditions (CMS vs DMS). DMS increased dexterity and reduced the risk of damage to healthy brain tissue. Post‐experimental questionnaires indicated that the system was well‐evaluated by experts.

Conclusion

The simulator was intuitively and realistically operated. It increased the safety and accuracy of the procedure without affecting intervention time. Future research can investigate incorporating this simulation into a real micro‐surgical robotic system.