Virtual Reality Exploration and Planning for Precision Colorectal Surgery

A decade of progress: bringing mixed reality image-guided surgery systems in the operating room

Advancements in mixed reality (MR) have led to innovative approaches in image-guided surgery (IGS). In this paper, we provide a comprehensive analysis of the current state of MR in image-guided procedures across various surgical domains. Using the Data Visualization View (DVV) Taxonomy, we analyze the progress made since a 2013 literature review paper on MR IGS systems. In addition to examining the current surgical domains using MR systems, we explore trends in types of MR hardware used, type of data visualized, visualizations of virtual elements, and interaction methods in use. Our analysis also covers the metrics used to evaluate these systems in the operating room (OR), both qualitative and quantitative assessments, and clinical studies that have demonstrated the potential of MR technologies to enhance surgical workflows and outcomes. We also address current challenges and future directions that would further establish the use of MR in IGS.

The use of mixed reality in the preoperative planning of colorectal surgery: Preliminary experience with a narrative review

New advanced technologies have recently been developed and preliminarily applied to surgery, including virtual reality (VR), augmented reality (AR) and mixed reality (MR). We retrospectively review all colorectal cases in which we used holographic 3D reconstruction from February 2020 to December 2022. This innovative approach was used to identify vascular anomalies, pinpoint tumor locations, evaluate infiltration into neighboring organs and devise surgical plans for both training and educating trainee assistants. We have also provided a state-of-the-art analysis, briefly highlighting what has been stated by the scientific literature to date. VR facilitates training and anatomical assessments, while AR enhances training and laparoscopic performance evaluations. MR, powered by HoloLens, enriches anatomic recognition, navigation, and visualization. Successful implementation was observed in 10 colorectal cancer cases, showcasing the effectiveness of MR in improving preoperative planning and its intraoperative application. This technology holds significant promise for advancing colorectal surgery by elevating safety and reliability standards.

An analysis of virtual reality in abdominal surgery-A scoping review

BACKGROUND

The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity.

METHODS

A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine.

RESULTS

Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training.

CONCLUSIONS

Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

Experience in the Application of Augmented Reality Technology in the Surgical Treatment of Patients Suffering Primary and Recurrent Pelvic Tumors

Surgical treatment of locally spread tumors in pelvic organs remains an urgent and complicated oncological problem. The recurrence rate after radical treatment ranges from 15.1% to 45.2%. The key to successful and safe surgical intervention lies in meticulous planning and intraoperative navigation, including the utilization of augmented reality (AR) technology. This paper presents the experience of clinically testing an AR technology application algorithm in the surgical treatment of 11 patients. The main stages of the algorithm are described. Radical operations incorporating intraoperative AR technology with favorable outcomes were performed on eight patients. One patient underwent a palliative intervention, while two patients did not undergo surgery. The testing of the algorithm for the application of AR technology in the surgical treatment of primary and recurrent pelvic tumors demonstrated both a technical possibility and reproducibility of this algorithm and the AR technology itself in clinical practice.

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience

INTRODUCTION

Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy.

METHODS

Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured.

RESULTS

Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively).

CONCLUSIONS

Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

Augmented reality presentation of the extracranial facial nerve: an innovation in parotid surgery

Surgeons used to be unaware of the facial nerve's position during parotid surgery. Now, with special magnetic resonance imaging (MRI) sequences, it can be located and converted into a 3D model displayed on an augmented reality (AR) device for surgeons to study and manipulate. This study explores the accuracy and usefulness of the technique for the treatment of benign and malignant parotid tumours. A total of 20 patients with parotid tumours had 3-Tesla MRI scans, and their anatomical structures were segmented using Slicer software. The structures were imported into a Microsoft HoloLens 2® device, displayed in 3D, and shown to the patient for consent. Intraoperative video recording was used to record the position of the facial nerve in relation to the tumour. The predicted path of the nerve taken from the 3D model was combined with surgical observation and video recording in all cases. The imaging proved to have application in both benign and malignant disease. It also improved the process of informed patient consent. Three-dimensional MRI imaging of the facial nerve within the parotid gland and its display in a 3D model is an innovative technique for parotid surgery. Surgeons can now see the nerve's position and tailor their approach to each patient's tumour, providing personalised care. The technique eliminates the surgeon's blind spot and is a significant advantage in parotid surgery.

Virtual reality simulation of panoramic radiographic anatomy for dental students

PURPOSE

This work aimed to utilize virtual reality (VR) in dental radiographic anatomical interpretation in junior dental students and test if it can enhance student learning, engagement, and performance.

METHODS

VR software for panoramic anatomy was developed. Sixty-nine first-year dental students were divided into a control group (lecture-based) and an experimental group (VR) to learn panoramic radiographic anatomy. Both groups were then tested on knowledge via a 20-question quiz. Student feedback on VR experience was collected via an online survey.

RESULTS

There was a statistically significant difference between lecture-based and VR students in the correct identification of anatomical landmarks. Lecture-based students scored higher in identifying the ear lobe, hyoid bone, condylar neck, and external oblique ridge, whereas VR students scored higher in identifying zygoma (Chi-squared test, p < 0.005). The VR group reported high evaluation on all perception items of the online feedback survey on their experience (Student t-test, p < 0.005).

CONCLUSIONS

Lecture-based students generally showed better performance in panoramic radiographic anatomy. Several structures were not correctly identified in both groups of novice students. The positive feedback of VR experience encourages future implementation in education to augment conventional methods of radiographic anatomy in dentistry with considerations to repeated exposures throughout undergraduate dental education.

PREOPERATIVE COMPUTED TOMOGRAPHY ANGIOGRAPHY IN MULTIDISCIPLINARY PERSONALIZED ASSESSMENT OF PATIENT WITH RIGHT-SIDED COLON CANCER: SURGEON AND RADIOLOGIST POINT OF VIEW

BACKGROUND

3D-CT angiography has made it possible to reach a qualitatively new level in the determination of treatment tactics for patients with colorectal cancer.

AIMS

This study aimed to analyze the clinical and radiological aspects that need to be discussed before surgery by a multidisciplinary team in patients with right-sided colon cancer.

METHODS

This study involved 103 patients with colorectal cancer who underwent preoperative 3D-CT angiography from 2016 to 2021.

RESULTS

All patients underwent radical D3 right hemicolectomy. The median quantity of removal lymph nodes were 24.71±10.04. Anastomotic leakage was diagnosed in one patient. We have identified eight most common types of superior mesenteric artery. The ileocolic artery crossed the superior mesenteric vein on the anterior surface in 64 (62.1%) patients and on the posterior surface in 39 (37.9%). In 58 (56.3%) patients, the right colic artery was either absent or was a nonindependent branch of superior mesenteric artery. The distance from the root of the superior mesenteric artery to the root of the middle colic artery was 37.8±12.8 mm and that from the root of the middle colic artery to the root of the ileocolic artery was 29.5±15.7 mm. The trunk of Henle was above the root of the middle colic artery in 66 (64.1%) patients, at the same level with the middle colic artery in 16 (15.5%), and below the middle colic artery in 18 (17.5%) patients.

CONCLUSIONS

Preoperative analysis of 3D-CT angiography is a key pattern in assessment of vascular anatomy and can potentially show the complexity of future lymphadenectomy and reduce the risk of anastomotic leakage.

Practical Application of Augmented/Mixed Reality Technologies in Surgery of Abdominal Cancer Patients

The technology of augmented and mixed reality (AR/MR) is useful in various areas of modern surgery. We considered the use of augmented and mixed reality technologies as a method of preoperative planning and intraoperative navigation in abdominal cancer patients. Practical use of AM/MR raises a range questions, which demand suitable solutions. The difficulties and obstacles we encountered in the practical use of AR/MR are presented, along with the ways we chose to overcome them. The most demonstrative case is covered in detail. The three-dimensional anatomical model obtained from the CT scan needed to be rigidly attached to the patient’s body, and therefore an invasive approach was developed, using an orthopedic pin fixed to the pelvic bones. The pin is used both similarly to an X-ray contrast marker and as a marker for augmented reality. This solution made it possible, not only to visualize the anatomical structures of the patient and the border zone of the tumor, but also to change the position of the patient during the operation. In addition, a noninvasive (skin-based) marking method was developed that allows the application of mixed and augmented reality during operation. Both techniques were used (8 clinical cases) for preoperative planning and intraoperative navigation, which allowed surgeons to verify the radicality of the operation, to have visual control of all anatomical structures near the zone of interest, and to reduce the time of surgical intervention, thereby reducing the complication rate and improving the rehabilitation period.

Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery—First Pilot Study

When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.

New Approach to Accelerated Image Annotation by Leveraging Virtual Reality and Cloud Computing

Three-dimensional imaging is at the core of medical imaging and is becoming a standard in biological research. As a result, there is an increasing need to visualize, analyze and interact with data in a natural three-dimensional context. By combining stereoscopy and motion tracking, commercial virtual reality (VR) headsets provide a solution to this critical visualization challenge by allowing users to view volumetric image stacks in a highly intuitive fashion. While optimizing the visualization and interaction process in VR remains an active topic, one of the most pressing issue is how to utilize VR for annotation and analysis of data. Annotating data is often a required step for training machine learning algorithms. For example, enhancing the ability to annotate complex three-dimensional data in biological research as newly acquired data may come in limited quantities. Similarly, medical data annotation is often time-consuming and requires expert knowledge to identify structures of interest correctly. Moreover, simultaneous data analysis and visualization in VR is computationally demanding. Here, we introduce a new procedure to visualize, interact, annotate and analyze data by combining VR with cloud computing. VR is leveraged to provide natural interactions with volumetric representations of experimental imaging data. In parallel, cloud computing performs costly computations to accelerate the data annotation with minimal input required from the user. We demonstrate multiple proof-of-concept applications of our approach on volumetric fluorescent microscopy images of mouse neurons and tumor or organ annotations in medical images.

[Perioperative augmented reality technology in surgical treatment of locally advanced recurrent rectal cancer]

Rectal cancer occupies the leading position among cancers, and incidence of locally advanced recurrences is still high despite comprehensive treatment. Combined resections are usually associated with high perioperative risks. These procedures are technically complex interventions requiring further improvement. Virtual reality technology in surgical treatment of locally advanced rectal cancer recurrence has not been widely discussed. The authors present multidisciplinary construction of the matched topographic-anatomical virtual model and virtual planning of the combined surgical intervention. Intraoperative use of augmented reality allowed specifying topographic and anatomical features of surgical area, level of vascular ligation, localization of tumor fixation points and resection borders. These data ensured safety and quality of resection. Further research of augmented reality technology and improvement of its technical aspects will improve the results of surgical treatment of patients with locally advanced pelvic tumors and recurrences.

Computed Tomography Colonography Angiography (CTC-A) prior to colectomy for cancer: A new tool for surgeons

The pre-operative work-up for non-metastatic colon cancer includes colonoscopy and thoraco-abdomino-pelvic computed tomography (CT) with intravenous (IV) contrast. Colonoscopic determination of the anatomical location of the tumor may be erroneous, particularly with a long redundant colon (dolichocolon), and the search for synchronous colon neoplasms is limited when the endoscope cannot traverse the tumor-bearing segment. While computed tomography colonography angiography (CTC-A) makes it possible to assess distant tumor metastasis, it remains limited for the assessment of loco-regional extension. CTC-A requires specific colonic preparation, controlled colonic insufflation with CO₂, and an injection of IV contrast. CTC-A provides a 3-D view of the overall morphology of the colon and precisely localizes the site of the colonic tumor. Merging the images of the colon with those of mesenteric and colonic vessels provides a representation of anatomical vascular variations. This information could help the surgeon to better plan the colectomy. The use of two-dimensional images of CTC-A with sections perpendicular to the major axis of the tumor-bearing colonic segment can provide precise information on the degree of parietal extension and be useful in evaluating the value of neo-adjuvant chemotherapy.

The Effect of Showing Images of the Foetus with the Virtual Reality Glass During Labour Process on Labour Pain, Birth Perception and Anxiety

AIM AND OBJECTIVES

This study was conducted to determine the effect of showing images of the foetus to the pregnant women with the virtual reality glass during labour process on labour pain, childbirth perception and anxiety level.

BACKGROUND

Virtual reality is an effective and inexpensive method that allows the creation of simulated scenarios in which it interacts with the virtual environment with multisensory stimuli.

DESIGN

This is a randomised controlled experimental study. This study was conducted with the guidelines of Consolidated Standards of Reporting Trials (CONSORT). The study was enrolled in the Clinical Trials database (NCT04664114).

METHODS

The study included 100 pregnant women (50 intervention group and 50 control group). Ultrasound images of the foetus were recorded on the 28th week of pregnancy of the women in the intervention group. These images were shown to the women with the virtual reality glass during labour process. Routine procedures were carried out for the women in the control group. The Visual Analog Scale (VAS) was applied to both groups when cervical dilatation was 4 cm and 9 cm. The Women's Perception for the Scale of Supportive Care Given During Labor (POBS) and the Perinatal Anxiety Screening Scale (PASS) were applied almost two hours after labour.

RESULTS

The VAS scores of the women in the intervention group with 9 cm dilatation and their PASS mean scores were significantly lower than women in the control group while their POBS score were significantly higher (p < 0.01).

CONCLUSION

The results of this study show that showing images of the foetus to women with virtual reality decreased labour pain and anxiety level.

RELEVANCE TO CLINICAL PRACTICE

It is known that supportive care given during labour is important both for the mother's and baby's health. Therefore, it is important that nurses and midwives, who spend the most time with women and provide the most support, reduce the pain and anxiety of the woman with nonpharmacological practices and make them feel positive feelings about delivery.

Intraoperative and postoperative complications in colorectal procedures: the role of continuous updating in medicine

Accepting surgical complications, especially those related to the learning curve, as unavoidable events in colorectal procedures, is like accepting to fly onboard an aircraft with a 10 to 20% chance of not arriving at final destination. Under this condition, it is very likely that the aviation industry and the concurrent reshaping of the world and of our lives would have not been possible in the absence of high reliability and reproducibility of safe flights. It's hard to imagine surgery without any intraoperative and/or postoperative complications. Nevertheless, there is a plenty of room for improvement by simply adopting what has been explicitly and scientifically demonstrated; training outside of the OR, usage of modern information technologies and application of evidence-based perioperative care protocols. Additionally, the possibility to objectively measure and monitor the technical and even non-technical skills and competencies of individual surgeons and even of OR teams through the application of structured and validated assessment tools can finally put an end to the self-referential, purely hierarchical, and indeed extremely unreliable process of being authorized or not to perform operations on patients. Last but not least, a wide range of new technologies spanning from augmented imaging modalities, virtual reality for intraoperative guidance, improved robotic manipulators, artificial intelligence to assist in preoperative patient specific risk assessment, and intraoperative decision-making has the potential to tackle several hidden roots of surgical complications.

Virtual Reality in Preoperative Planning of Adolescent Idiopathic Scoliosis Surgery Using Google Cardboard

OBJECTIVE

Preoperative planning in spine surgery is a fundamental step of the surgical workup and is often assisted by direct visualization of anatomical 2-dimensional images. This process is time-consuming and may excessively approximate the 3-dimensional (3D) nature of spinal anatomy. Virtual reality (VR) is an emerging technology capable of reconstructing an interactive 3D anatomical model that can be freely explored and manipulated.

METHODS

Sixty patients with adolescent idiopathic scoliosis underwent correction of the scoliotic curve by posterior arthrodesis after preoperative planning using traditional on-screen visualization of computed tomography scans (control group, n = 30) or exploration of a 3D anatomical model in VR using Google Cardboard (Google Inc.) (VR group, n = 30). Mean operative time, blood loss, length of hospital stay, and surgeon's satisfaction were assessed after surgery.

RESULTS

The use of VR led to a significant decrease in operative time and bleeding while increasing the surgeon's satisfaction compared to the control group.

CONCLUSION

Preoperative planning with VR turned out to be effective in terms of operative time and blood loss reduction. Moreover, such technology proved to be reproducible, costeffective, and more satisfactory compared to conventional planning.

Peroral traction-assisted natural orifice trans-anal flexible endoscopic rectosigmoidectomy followed by intracorporeal colorectal anastomosis in a live porcine model

BACKGROUND

Compared to traditional open surgery, laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain, a shorter hospital stay, and better quality of life. In 2007, Whiteford et al reported the first natural orifice trans-anal endoscopic surgery (NOTES) sigmoidectomy using transanal endoscopic microsurgery. To date, all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.

AIM

To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.

METHODS

Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during the operation. The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps: (1) The rectosigmoid colon was tattooed with India ink by submucosal injection; (2) Creation of gastrostomy by directed submucosal tunneling; (3) Peroral external traction using endoloop ligation; (4) Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) Peroral external traction-assisted dissection of the left side of the colon; (6) Trans-anal rectosigmoid specimen transection, where an anvil was inserted into the proximal segment after purse-string suturing; (7) Intracorporeal colorectal end-to-end anastomosis using a circular stapler by a single stapling technique; and (8) Closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed, and the air-under-water leak test was carried out.

RESULTS

The procedure was completed in all three animals, with the operation time ranging from 193 min to 259 min. Neither major intraoperative complications nor hemodynamic instability occurred during the operation. The length of the resected specimen ranged from 7 cm to 13 cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals.

CONCLUSION

Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.

Advanced 3D "Modeling" and "Printing" for the Surgical Planning of a Successful Case of Thoraco-Omphalopagus Conjoined Twins Separation

Background

The surgical separation of two Conjoined Twins is a particularly complex operation. Surgical times are particularly long and post-operative complications are very frequent in this type of procedure. We report a clinical case of surgical separation of two thoraco-omphalopagus conjoined twins in which, thanks to the use of (3D) three dimensional technologies, we were able to significantly reduce operative times and improve clinical outcomes.

Methods

We performed a 3D reconstruction of the anatomical parts involved in congenital fusion using Computer Tomography (CT) images.We obtained virtual anatomical models of the patients which allowed us to estimate essential details as the residual post-operative thoracic volume as well as the exact position of resection planes for both the general separation and for the hepatic splitting procedure. Subsequently, we printed 3D anatomical models of the thoracic cage and sternum and of the liver with the plane of resection. Finally, we printed an additional 3D anatomical model of the two patients representing different organs with multiple colors and materials.

Results

The use of 3D printing reduced the duration of surgery by 30% with a favorable patient outcome. Two years after the operation, the patients do not present any type of deficit and have a normal life without any significant complication.

Conclusion

Virtual anatomical 3D models and 3D printing represent a valid technological tool to support complex surgical operations, especially in pre-surgical planning. 3D models are important tools to better understand complex anatomy and to discuss clinical cases among members of the surgical team.

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.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.

METHODS

Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.

RESULTS

There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).

CONCLUSIONS

VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.

LEVEL OF EVIDENCE

Level 1.

Head-Mounted Mixed-Reality Technology During Robotic-Assisted Transanal Total Mesorectal Excision

INTRODUCTION

Head-mounted mixed-reality technologies may enable advanced intraoperative visualization during visceral surgery. In this technical note, we describe an innovative use of real-time mixed reality during robotic-assisted transanal total mesorectal excision.

TECHNIQUE

Video signals from the robotic console and video endoscopic transanal approach were displayed on a virtual monitor using a head-up display. The surgeon, assistant, and a surgical trainee used this technique during abdominal and transanal robotic-assisted total mesorectal excision. We evaluated the feasibility and usability of this approach with the use of validated scales.

RESULTS

The technical feasibility of the real-time visualization provided by the current setup was demonstrated for both the robotic and transanal parts of the surgery. The surgeon, assistant, and trainee each used the mixed-reality device for 15, 55, and 35 minutes. All participants handled the device intuitively and reported a high level of comfort during the surgery. The task load was easily manageable (task load index: <4/21), although the surgeon and assistant both noted a short delay in the real-time video.

CONCLUSION

The implementation of head-mounted mixed-reality technology during robotic-assisted transanal total mesorectal excision can benefit the operating surgeon, assistant, and surgical trainee. Further improvements in display quality, connectivity, and systems integration are necessary.

Robotic-assisted stereotactic real-time navigation: initial clinical experience and feasibility for rectal cancer surgery

BACKGROUND

Real-time stereotactic navigation for transanal total mesorectal excision has been demonstrated to be feasible in small pilot series using laparoscopic techniques. The possibility of real-time stereotactic navigation coupled with robotics has not been previously explored in a clinical setting.

METHODS

After pre-clinical assessment, and configuration of a robotic-assisted navigational system, two patients with locally advanced rectal cancer were selected for enrollment into a pilot study designed to assess the feasibility of navigation coupled with the robotic da Vinci Xi platform via TilePro interface. In one case, fluorescence-guided surgery was also used as an adjunct for structure localization, with local administration of indocyanine green into the ureters and at the tumor site.

RESULTS

Each operation was successfully completed with a robotic-assisted approach; image-guided navigation provided computed accuracy of ± 4.5 to 4.6 mm. The principle limitation encountered was navigation signal dropout due to temporary loss of direct line-of-sight with the navigational system's infrared camera. Subjectively, the aid of navigation assisted the operating surgeon in identifying critical anatomical planes. The combination of fluorescence with image-guided surgery further augmented the surgeon's perception of the operative field.

CONCLUSIONS

The combination of stereotactic navigation and robotic surgery is feasible, although some limitations and technical challenges were observed. For complex surgery, the addition of navigation to robotics can improve surgical precision. This will likely represent the next step in the evolution of robotics and in the development of digital surgery.

Toward Holographic-Guided Surgery

The implementation of augmented reality (AR) in image-guided surgery (IGS) can improve surgical interventions by presenting the image data directly on the patient at the correct position and in the actual orientation. This approach can resolve the switching focus problem, which occurs in conventional IGS systems when the surgeon has to look away from the operation field to consult the image data on a 2-dimensional screen. The Microsoft HoloLens, a head-mounted AR display, was combined with an optical navigation system to create an AR-based IGS system. Experiments were performed on a phantom model to determine the accuracy of the complete system and to evaluate the effect of adding AR. The results demonstrated a mean Euclidean distance of 2.3 mm with a maximum error of 3.5 mm for the complete system. Adding AR visualization to a conventional system increased the mean error by 1.6 mm. The introduction of AR in IGS was promising. The presented system provided a solution for the switching focus problem and created a more intuitive guidance system. With a further reduction in the error and more research to optimize the visualization, many surgical applications could benefit from the advantages of AR guidance.