Exploring the use of virtual reality in surgical education

Development and Validation of a Realistic Neonatal Intestinal Jejunoileal Atresia Simulator for the Training of Pediatric Surgeons

Background: Neonatal surgical pathology presents highly technical complexity and few opportunities for training. Many of the neonatal surgical entities are not replicable in animal models. Realistic 3D models are a cost-effective and efficient alternative for training new generations of pediatric surgeons. Methods: We conceptualized, designed, and produced an anatomically realistic model for the open correction of jejunoileal atresia. We validated it with two groups of participants (experts and non-experts) through face, construct, and content validity questionnaires. Results: The model was validated by eleven experts and nine non-experts. The mean procedure time for the experts and non-experts groups was 41 and 42 min, respectively. Six non-experts and one expert did not complete the procedure by the designed time (45 min) (p = 0.02). The mean score of face validity was 3.1 out of 4. Regarding construct validity, we found statistically significant differences between groups for the correct calculation of the section length of the antimesenteric border (Nixon's technique) (p < 0.01). Concerning content validity, the mean score was 3.3 out of 4 in the experts group and 3.4 out of 4 in the non-experts group. Conclusions: The present model is a realistic and low-cost valid option for training for open correction of jejunoileal atresia. Before drawing definitive conclusions, future studies with larger sample sizes and blinded validators are needed.

Determining the learning curve of minimally invasive antireflux surgery: systematic review, meta-analysis, and meta-regression

The rapid uptake of minimally invasive antireflux surgery has led to interest in learning curves for this procedure. This study ascertains the learning curve in laparoscopic and robotic-assisted antireflux surgery. A systematic review of the literature pertaining to learning curves in minimally invasive fundoplication with or without hiatal hernia repair was performed using PubMed, Medline, Embase, Web of Science, and Cochrane Library databases. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase. Twenty-five studies met the eligibility criteria. A meta-regression analysis was performed to quantitatively investigate the trend of number of cases required to achieve surgical proficiency from 1996 to present day. Using a mixed-effects negative binomial regression model, the predicted learning curve for laparoscopic and robotic-assisted antireflux surgery was found to be 24.7 and 31.1 cases, respectively. The meta-analysis determined that surgeons in their learning phase may experience a moderately increased rate of conversion to open procedure (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.28, 4.64), as well as a slightly increased rate of intraoperative complications (OR 1.60; 95% CI 1.08, 2.38), postoperative complications (OR 1.98; 95% CI 1.36, 2.87), and needing reintervention (OR 1.64; 95% CI 1.16, 2.34). This study provides an insight into the expected caseload to be competent in performing antireflux surgery. The discrepancy between outcomes during and after the learning curve for antireflux surgery suggests a need for close proctorship for learning surgeons.

An international consensus panel on the potential value of Digital Surgery

OBJECTIVES

The use of digital technology in surgery is increasing rapidly, with a wide array of new applications from presurgical planning to postsurgical performance assessment. Understanding the clinical and economic value of these technologies is vital for making appropriate health policy and purchasing decisions. We explore the potential value of digital technologies in surgery and produce expert consensus on how to assess this value.

DESIGN

A modified Delphi and consensus conference approach was adopted. Delphi rounds were used to generate priority topics and consensus statements for discussion.

SETTING AND PARTICIPANTS

An international panel of 14 experts was assembled, representing relevant stakeholder groups: clinicians, health economists, health technology assessment experts, policy-makers and industry.

PRIMARY AND SECONDARY OUTCOME MEASURES

A scoping questionnaire was used to generate research questions to be answered. A second questionnaire was used to rate the importance of these research questions. A final questionnaire was used to generate statements for discussion during three consensus conferences. After discussion, the panel voted on their level of agreement from 1 to 9; where 1=strongly disagree and 9=strongly agree. Consensus was defined as a mean level of agreement of >7.

RESULTS

Four priority topics were identified: (1) how data are used in digital surgery, (2) the existing evidence base for digital surgical technologies, (3) how digital technologies may assist surgical training and education and (4) methods for the assessment of these technologies. Seven consensus statements were generated and refined, with the final level of consensus ranging from 7.1 to 8.6.

CONCLUSION

Potential benefits of digital technologies in surgery include reducing unwarranted variation in surgical practice, increasing access to surgery and reducing health inequalities. Assessments to consider the value of the entire surgical ecosystem holistically are critical, especially as many digital technologies are likely to interact simultaneously in the operating theatre.

Virtual Reality in Acute and Chronic Pain Medicine: An Updated Review

PURPOSE OF REVIEW

This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations.

RECENT FINDINGS

Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.

LapBot-Safe Chole: validation of an artificial intelligence-powered mobile game app to teach safe cholecystectomy

BACKGROUND

Gaming can serve as an educational tool to allow trainees to practice surgical decision-making in a low-stakes environment. LapBot is a novel free interactive mobile game application that uses artificial intelligence (AI) to provide players with feedback on safe dissection during laparoscopic cholecystectomy (LC). This study aims to provide validity evidence for this mobile game.

METHODS

Trainees and surgeons participated by downloading and playing LapBot on their smartphone. Players were presented with intraoperative LC scenes and required to locate their preferred location of dissection of the hepatocystic triangle. They received immediate accuracy scores and personalized feedback using an AI algorithm ("GoNoGoNet") that identifies safe/dangerous zones of dissection. Player scores were assessed globally and across training experience using non-parametric ANOVA. Three-month questionnaires were administered to assess the educational value of LapBot.

RESULTS

A total of 903 participants from 64 countries played LapBot. As game difficulty increased, average scores (p < 0.0001) and confidence levels (p < 0.0001) decreased significantly. Scores were significantly positively correlated with players' case volume (p = 0.0002) and training level (p = 0.0003). Most agreed that LapBot should be incorporated as an adjunct into training programs (64.1%), as it improved their ability to reflect critically on feedback they receive during LC (47.5%) or while watching others perform LC (57.5%).

CONCLUSIONS

Serious games, such as LapBot, can be effective educational tools for deliberate practice and surgical coaching by promoting learner engagement and experiential learning. Our study demonstrates that players' scores were correlated to their level of expertise, and that after playing the game, most players perceived a significant educational value.

Virtual Reality With Eye Tracking for Pediatric Ophthalmology: A Systematic Review

Virtual reality presents an efficient and engaging approach to ophthalmological diagnosis and treatment in children. This systematic review investigates the current state of eye tracking technology integrated into virtual reality for the spectrum of pediatric ophthalmology. The search encompassed the MEDLINE database via PubMed, without imposing any time restrictions. A total of 20 relevant studies that met our inclusion criteria were incorporated and categorized into the following domains: diagnosis, examination, treatment, and rehabilitation use of virtual reality devices within the realm of pediatric ophthalmology. Strabismus examinations and postoperative monitoring, inherited retinal degeneration examination and visual function testing, therapy of amblyopia, glaucoma visual field testing, cerebral visual impairment rehabilitation, and neuro-ophthalmic disease examination were included in the final analysis. Pediatric ophthalmology offers a promising landscape for the integration of eye tracking technology within virtual reality, with accelerated, quantifiable, and objective examination and diagnosis, and precise, real-time measurements that are crucial in children. Virtual reality is an engaging experience, easily applied in a pediatric setting and facilitating compliance during examination and adherence to therapy. Although our systematic review provides insights into the current state of research, it is anticipated that further exploration is required for the widespread utilization of eye tracking in virtual reality within pediatric ophthalmology. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

The Virtual Reality Radiology Workstation: Current Technology and Future Applications

Virtual reality (VR) and augmented reality (AR) technology hold potential across many disciplines in medicine to expand the delivery of education and healthcare. VR-AR applications in radiology, in particular, have gained prominence and have demonstrated advantages in many areas within the field. Recently, VR software has emerged to redesign the physical radiology workstation (ie, reading room) to expand the possibilities of diagnostic interpretation. Given the novelty of this technology, there is limited research investigating the potential applications of a simulated radiology workstation. In this review article, we explore VR-simulated reading room technology in its current form and illustrate the practical applications this technology will bring to future radiologists and learners. We also discuss the limitations and barriers to adopting this technology that must be overcome to truly understand its potential benefits. VR reading room technology offers great potential in radiology, but further research is needed to appreciate its benefits and identify areas for improvement. The findings and insights presented in this review contribute to the ongoing discourse on future technological advancements in radiology and healthcare, offering valuable recommendations for further research and practical implementation.

Education in Laparoscopic Cholecystectomy: Design and Feasibility Study of the LapBot Safe Chole Mobile Game

BACKGROUND

 Major bile duct injuries during laparoscopic cholecystectomy (LC), often stemming from errors in surgical judgment and visual misperception of critical anatomy, significantly impact morbidity, mortality, disability, and health care costs.

OBJECTIVE

 To enhance safe LC learning, we developed an educational mobile game, LapBot Safe Chole, which uses an artificial intelligence (AI) model to provide real-time coaching and feedback, improving intraoperative decision-making.

METHODS

 LapBot Safe Chole offers a free, accessible simulated learning experience with real-time AI feedback. Players engage with intraoperative LC scenarios (short video clips) and identify ideal dissection zones. After the response, users receive an accuracy score from a validated AI algorithm. The game consists of 5 levels of increasing difficulty based on the Parkland grading scale for cholecystitis.

RESULTS

 Beta testing (n=29) showed score improvements with each round, with attendings and senior trainees achieving top scores faster than junior residents. Learning curves and progression distinguished candidates, with a significant association between user level and scores (P=.003). Players found LapBot enjoyable and educational.

CONCLUSIONS

 LapBot Safe Chole effectively integrates safe LC principles into a fun, accessible, and educational game using AI-generated feedback. Initial beta testing supports the validity of the assessment scores and suggests high adoption and engagement potential among surgical trainees.

Augmented Reality (AR) in Surgery in Low- and Middle-Income Countries (LMICs): A Scoping Review

Surgical disparities persist in low- and middle-income countries (LMICs). Insufficient access to surgical care places a large burden on these regions, with high mortality rates for otherwise standard procedures performed in high-income countries (HICs). Augmented Reality (AR) and Virtual Reality (VR) now provide us with a platform to improve the delivery of surgical access and training to LMICs. The use of AR technologies to provide additional training to surgeons and residents globally can help bridge the gap and reduce health disparities in LMICs. The goal of this scoping review is to evaluate whether surgical trainees and surgeons from LMICs have access to or use AR software in their training or practice. A systematic search was conducted on seven databases. Inclusion criteria included populations in LMICs with access to AR-based training. Articles using VR software, or those conducted in HICs were excluded from the review. From the 428 records screened, 58 reports were assessed for eligibility, and of these, a total of six studies were included in the review. Five of the six studies used mentors from an HIC, including the United States (US) and the United Kingdom (UK), whereas one study had mentorship from another LMIC. Three surgical specialties were explored: neurosurgery, plastic surgery, and urology. Although the integration of AR in surgical training is promising, the six studies evaluated in this review emphasize that costs and connection issues are major challenges that can set back these technologies in the operating room. Despite these revelations, with certain improvements, AR training programs are promising as they can help to reduce the global disparity in surgical proficiency.

Editorial: Immersive media in connected health-volume II

Immersive media, particularly Extended Reality (XR), is at the forefront of revolutionizing the healthcare industry. Healthcare provides XR with "silver bullet" use cases that add value and societal effect to the technology. Healthcare interventions frequently require imaging or visualization to be applied correctly, and the sensation of presence that XR can provide is crucial as a training aid for healthcare learners. From anatomy to surgical training, multimodal immersion in the reality of a medical situation increases the impact of an XR resource compared to the usual approach. Thus, healthcare has become a specialized focus for the immersive media sector, with a multitude of development and research underway. This research subject, which followed on from the previous one, yielded an eclectic group of works spanning the gamut of immersive media applications in healthcare. The underlying theme in these works remains a consistent focus on calibrating, validating, verifying, and standardizing procedures, instruments, and technologies in order to constantly rigorously streamline the means and materials that will integrate immersive technologies in healthcare. In that spirit, we share the findings from this research topic as a motivator for rigorous and evidence-based use of immersive media in digital and connected health.

Thematic analysis of stakeholder perceptions for co-creative healthcare XR resource design and development; traversing a minefield of opportunities

Introduction

The expansive curricular volume of healthcare education makes a necessity the incorporation of innovative methods and immersive media in it. The core challenge in such approaches is the timely development of relevant immersive content such as Virtual, Augmented or Mixed Reality (VR/AR/MR) resources for healthcare topics. There is currently significant interest in the use of co-creative methods for streamlining immersive content development.

Methods

A core research pursuit in this translational research field is the formulation of evidence-based, optimized workflows that streamline immersive content creation allowing for rapid expansion of innovative educational approaches in healthcare curricula. The purpose of this paper is to aggregate the perceptions of healthcare technologists and educators who participated in a series of co-creation sessions in order to elicit their best practice insights for design and development of XR educational resources using co-creative methods.

Results

According to our thematic analysis, findings of the qualitative study demonstrated that a rigorous organizational approach is required to maintain a constructive exchange of information and to keep the design process alive for both content and technical experts. In addition, rapid prototype and display of co-created features can empower their contributions and help them design more efficiently.

Discussion

Co-creative content production can benefit from adaption of existing frameworks and lightweight authoring environments that can facilitate generalized XR content development use cases.

Advancements in Hypospadias Management: Trends, Techniques, Training, and Patient-Centric Outcomes

Hypospadias has drawn increasing attention due to its prevalence, complex etiology, and significant impacts on psychological and sexual quality of life. This comprehensive review delves into the facets of hypospadias management, exploring pivotal themes that shape present understanding and practice. We demonstrate potential explanatory factors for its incidence through an analysis of geographic, genetic, and environmental influences. We then contextualize care by exploring historical and evolving surgical techniques, and highlight that advances in surgical approaches employ a spectrum of repair strategies. Innovation in surgical training, with a focus on simulation-based methodologies, offers a bridge between didactic learning and real-world application, which is particularly relevant due to the demonstrated effect of personal experience with hypospadias repair outcomes. Considering the importance of mentorship, case exposure, and hands-on practice, a holistic understanding of expertise cultivation at each training stage is essential. Lastly, patient-centric outcomes research must take center stage, particularly as the impact of our interventions on children with hypospadias will be judged by them as adults. Shifting from solely surgeon-reported outcomes to patient-reported outcomes is emphasized in the review, allowing for a more comprehensive assessment of the influence of surgical interventions across the lifespan. Integrating patients' perspectives refines surgical decision-making to align with expectations, ultimately enhancing overall satisfaction. Our multi-pronged exploration of advancements in hypospadias underscores the symbiotic relationship between evolving surgical techniques, training methodologies, personal experience, and patientreported outcomes. As the field progresses, these insights will collectively contribute to optimizing hypospadias care, advancing both medical practice and patient well-being.

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.

Three-Dimensional Printing and Bioprinting in Renal Transplantation and Regenerative Medicine: Current Perspectives

For patients with end-stage kidney disease (ESKD), renal transplantation is the treatment of choice, constituting the most common solid organ transplantation. This study aims to provide a comprehensive review regarding the application of three-dimensional (3D) printing and bioprinting in renal transplantation and regenerative medicine. Specifically, we present studies where 3D-printed models were used in the training of surgeons through renal transplantation simulations, in patient education where patients acquire a higher understanding of their disease and the proposed operation, in the preoperative planning to facilitate decision-making, and in fabricating customized, tools and devices. Three-dimensional-printed models could transform how surgeons train by providing surgical rehearsal platforms across all surgical specialties, enabling training with tissue realism and anatomic precision. The use of 3D-printed models in renal transplantations has shown a positive impact on surgical outcomes, including the duration of the operation and the intraoperative blood loss. Regarding 3D bioprinting, the technique has shown promising results, especially in the field of microfluidic devices, with the development of tissue demonstrating proximal tubules, glomerulus, and tubuloinerstitium function, and in renal organoid development. Such models can be applied for renal disease modeling, drug development, and renal regenerative medicine.

Translational research and innovation in modern transplant practice: Paradigms from Greece and around the world

The continuous clinical and technological advances, together with the social, health and economic challenges that the global population faces, have created an environment where the evolution of the field of transplantation is essentially necessary. The goal of this special issue is to provide a picture of the current status of transplantation in Greece as well as in many other countries in Europe and around the world. Authors from Greece and several other countries provide us with valuable insight into their respective areas of transplant expertise, with a main focus on the field of translational research and innovation. The papers that are part of this Special Issue "Translational Research and Innovation and the current status of Transplantation in Greece" have presented innovative and meaningful approaches in modern transplant research and practice. They provide us with a clear overview of the current landscape in transplantation, including liver transplantation in the context of a major pandemic, the evolution of living donor kidney transplantation or the evolution of the effect of hepatitis C virus infection in transplantation, while at the same time explore more recent challen ges, such as the issue of frailty in the transplant candidate and the changes brought by newer treatments, such as immunotherapy, in transplant oncology. Additionally, they offer us a glimpse of the effect that technological innovations, such as virtual reality, can have on transplantation, both in terms of clinical and educational aspects. Just as critical is the fact that this Special Issue emphasizes the multidisciplinary, collaborative efforts currently taking place that link transplant research and innovation with other cutting-edge disciplines such as bioengineering, advanced information technology and artificial intelligence. In this Special Issue, in addition to the clinical and research evolution of the field of transplantation, we are witnessing the importance of interdisciplinary collaboration in medicine.