Immersive virtual reality for surgical training in trauma and orthopaedic surgery

Thomas Lewis, Mark Bowditch, Wathik El-Alami, Diane Back and Adil Ajuied

Thomas Lewis is an ST7 trainee from South East Thames. He has a strong research background with peer reviewed publications, international and national presentations spanning research projects in surgery, anatomy, surgical education and mobile health. He is the regional virtual reality lead for the South East Thames Deanery.

Mark Bowditch is a Consultant and Divisional Clinical Director for MSK & surgical specialties at the East Suffolk and North Essex NHS Foundation Trust. Mark’s specialist interests are in surgery of the knee and all levels of surgical education and he is currently the Head of School of Surgery in the East of England.

Wathik El-Alami is a Consultant Trauma and Orthopaedic surgeon at Guy’s and St Thomas’ NHS Foundation Trust. He is the Director of Medical Education and has a keen interest in utilising technology and simulation for improving medical education.

Diane Back is a Consultant Trauma and Orthopaedic surgeon at Guy’s and St Thomas’ NHS Foundation Trust. She is the Training Programme Director of South East Thames and is passionate about improving training.

Adil Ajuied has worked as a Consultant at Guy’s and St Thomas’ Hospitals since 2009 and specialises in all aspects of knee surgery. He completed a postgraduate Masters’ degree, and has been appointed a Senior Honorary Clinical Lecturer in Trauma and Orthopaedics as well as Director of Education for South London Orthopaedics. He has served as an executive board member of BASK, and Associate Editor of the Knee Journal, as well as convening scores of educational and instructional courses. He has a strong interest in how new technologies and innovations can be leveraged to enhance training and ultimately patient outcomes.

Surgical training is widely acknowledged to be vitally important to maintain the surgical workforce of the future. Delivering surgical training in the modern NHS is technically challenging due to numerous factors including access to training opportunities, balancing service commitments, theatre pressures, all of which have been exacerbated by the COVID pandemic [1-3]. Simulation, technical instructional courses offer trauma and orthopaedic surgery trainees the opportunity to develop their technical and non-technical surgical skills [4-9].

What is surgical simulation?

Surgical simulation comes in multiple modalities ranging from simple low fidelity simulation such as sawbones tutorials, through detailed procedures specific computerised simulators, all the way to cadaveric laboratory-based simulation. A more recent development is that of procedure specific virtual reality surgical simulation, allowing a more immersive experience. Recent studies have suggested that the use of virtual reality (VR) during the training of orthopaedic surgery residents improves surgical performance [4-6,10-11]

What exactly is VR? VR utilises readily available hardware, this consists of three main components; firstly a headset, which incorporates stereoscopic visualisation, microphones, accelerometers, speakers and enables users to experience a 3-dimensional computer-generated multisensory environment which responds to their head and body movements. The second component are two handsets which contain accelerometers and control buttons and joysticks. These are used to interact and manipulate with the virtual world. Lastly, the third component is that of a very intricate and sophisticated software package that describes the VR environment, and how you will interact with it.

Virtual reality in surgical training

Integrating VR into surgical training has a number of advantages as shown in Table 1. Trainees have the opportunity to review and practice the procedural steps of an operation prior to attending a real world operating theatre. The most important aspect of VR in surgical simulation is that trainees can learn the ordered steps of a surgical procedure (the work-flow), in a safe and self-directed fashion. Trainees can also gain familiarity with the theatre environment setup, instruments and develop their situational awareness and non-technical skills managing a procedure all without placing patients at risk [12].

Table 1: Advantages and disadvantages of virtual reality in trauma and orthopaedic surgery surgical training.

Advantages

Can perform procedures in risk-free environment

Accessibility and availability of virtual theatre environment not limited regardless of external factors e.g. geography or time

Opportunity for trainees to focus on operative competence and skills in a consistent manner

Simulate and develop non-technical human factors skills through interaction with other multi-disciplinary team members

Develop knowledge of technical procedural skills for an operation prior to theatre

Regular assessment and feedback on technical performance Scenarios can be adjusted for different skill levels

Improved accessibility to regional training opportunities as can join virtual lecture theatres and breakout rooms independent of geography (for both trainees and trainers)

Immersive simulated environment compared to other simulation techniques

Disadvantages

Lack of tissue handling and haptic feedback

Limited modules currently available

Cost of hardware and ongoing software licences

Hardware and software limitations e.g. resolution, model freedom, instrumentation

At present, most surgical VR modules are quite didactic in their workflow structure, but as they evolve and become more sophisticated, alterative surgical techniques and strategies will become options within individual modules, as will intra-operative complications and their management.

For many years surgical institutions and Surgeons, have been compared to pilots and the wider aviation industry respectively. We have sought and adopted within surgery insights and best practice from aviation around safety, and standardisation of processes. Examples of this include the WHO checklist, the no-blame culture, and the right to speak up. VR surgical simulation, allows us to draw another parallel with the aviation industry, where all commercial and much civil aviation transitions from the class room through flight-simulators, before getting to real world flight. Indeed, commercial pilots, frequently return to the flight-simulator for re-licencing assessments, upskilling, and to train others.

VR will never replace the real world haptic feedback of actual tissue handling as it cannot recreate the muscle memory that comes from handling and operating on actual tissue, however we believe it can improve the efficiency of surgical education and maximise the learning opportunity that can be gained from that ever-dwindling training resource, time in theatre [13].

There are also advantages to integrating VR into medical training unrelated to the development of technical and non-technical skills. There are no geographical restrictions so trainees and trainers can collaborate in the same VR physical environment, while being geographically remote.

Putting VR to the test

At the beginning of August 2022, we held a virtual reality surgical education day for trainees across south London in order to explore the utility of virtual reality for surgical training. The day consisted of lectures delivered within a VR lecture theatre to a large auditorium of delegates, before each entering their own individual operating theatre to perform two different surgical procedures. Each trainee performed a therapeutic hip arthroscopy for femora-acetabular impingement and an anterior cruciate ligament reconstruction (Figure 1 & 2).

Figure 1: Photograph of delegate using virtual reality headset and controllers to perform simulated procedures in a virtual operating theatre environment.

Figure 2: Photograph of delegate using virtual reality headset and controllers to perform simulated procedures in a virtual operating theatre environment.

Each trainee had 1:1 consultant supervision in their individual theatre (Figure 3) and were able to receive targeted feedback and teaching regarding each step of the procedure.

Figure 3: Screenshot demonstrating an operating surgeon teaching other surgeons in a virtual reality operating theatre.

The feedback from the trainees was universally positive as demonstrated in Figure 4. Trainees reported that the simulated theatres felt ‘realistic’ and offered the opportunity to take time to understand the steps of a procedure prior to theatre. Multiple trainees reported that the structured work-flow within the simulation module aided them in understanding the critical steps of the procedure’s set up and execution, that become intuitive for the experienced trainer and hence may often be skimmed over or purely taught.

Figure 4: Participant responses following virtual reality surgical training day (0 (worst response) - 10 (best response).

VR allowed trainees access to information and training opportunities that they would otherwise never have the opportunity to see, such as to explant a him with femoral acetabular impingement before, mid and post cam resection, assessing the bony architecture of the pathology and it’s real time response to surgical intervention.

Other benefits reported by the trainees included, feeling that they would require less real world training cases to gain competence in a particular procedure (flattening the learning curve), the opportunity to ‘familiarise with operations that are done rarely’ and and ‘improve understanding of surgical instrumentation’. The virtual reality modules recorded technical data which provided each trainee with immediate feedback on their progress and helped them identify areas of development for future cases. 94% of attendees felt that virtual reality training should be incorporated into their current surgical training programme.

“[Virtual reality] would allow for much greater exposure to the routine of surgical procedures. Significantly limited opportunities at the moment therefore this would be a vital way to bridge the gap. Feels like undoubtedly the future of training.”

Is VR training effective?

The evidence base for VR simulation in trauma and orthopaedic surgery is relatively limited with VR yet to be broadly incorporated into surgical training. A number of recent systematic reviews of VR surgical simulation in orthopaedics have found VR simulators are excellent tools for improving surgical training and skills acquisition [4-8,14]. Metrics for surgical skill that were studied included mean time and accuracy to perform an operation, instrument handling, implant placement, knowledge of procedural steps and efficiency of movement. There are a number of randomised control trials, across a number of orthopaedic subspecialties, which demonstrated that VR can improve surgical skills acquisition, especially in comparison to non-VR training simulation methods. Although the results and potential applications of VR are encouraging there are a number of important limitations. The most important of these is the lack of methodologically robust high quality, large-scale studies with long follow-up periods.

A number of studies assessing trainee attitudes to virtual reality for surgical education have found encouraging results in terms of enjoyment, utility and efficacy, when compared to more traditional teaching methods. Trainees reported they saw a role for VR in surgical training, particularly during the early phases of training where operative opportunities were increasingly limited. There is emerging evidence of construct validity and transferability of VR acquired skills to the real world operating theatre environment [4-7,14-15] however further research is certainly needed in this area. Virtual reality simulation is potentially more effective than traditional simulation methods and may help mitigate surgical skill decay by providing additional opportunities to refresh knowledge prior to attending theatre16. Skill acquisition and retention is particularly important in surgical training as the nature of rotational sub-speciality-based placements mean that it is possible to deskill without regular refreshment of cognitive and manual skills. Complex cognitive and technical skills decay rapidly compared to simple tasks with interval task iteration shown to be an effective means of maintaining competence. VR may have a valuable role to play in allowing safe and convenient skill updating, alongside objective VR procedure specific metrics.

Constraints to implementation

There are current barriers to implementation of virtual reality of which the greatest is cost and accessibility of hardware and associated software (Figure 5) [17]. However, given the current pressures on surgical training, alternative strategies to enhance training and education such as virtual reality may play an integral role in training. General challenges to adoption of virtual reality technology include reduced face-to-face communications, cost limitations (in terms of hardware and ongoing software licences), educational, and users’ attitude. There are also specific challenges that need to be addressed for successful implementation. These include ensuring support from relevant stakeholders such as Health Education England, SAC, JCST, ISCP, local TPD’s, deaneries and hospital trusts. Given the limited time available for surgical training, integrating VR into training may come at the expense of other training opportunities such as regional teaching days so this needs to be considered. One major barrier is the limited evidence base to support the transferability of technical and non-technical skills from VR training to real-life hospital environments. Finally, as with any new technology, additional support in terms of hardware and availability of software modules will be seen as key to implementation.

Figure 5: Key themes identified related to implementation of virtual reality into surgical training.

The potential for virtual reality extends beyond surgical training to the wider theatre team. We have piloted a proof of concept MDT collaborative simulation by virtually performing a case with an anaesthetist, scrub nurses, circulating staff and other theatre members all in one theatre. This has many future applications to focus on non-technical skills such as human factors and communication in theatre as well as simulation of critical scenarios without placing patients at risk or using real world resources [18].

Conclusion

In summary, immersive virtual reality has great potential to positively improve surgical training by allowing trainees to develop their technical and non-technical skills in a range of scenarios without placing patients at risk and improving the efficiency of learning when physically in theatre. There are a number of barriers to implementation that may limit the adoption of virtual reality into surgical training and future research should focus on evaluating the transferability of technical and non-technical skills developed in VR to the real operating theatre environment.

References

References can be found online at: www.boa.ac.uk/publications/JTO