Preparing for the future of cardiothoracic surgery with virtual reality simulation and surgical planning:a narrative review

Background and Objective: Virtual reality (VR) technology in cardiothoracic surgery has been an area of interest for almost three decades, but computational limitations had restricted its implementation. Recent advances in computing power have facilitated the creation of high-fidelity VR simulations and anatomy visualisation tools. We undertook a non-systematic narrative review of literature on VR simulations and preoperative planning tools in cardiothoracic surgery and present the state-of-the-art, and a future outlook. Methods: A comprehensive search through MEDLINE database was performed in November 2022 for all publications that describe the use of VR in cardiothoracic surgery regarding training purposes, education, simulation, and procedural planning. We excluded papers that were not in English or Dutch, and that used two-dimensional (2D) screens, augmented, and simulated reality. Key Content and Findings: Results were categorised as simulators and preoperative planning tools. Current surgical simulators include the lobectomy module in the LapSim for video assisted thorascopic surgery which has been extensively validated, and the more recent robotic assisted lobectomy simulators from Robotix Mentor and Da Vinci SimNow, which are increasingly becoming integrated into the robotic surgery curriculum. Other perioperative simulators include the CardioPulmonary VR Resuscitation simulator for advanced life support after cardiac surgery, and the VR Extracorporeal Circulation (ECC) simulator for perfusionists to simulate the use of a heart-lung machine (HLM). For surgical planning, there are many small-scale tools available, and many case/pilot studies have been published utilising the visualisation possibilities provided by VR, including congenital cardiac, congenital thoracic, adult cardiac, and adult thoracic diseases. Conclusions: There are many promising tools becoming available to leverage the immersive power of VR in cardiothoracic surgery. The path to validate these simulators is well described, but large-scale trials producing high-level evidence for their efficacy are absent as of yet. Our view is that these tools will become increasingly integral parts of daily practice in this field in the coming decade.</p

Fabrication and Assessment of 3D Printed Anatomical Models of the Lower Limb for Anatomical Teaching and Femoral Vessel Access Training in Medicine

For centuries, cadaveric dissection has been the touchstone of anatomy education. It offers a medical student intimate access to his or her first patient. In contrast to idealized artisan anatomical models, it presents the natural variation of anatomy in fine detail. However, a new teaching construct has appeared recently in which artificial cadavers are manufactured through three-dimensional (3D) printing of patient specific radiological data sets. In this article, a simple powder based printer is made more versatile to manufacture hard bones, silicone muscles and perfusable blood vessels. The approach involves blending modern approaches (3D printing) with more ancient ones (casting and lost-wax techniques). These anatomically accurate models can augment the approach to anatomy teaching from dissection to synthesis of 3D-printed parts held together with embedded rare earth magnets. Vascular simulation is possible through application of pumps and artificial blood. The resulting arteries and veins can be cannulated and imaged with Doppler ultrasound. In some respects, 3D-printed anatomy is superior to older teaching methods because the parts are cheap, scalable, they can cover the entire age span, they can be both dissected and reassembled and the data files can be printed anywhere in the world and mass produced. Anatomical diversity can be collated as a digital repository and reprinted rather than waiting for the rare variant to appear in the dissection room. It is predicted that 3D printing will revolutionize anatomy when poly-material printing is perfected in the early 21st century. (C) 2015 American Association of Anatomists

Improving implant training for physicians and their teams in under-represented regions

The burden of cardiovascular disease is increasing globally, with low- and middle-income countries (LMICs) absorbing most of the burden while lacking the necessary healthcare infrastructure to combat the increase. In particular, the disparity in pacemaker implants between high-income countries and LMICs is glaring, partially spurned by reduced numbers of physicians and supporting staff who are trained in pacemaker implant technique. Herein, we will discuss current pacemaker implant training models, outline training frameworks that can be applied to underserved regions, and review adjunctive training techniques that can help supplement traditional training models in LMICs

Virtual and Augmented Reality in Medical Education

Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models that are currently upgrading medical education. VR provides a 3D and dynamic view of structures and the ability of the user to interact with them. The recent technological advances in haptics, display systems, and motion detection allow the user to have a realistic and interactive experience, enabling VR to be ideal for training in hands-on procedures. Consequently, surgical and other interventional procedures are the main fields of application of VR. AR provides the ability of projecting virtual information and structures over physical objects, thus enhancing or altering the real environment. The integration of AR applications in the understanding of anatomical structures and physiological mechanisms seems to be beneficial. Studies have tried to demonstrate the validity and educational effect of many VR and AR applications, in many different areas, employed via various hardware platforms. Some of them even propose a curriculum that integrates these methods. This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented

An Inexpensive Cardiovascular Flow Simulator for Cardiac Catheterization Procedure Using a Pulmonary Artery Catheter

Cardiac catheterization associated with central vein cannulation can involve potential thrombotic and infectious complications due to multiple cannulation trials or improper placement. To minimize the risks, medical simulators are used for training. Simulators are also employed to test medical devices such as catheters before performing animal tests because they are more cost-effective and still reveal necessary improvements. However, commercial simulators are expensive, simplified for their purpose, and provide limited access sites. Inexpensive and anatomical cardiovascular simulators with central venous access for cannulation are sparse. Here, we developed an anatomically and physiologically accurate cardiovascular flow simulator to help train medical professionals and test medical devices. Our simulator includes an anatomical right atrium/ventricle, femoral and radial access sites, and considers the variability of arm position. It simulates physiological pulsatile blood flow with a setting for constant flow from 3 to 6 L/min and mimics physiological temperature (37◦C). We demonstrated simulation by inserting a catheter into the system at radial/femoral access sites, passing it through the vasculature, and advancing it into the heart. We expect that our simulator can be used as an educational tool for cardiac catheterization as well as a testing tool that will allow for design iteration before moving to animal trials

Development and Validation of a Hybrid Virtual/Physical Nuss Procedure Surgical Trainer

With continuous advancements and adoption of minimally invasive surgery, proficiency with nontrivial surgical skills involved is becoming a greater concern. Consequently, the use of surgical simulation has been increasingly embraced by many for training and skill transfer purposes. Some systems utilize haptic feedback within a high-fidelity anatomically-correct virtual environment whereas others use manikins, synthetic components, or box trainers to mimic primary components of a corresponding procedure. Surgical simulation development for some minimally invasive procedures is still, however, suboptimal or otherwise embryonic. This is true for the Nuss procedure, which is a minimally invasive surgery for correcting pectus excavatum (PE) – a congenital chest wall deformity. This work aims to address this gap by exploring the challenges of developing both a purely virtual and a purely physical simulation platform of the Nuss procedure and their implications in a training context. This work then describes the development of a hybrid mixed-reality system that integrates virtual and physical constituents as well as an augmentation of the haptic interface, to carry out a reproduction of the primary steps of the Nuss procedure and satisfy clinically relevant prerequisites for its training platform. Furthermore, this work carries out a user study to investigate the system’s face, content, and construct validity to establish its faithfulness as a training platform

Fabrication and Assessment of 3D Printed Anatomical Models of the Lower Limb for Anatomical Teaching and Femoral Vessel Access Training in Medicine

For centuries, cadaveric dissection has been the touchstone of anatomy education. It offers a medical student intimate access to his or her first patient. In contrast to idealized artisan anatomical models, it presents the natural variation of anatomy in fine detail. However, a new teaching construct has appeared recently in which artificial cadavers are manufactured through three-dimensional (3D) printing of patient specific radiological data sets. In this article, a simple powder based printer is made more versatile to manufacture hard bones, silicone muscles and perfusable blood vessels. The approach involves blending modern approaches (3D printing) with more ancient ones (casting and lost-wax techniques). These anatomically accurate models can augment the approach to anatomy teaching from dissection to synthesis of 3D-printed parts held together with embedded rare earth magnets. Vascular simulation is possible through application of pumps and artificial blood. The resulting arteries and veins can be cannulated and imaged with Doppler ultrasound. In some respects, 3D-printed anatomy is superior to older teaching methods because the parts are cheap, scalable, they can cover the entire age span, they can be both dissected and reassembled and the data files can be printed anywhere in the world and mass produced. Anatomical diversity can be collated as a digital repository and reprinted rather than waiting for the rare variant to appear in the dissection room. It is predicted that 3D printing will revolutionize anatomy when poly-material printing is perfected in the early 21st century. (C) 2015 American Association of Anatomists

Development of a virtual reality ophthalmoscope prototype

El examen visual es un procedimiento importante que proporciona información acerca de la condición del fondo de ojo, permitiendo la observación e identificación de anomalías, como ceguera, diabetes, hipertensión, sangrados resultado de traumas, entre otros. Un apropiado examen permite identificar condiciones que pueden comprometer la visión, sin embargo, éste es desafiante porque requiere de una práctica extensiva para desarrollar las habilidades para una adecuada interpretación que permiten la identificación exitosa de anomalías en el fondo de ojo con un oftalmoscopio. Para ayudar a los practicantes a desarrollar sus habilidades para la examinación ocular, los dispositivos de simulación médica están ofreciendo oportunidades de entrenamiento para explorar numerosos casos del ojo en escenarios simulados, controlados y monitoreados. Sin embargo, los avances en la simulación del ojo han llevado a costosos simuladores con acceso limitado ya que la práctica se mantiene con interacciones para un aprendiz y en algunos casos, ofreciendo al entrenador la visión para la interacción del practicante. Gracias a los costos asociados a la simulación médica, hay varias alternativas reportadas en la revisión de la literatura, presentando aproximaciones efectividad-costo y nivel de consumo para maximizar la efectividad del entrenamiento para el examen de ojo. En este trabajo se presenta el desarrollo de una aplicación con realidad aumentada inmersiva y no-inmersiva, para dispositivos móviles Android con interacciones a través de un controlador impreso en 3D con componentes electrónicos embebidos que imitan a un oftalmoscopio real. La aplicación presenta a los usuarios un paciente virtual visitando al doctor para un examen ocular, y requiere que el aprendiz ejecute el examen de fondo de ojo haciendo diagnosticando sus hallazgos. La versión inmersiva de la aplicación requiere del uso de un casco de realidad virtual, además del prototipo 3D de oftalmoscopio, mientras que la no inmersiva, requiere únicamente del marcador dentro del campo de visión del dispositivo móvil.The eye examination is an important procedure that provides information about the condition of the eye by observing its fundus, thus allowing the observation and identification of abnormalities, such as blindness, diabetes, hypertension, and bleeding resulting from traumas among others. A proper eye fundus examination allows identifying conditions that may compromise the sight; however, the eye examination is challenging because it requires extensive practice to develop adequate interpretation skills that allows successfully identifying abnormalities at the back of the eye seen through an ophthalmoscope. To assist trainees in developing the eye examination skills, medical simulation devices are providing training opportunities to explore numerous eye cases in simulated, controlled, and monitored scenarios. However, advances in eye simulation have led to expensive simulators with limited access as practice remain conducted on a one trainee basis in some cases offering the instructor a view of the trainee interactions. Because of the costs associated with medical simulation, there various alternatives reported in the literature review presenting cost-effective and consumerlevel approaches to maximize the effectiveness of the eye examination training. In this work, we present the development an immersive and non-immersive augmented reality application for Android mobile devices with interactions through a 3D printed controller with embedded electronic components that mimics a real ophthalmoscope. The application presents users with a virtual patient visiting the doctor for an eye examination, and requires the trainees to perform the eye fundus examination and diagnose their findings. The immersive version of the application requires the trainees to wear a mobile VR headset and hold the 3D printed ophthalmoscope, while the non-immersive version requires them to hold the marker within the field of view of the mobile device.Pregrad