Challenges in Surgical Training- Exploring the role of virtual and augmented reality

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In the field of surgery, major changes that have occurred include the advent of minimally invasive surgery and the realization of the importance of the ‘systems’ in the surgical care of the patient (Pierorazio & Allaf, 2009). Challenges in surgical training are two-fold: (i) to train the surgical residents to manage a patient clinically (ii) to train them in operative skills (Singh & Darzi,2013). In Pakistan, another issue with surgical training is
 that we have the shortest duration of surgical training in general surgery of four years only, compared to six to eight years in Europe and America (Zafar & Rana, 2013). Along with it, the smaller number of patients to surgical residents’ ratio is also an issue in surgical training. This warrants formal training outside the operation room. It has been reported by many authors that changes are required in the current surgical training system due to the significant deficiencies in the graduating surgeon (Carlsen et al., 2014; Jarman et al., 2009; Parsons, Blencowe, Hollowood, & Grant, 2011). Considering surgical training, it is imperative that a surgeon is competent in clinical management and operative skills at the end of the surgical training. To achieve this outcome in this challenging scenario, a resident surgeon should be provided with the opportunities of training outside the operation theatre, before s/he can perform procedures on a real patient. The need for this training was felt more when the Institute of Medicine in the USA published a report, ‘To Err is Human’ (Stelfox, Palmisani, Scurlock, Orav, & Bates, 2006), with an aim to reduce medical errors. This is required for better training and objective assessment of the surgical residents. The options for this training include but are not limited to the use of mannequins, virtual patients, virtual simulators, virtual reality, augmented reality, and mixed reality. Simulation is a technique to substitute or add to real experiences with guided ones, often immersive in nature, that reproduce substantial aspects of the real world in a fully interactive way. Mannequins, virtual simulators are in use for a long time now. They are available in low fidelity to high fidelity mannequins and virtual simulators and help residents understand the surgical anatomy, operative site and practice their skills. Virtual patients can be discussed with students in a simple format of the text, pictures, and videos as case files available online, or in the form of customized software applications based on algorithms. In a study done by Courtielle et al, they reported that knowledge retention is increased in residents when it is delivered through virtual patients as compared to lecturing (Courteille et al., 2018).But learning the skills component requires hands-on practice. This gap can be bridged with virtual, augmented, or mixed reality. There are three types of virtual reality (VR) technologies: (i) non-immersive, (ii) semi-immersive, and (iii) fully immersive. Non-immersive (VR) involves the use of software and computers. In semi-immersive and immersive VR, the virtual image is presented through the head-mounted display(HMD), the difference being that in the fully immersive type, the virtual image is completely obscured from the actual world. Using handheld devices with haptic feedback the trainee can perform a procedure in the virtual environment (Douglas, Wilke, Gibson, Petricoin, & Liotta, 2017). Augmented reality (AR) can be divided into complete AR or mixed reality (MR). Through AR and MR, a trainee can see a
 virtual and a real-world image at the same time, making it easy for the supervisor to explain the steps of the surgery. Similar to VR, in AR and MR the user wears an HMD that shows both images. In AR, the virtual image is transparent whereas, in MR, it appears solid (Douglas et al., 2017). Virtual augmented and mixed reality has more potential to train surgeons as they provide fidelity very close to the real situation and require fewer physical resources and space compared to the simulators. But they are costlier, and affordability is an issue. To overcome this, low-cost solutions to virtual reality have been developed. It is high time that we also start thinking on the same lines and develop this means of training our surgeons at an affordable cost.