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Immersive Virtual Reality: The Next Frontier in Surgical Education
How bite-sized virtual trips to the operating theatre will bridge the gap between reading about surgery and actually performing surgery.

by Dr Chen Min Wei and Samuel Choo

Being a surgeon is a high-risk profession. To put things in perspective, 12 years of basic education is followed by a minimum of five years in medical school. The grind of studying and examinations continues for another 10 years or thereabouts before you truly begin your journey as a surgeon. You spend hours on end honing your mind and your hands. Yet, the first time you hold a scalpel or the first time you open that skull, you still hold your breath with a tinge of trepidation because you know the consequences if you fail.

Traditional surgical training, at least in my own imagination, was like learning to be a pilot. You would read volumes and volumes about the basics, the technicalities, and the pitfalls. Then you would sit in the cockpit to observe. If you’re lucky, the teacher for the day would be kind and brave (or foolish) enough to let you dabble with one or two controls. If you’re one of the lucky ones, you may never encounter a failed engine or severe turbulence or an icy runway. While you are learning your trade, however, you almost never get to hold the reigns. Whatever your experience, one day, you are suddenly given your wings because on paper you have ticked all the necessary boxes.

The problem with such a system is manifold. Learning opportunities are random and not all-encompassing as you can only be in one cockpit at a time. The mentor you get is also the luck of the draw and what you learn from the same mentor may vary from event to event depending on their own experiences. Lastly, anybody who is in a skill-based profession knows that watching and reading is vastly different from actually doing it to perfection.

In surgery, one mistake can lead to death. Therefore, the patient’s safety always comes first and training is kept within tight bounds that advance incrementally over many years of surgical training. Surgery also demands absolute concentration and it is difficult for the mentor to constantly articulate his thoughts and considerations whilst operating at the same time. Rare and valuable moments of learning can thus pass in the blink of an eye. Yet once again, the day will suddenly come where you are certified as a surgeon bearing all the weight of responsibility. This transition, in my mind, has never been smooth.

Before this digital age, books and cadavers were the only tools outside of the operating theatre that surgeons could rely on. Books remain a treasure trove of knowledge. Surgery, however, is a very personalised skill and demands creativity. Some even describe it as an art. It is the manifestation of the individual surgeon’s personality and temperament. The mental visualisation after reading about how to remove a tumour will thus vary from surgeon to surgeon. Practising on cadavers allows familiarisation of the anatomy but cannot replicate the stakes and struggles of real surgery. There is no bleeding that can obscure your view. There are no dynamic changes to test your mental agility. It is almost like putting building blocks together based on the instruction manual. Both these elements remain crucial to a surgeon’s training but fall short.

Then YouTube came along. Many famous surgeons and medical centres around the world started creating YouTube videos to showcase top brass surgery. They were often highly edited to omit catastrophes or designed to celebrate the high technical ability of the performing surgeon. They also focused only on blockbuster parts of the surgery. Worse still, they were often presented in 2D. In surgery, the concept of depth perception is paramount. Surgery is sometimes performed through holes that are 4 to 5 cm wide and 10 cm deep. Having an appreciation of how the anatomical structures come down to the depth is an important skill that needs to be acquired.

Despite these shortcomings, it was a vast improvement from what was available previously. However, many of us who watched these videos during our training found that replicating what we saw was easier said than done and it made us question our own abilities. The wiser and older ones would point out that there is much more to performing surgery than just the five-minute highlights clip. The whole preparation for the case sets everything up for the actual surgery to be smooth. This, however, only seems to be acquired with time and rounds of “trial and error” before surgeons settle on what suits them.

It is at this juncture where virtual reality (VR), or rather immersive virtual reality, steps in. It has the potential to be the perfect bridge between the apprentice and the practitioner. Real-life surgery, and all that the operating theatre has to offer, are captured in real-time using stereoscopic 3D cameras and microscopes. These recordings are then edited and spliced into short but succinct reels, each with very specific lessons. These environments can be viewed using various types of VR headsets, ranging from standalone headsets to smartphone-based ones. Narration is done to highlight and explain each specific point in tandem, utilising a practical pedagogy aimed at helping users transfer their learnings into their own surgical practice. The virtual reality viewing format can present stereoscopic 3D content to allow for the appreciation of depth. Individual viewing is also logistically easier as compared to the alternative for viewing stereoscopic 3D, which would be similar to going to a movie theatre to watch a 3D movie.

With these recordings, you get to experience the lighting, the speed of events, and the thought process of the surgeon. You can see the surgeon’s hand movements, the choice of instruments, and the positioning of the body, elbows, and hands for optimum efficiency. You witness how they grapple with disasters or unforeseen events. You literally follow how and why the surgeon places the patient in a certain manner. You see the minor adjustments. All this as if you were there on the spot in the perfect position. No longer do trainees need to stand for 12 hours just to glean 30 minutes of tips or crank their necks just to see a small corner of the action. Better still, you can relive the case as many times as you want, anytime you want. Now imagine a whole library containing hundreds of surgeries that are curated and organised in this manner. A library with international contributors from a wide range of geographies, providing international exposure and “content localisation” simultaneously.

Such a prospect has the potential to significantly lower the barriers to entry for international learning while providing a new depth of learning through the juxtaposition of setups, techniques, and approaches from surgeons near and far. Entering theatres in multiple countries all within a lunch break. With high-yield learning resources such as these, the surgical trainee will be better prepared for what’s to come when they take up the reigns.

We go back to the analogy of pilot training. Simulators have been used to train pilots even before World War II. There are many studies that show how flight simulators have drastically improved aviation safety. This is also the trend as simulators become more comprehensive and sophisticated. In our equally high-risk profession as surgeons, why aren’t we embracing the same technology? Of course, one may argue that surgery is a different kettle of fish as the human body is still an entity we know so much yet so little about. This makes it impossible to create and simulate every single scenario that happens in surgery. But immersive virtual reality comes close to preparing the surgeon’s mind for what’s to come. And in time to come, immersive VR will become interactive virtual reality with haptic feedback. We may then truly have a surgical simulator of our own.

About the Authors

Dr Chen Min Wei
Dr Chen Min Wei is a Consultant Neurosurgeon from the National Neuroscience Institute with an interest in skull base and neurovascular surgery.

Samuel Choo
Samuel Choo, Co-Founder and Head of Product at Kyalio, a virtual reality surgical and medical education start-up based in Singapore and Taiwan.

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