Could virtual surgery help real-life patients?
Virtual reality holds the potential to revolutionise medical training by allowing surgeons to practise procedures in advance. Here neurosurgeon and brain cancer researcher Ryan Mathew imagines a future in which the technology is used routinely to prepare for medical procedures.
I enter the operating room to see my patient lying on the table sedated by my anaesthetic colleague. I look to the right at a bank of monitors and remind myself of the brain scans — a large tumour on the left side of the brain. It’s going to be tricky.
I put on my glasses and look at his head. I can see the clear imprint of the tumour, glowing green and slightly transparent, overlying his hair. Around it are blood vessels in red, nerve fibres in blue and the fluid filled spaces of the brain in yellow. Calculating my best angle of approach, I turn my head slightly from one side to the other, while all the time the green glow takes on a slightly different shape.
I take my right index finger and trace a large hole on my patient’s head. My biggest anxiety is not the tumour itself however, but what’s just beyond it — areas of the brain responsible for speech and language. Doing as little damage to this area, while removing as much tumour as possible will be crucial to a positive result. My ability to achieve this could determine whether my patient lives.
Thankfully, after a complex procedure, all goes well. What’s most remarkable however, is that I haven’t left home yet. Or even got dressed. I haven’t even had my first coffee of the day. And surely no surgeon in the history of surgery could ever do an operation before their first coffee of the day. I have just ‘performed’ this operation from the comfort of my own home using virtual reality.
The holy grail of medical training?
Immersive technology is not yet advanced enough to simulate real surgery — making the scenario described above impossible for now. But this is probably the area in which immersive technologies and virtual reality can revolutionise surgery the most. The ability to rehearse an operation, the ability to make mistakes and push the boundaries, all in the safety of a virtual environment, is the Holy Grail.
Recent research by my colleagues at Leeds has shown that surgeons get progressively better at performing a procedure as they repeat it a number of times. They have recommended that surgeons group similar procedures together as much as possible to improve patient outcomes.
Now my colleague Dr Faisal Mushtaq is looking at the use of virtual and augmented reality techniques to help surgeons warm up for procedures such as brain surgery. His team is looking at converting MRI and PET scans of a patient’s brain into virtual objects that surgeons are able to visualise and interact with. But we are still a very long way from being able to perform surgery on a virtual patient.
Riding the wave of technology
Use of navigation has been commonplace for many years in neurosurgery. It is used in the operation planning stage, and during the operation itself. As the technology has become more sophisticated, additional features have become available. Computers are now able to identify structures on scans and assign them a unique colour.
The addition of imaging during an operation — getting an ‘update’ on the surgical progress and allowing for comparison to the original images — has made these systems even more useful. However, the equipment remains cumbersome, and economically challenging to update or replace due to the initial expense. Perhaps most importantly however, from the surgeons’ perspective, it is not possible to use these systems outside of the theatre environment.
The development of virtual reality and immersive technologies could revolutionise these systems making them cheaper and easier to use. It does not appear to require a reinvention of the wheel — just an integration of commonly used software into more modern devices.
For example, augmented-reality glasses that a surgeon could wear would overlay of the same computer-generated images of the tumour onto the patient’s head. It’s a simple change from looking at a screen to looking at the actual patient to ‘see’ the tumour. Simple, but infinitely more natural.
Coupled with virtual reality, it would be possible to be completely immersed in the operating room environment, anatomy room or surgical wet-lab. The portability of such devices would potentially make this planning and ‘rehearsal’ possible in the office, or at home, and that has significant implications for training.
Virtual cutting time
Immersive technologies potentially have a huge role to play in the training of future surgeons. As an apprentice specialty, it is a true mantra that there is no substitute for actually operating. Reading books, watching videos and even watching someone else doing the operation in theatre all have their limitations.
In recent years, the increased pressures on trainees to deliver services have resulted in reduced ‘cutting time.’ Educational bodies and commercial entities have responded by developing physical simulation models. However, these fail to recreate the theatre environment and the physical models are still a poor representation of the tissue characteristics encountered in real patients. Moreover, they are disposable by nature and therefore expensive.
Immersive technologies will face similar challenges in engineering the physical characteristics of human tissue — not only in handling but also in cutting, stopping bleeding and manipulating. However, all the other current challenges could be relatively easily addressed.
For example, virtual reality could be used to recreate the noise and distraction of a theatre environment. This would enable trainees to interact with colleagues, deal with unexpected logistical challenges and allow assessors to objectively evaluate trainees in the same scenarios, over time and between trainees. Moreover, the ability to reboot simulated scenarios and operations offers huge cost savings.
Finally, a system that enables trainees to rehearse any operation, using real patient images and anatomical data will be invaluable in a similar fashion to the advantages offered to the more established surgeon. As a final training opportunity, the ability to watch experienced surgeons do the operation, and even pre-select ‘alternative endings’ would be a great insight for trainees into the decision-making mindset of mentors.
From virtual reality to real life
Surgeons are notorious for believing that problems can be solved with technology. Most surgeons believe the translation of real-world challenges can easily be met by maths and engineering. This both flatters and insults our computer science and engineering colleagues all at once. The computer programming required to achieve even the simplest of virtual surgeries is massive.
Creating virtual human tissue, producing the movement characteristics of surgical tools, creating virtual theatre environments — these are just some of the significant barriers to overcome. Perhaps most crucially, it is important that surgeons, computer scientists and engineers work together at every stage, to understand each other’s work.
Virtual reality is currently a massive investment area for major tech companies.We have a unique opportunity at universities and in the NHS to ride the wave of this commercial investment and use it to enhance our service delivery, and ultimately improve patient outcomes in real life.
