Virtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery

doi:10.1016/j.wneu.2018.01.067

World Neurosurgery

Volume 112, April 2018, Pages 126-130

https://doi.org/10.1016/j.wneu.2018.01.067 Get rights and content

Highlights

•
Microsurgical skills need continuous training to be developed.
•
Traditional microsurgical laboratories are expensive.
•
We set up a training model using a computer, smartphones, and virtual reality glasses.
•
We progressively performed more and more complex microsurgical exercises.
•
Our proposed training model is an affordable and efficient system to improve eye-hand coordination and dexterity in microsurgery.

Objective

Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses.

Methods

A smartphone placed on a holder at a height of about 15–20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses.

Results

Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions.

Conclusion

Our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes.

Introduction

Technologic advances have driven the development of modern neurosurgery. The introduction of the surgical microscope resulted in a marked improvement in postoperative results. New complementary devices, such as endoscopes and lastly exoscopes, have been introduced in the past decades and are incessantly refined.1, 2, 3, 4, 5, 6

Residents and young surgeons require a continuous training process in order to develop eye-hand coordination and dexterity in using these tools.⁷ Well-equipped microsurgical laboratories are available only in advanced countries. As a consequence, most residents and surgeons have no access to those. In addition, microsurgical tools are expensive, and it is not so easy to set up an affordable self-laboratory.

In this regard, modern technology may be useful to develop new and less expensive devices for microsurgical training. Herein, we present a novel microsurgical training system that does not require a conventional microscope, an endoscope, or an exosocope. On the other hand, our training model is based on the “eye-hands blind (EHB) technique” and requires a high-resolution personal computer screen, smartphones, and virtual reality (VR) glasses.

Section snippets

Methods

Our training model requires the following tools:

•
a Mac running OS X Yosemite or later versions (Apple Inc., Cupertino, California, USA) with a high-resolution screen and free software packages (QuickTime Player, TeamViewer, and Reality Augmented);
•
2 iPhones (Apple Inc., Cupertino, California, USA) with a high-resolution video camera (the software should be updated to the last iOX version, and TeamViewer installed);
•
VR glasses;
•
an IOS lightning cable (Apple Inc., Cupertino, California, USA); and
•

Results

At the beginning, using the previously described training model, we practiced easy tasks with microscissors and microforceps, in order to get the feel with the almost inexistent tridimensional image (Video 1, illustrating our microsurgical training looking at the computer screen). Then, once we improved our EHB technique, we progressively performed more complex exercises such as microsutures with 7-0 and 10-0 polypropylene, as well as microanastomosis. It did not take long to set up our system,

Discussion

It is undeniable the importance that the surgical microscope, with its high illumination and 3D magnification, has had on the development of modern neurosurgery over the past 50 years. Still nowadays, the majority of the most complex neurosurgical procedures are performed using an operating microscope.1, 2, 3, 6, 7, 8

However, in the past decades endoscopes and exoscopes have been increasingly used in neurosurgery as they may offer a valuable close-up view of the working area through a minimally

Conclusion

In conclusion, our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes.

References (11)

A. Huotarinen et al.
Easy, efficient and mobile way to train microsurgical skills during busy life of neurosurgical residency in resource-challenged environment
World Neurosurg
(2017)
H. Krayenbühl et al.
[The use of binocular microscopes in neurosurgery]
Wien Z Nervenheilkd Grenzgeb
(1967)
M.G. Yaşargil et al.
The use of the binocular microscope in neurosurgery
Bibl Ophthalmol Suppl Ad Ophthalmol
(1970)
P.J. Jannetta
The surgical binocular microscope in neurological surgery
Am Surg
(1968)
H.B. Griffith
Technique of fontanelle and persutural ventriculoscopy and endoscopic ventricular surgery in infants
Childs Brain
(1975)

There are more references available in the full text version of this article.

Cited by (30)

Topographical Systematization of Human Placenta Model for Training in Microneurosurgery
2024, World Neurosurgery
Neurosurgical training continuously seeks innovative methods to enhance the acquisition of essential technical skills for neurosurgeons worldwide. While various training models have been employed, few truly replicate real-life conditions optimally. Human placenta is a good model for neurosurgical microsurgery training due to its anatomic similarities to neurovascular structures. Placental vessels exhibit a branching pattern and caliber comparable with intracranial vessels, making them suitable for practicing microsurgical techniques. The study aims to delineate the anatomic zones of the placenta and propose a segmented training model, resulting in a reproducible, cost-effective, and realistic neurosurgical microsurgery training environment.
Twenty human placentas were meticulously prepared, injected with dyes, and categorized into zones on the basis of anatomic features. Measurements of placental vessels were recorded and compared with cerebral vessels. The placenta was divided into 4 quadrants to facilitate specific training techniques.
Our results revealed varying vessel diameters across placental zones, closely resembling cerebral vessels. Different microsurgical techniques were applied to specific placental zones, thereby optimizing training scenarios. The applicability section described exercises such as membrane dissection, vessel skeletonization, aneurysm creation, vascular bypass, and tumor dissection within the placental model, providing detailed guidance on the zones suitable for each exercise.
Human placenta serves as an effective microsurgical training model for neurosurgery, enhancing neurosurgeons' skills through anatomic segmentation. Integrating this model into training programs can significantly contribute to skill acquisition and improved surgical outcomes. Further research is warranted to refine and expand its utilization, complemented by clinical experiences and other simulation tools.
Learning, teaching, and training in microsurgery: A systematic review
2022, Hand Surgery and Rehabilitation
Citation Excerpt :
In terms of magnification, the operating microscope is the gold-standard when learning microsurgery, because this tool is used in the OR. However, using microsurgical loupes or a smartphone screen would make initial training and continuing education more accessible for this skillset [72,83]. Therefore, the basic and knowledge enhancement stages of this educational program could use these three types of tools (microscope, loupes, and phone screen), while the consolidation phase would use the microscope.
Numerous microsurgical training techniques and materials have been developed to reduce animal use and training costs. This systematic review aimed to catalog the available microsurgery learning methods on non-living material in order to define an educational program. The PubMed database was searched for English and French articles related to the initial learning of microsurgery with inert, non-living, or digital material and containing the keywords “microsurgery”, “non-living”, “simulation” and “virtual reality”. Among the 488 articles found, 82 were included. This work reports the main microsurgery learning supports. They were classified according to the material used: inert material, cadaveric animal tissues, human cadaver model, virtual reality, and digital technologies. The educational program proposes here is a two-step program that uses non-living material (basic and deepening) before progressing to living models. This initial learning phase teaches basic microsurgical skills (precision, tremor management, and magnification). Then, frequent home training sessions help to maintain the acquired skills. Ethical, organizational, and economic constraints limit access to animal models. Therefore, inert models seem to be ideal support for initial microsurgical learning. The multiplicity of models described makes it possible to achieve progressive learning depending on which models are available.
De nombreux supports pour l’apprentissage de la microchirurgie ont été développés afin de réduire le nombre d’animaux utilisés et les coûts de formation. L’objectif de cette revue de la littérature était de dresser un répertoire des méthodes d’apprentissage sur du matériel non vivant afin de proposer un programme pédagogique. Une recherche sur PubMed a été réalisée permettant d’analyser tous les articles rédigés en anglais et en français relatifs à l’apprentissage initial de la microchirurgie sur matériel inerte et contenant les termes “microchirurgie”; “non vivants”; “simulation” et “réalité virtuelle”. Parmi les 488 articles retrouvés, 82 ont été inclus. Ce travail rapporte les principaux supports pour l’apprentissage de la microchirurgie. Ils ont été classés en fonction du matériel utilisé: matériel inerte, tissus animaux cadavériques, modèle cadavérique humain, réalité virtuelle et technologies numériques. Le programme pédagogique propose un apprentissage en deux étapes de base et d’approfondissement sur matériel non vivant, avant d’envisager le passage au matériel vivant. Cet apprentissage initial permettrait d’acquérir les compétences nécessaires sous microscope sur la gestuelle, la gestion du tremblement et de la magnification. Ensuite, un entraînement fréquent à domicile permettrait d’entretenir les compétences acquises. Les contraintes éthiques, organisationnelles et économiques limitent de plus en plus l’accès à l’expérimentation animale. Ainsi, les modèles inertes semblent être le support idéal dans l’apprentissage initial de la microchirurgie. La multiplicité des modèles décrits permet d’envisager un apprentissage progressif en fonction de la reproductibilité et de l’accès à ces modèles.
Telementoring Feasibility Using a Novel Low-cost Lazy Glass Microsurgical Simulator: A “Proof of Concept” Experimental Study
2022, World Neurosurgery
Citation Excerpt :
Free access to online platforms like Google Meet, which is compatible with most smartphones, provides a cost-effective solution to ensure virtual connectivity between mentors and mentees. Other visualization methods used in microsurgery and simulation training include virtual reality simulations17 and 2-dimensional and 3-dimensional exoscopes,18-20 which again require heavy financial investment. Furthermore, in contrast to the in-person physical mentoring sessions, telementoring modality prunes the costs incurred due to travel and accommodation for mentors and participants.
In order to mitigate the challenges in microsurgical skill acquisition and training, especially in the COVID-19 era, we devised a novel microsurgical telementoring protocol for imparting microsurgical skill training in a socially distanced setting. We objectively analyzed its feasibility among neurosurgical trainees.
In a controlled experimental design, 8 residents at different stages of their tenure participated in a lazy glass microsurgical simulator–based telementoring exercise. Microsuturing with 4-0 silk, 10-0 nylon on silastic sheets, and eggshell peeling tasks were performed by the residents prior to and after a telementoring session by a panel of 4 neurosurgical experts. Impact of telementoring was assessed in terms of surgical accuracy, efficiency, and dexterity by providing objective (Performance score [PS]), subjective (Neurosurgery Education and Training School [NETS] score), and cumulative scores (CS). Subgroup analysis was performed to assess the impact at different stages of residency.
PS, NETS score, and CS were significantly improved by telementoring sessions for 10-0 nylon micro-suturing (P < 0.001), and egg-hell peeling tasks (P < 0.01). PS and CS improved significantly (P = 0.01) after telementoring sessions for 4-0 silk microsuturing. Both pre- and post-training CS were similar across the 2 subgroups PGY 1–4 and PGY 5–6 (P > 0.05).
Telementoring is a viable alternative for neurosurgical resident training in the COVID-19 era, where reduction in elective surgeries and social distancing norms preclude conventional teaching. Lazy glass microsurgical simulator–based structured telementoring protocol is a cost-effective tool to augment surgical proficiency and finesse, irrespective of stage of residency.
A Novel Low-Cost Exoscopy Station for Training Neurosurgeons and Neurosurgery Trainees
2021, World Neurosurgery
The loss of stereopsis and the need for markedly enhanced hand-eye coordination are obstacles to overcome when performing exoscopic procedures, but both should improve with training. Our objectives were to describe an exoscopy training station and to compare time and performance of a given microsurgical technique among neurosurgery residents and junior neurosurgeons.
We designed a low-cost exoscopy training station featuring a notebook computer, a webcam, and a light-emitting diode source. Surgeons and surgical trainees with no experience in exoscopy were enrolled and divided into 2 groups (trainees and controls). Performance and time in suture placement were evaluated by a skilled observer in both groups at baseline and 3 days later. Between evaluations, trainees completed an exoscopy training module.
There were 22 participants divided equally into 2 groups. At baseline, trainees had a greater percentage of proper sutures than controls (58% vs. 35%), but they were also slower (32 minutes vs. 25 minutes). On final evaluation, not only were trainees approximately 14 minutes faster than at baseline (P = 0,03), but also their successful suture rate had increased by 18% (final rate 76%, P = 0.02). Moreover, controls were faster compared with baseline by 6 minutes (P = 0.003), but their percentage of successful sutures did not increase (final rate 38%, P = 0.49). The change from baseline to final evaluation favored trainees for both outcomes (P = 0.03 and P = 0.02).
Using the exoscopy training station, the trainees were able to improve their time and performance of exoscopy compared with the controls.
360° video recording inside a GI endoscopy room: Technical feasibility and its potential use for the acquisition of gastrointestinal endoscopy skills. Pilot experience
2021, Gastroenterologia y Hepatologia
New advances in video processing, 3-dimensional designs, and augmented/virtual reality are exciting and evolving fields. These new tools can facilitate the learning phase of basic or advanced endoscopic procedures. Herein, we explain our initial experience, creating an immersive virtual reality (IVR) by using 360-degree recording videos from an interventional endoscopy room.
Some common terms used around this technology, such as Augmented reality (AR), Virtual Reality (VR), Three hundred sixty videos, and Mixed Reality (MR), are discussed below.
Three examples of VR 360 endoscopic room videos are included in this article.
Los nuevos avances en el procesamiento de vídeos, diseños en 3D y realidad virtual y aumentada son áreas de mucho interés y en pleno auge. Estas nuevas tecnologías pueden facilitar la fase de aprendizaje en el campo de la endoscopia, tanto en procedimientos básicos como en avanzados. En este artículo, detallamos nuestra experiencia inicial en la creación de situaciones inmersivas en realidad virtual (IVR) utilizando grabaciones en 360° de una sala de endoscopia.
Asimismo, abordamos algunos términos de uso frecuente en relación con esta tecnología, como son la realidad aumentada (RA), realidad virtual (RV), vídeos en 360° y la realidad mixta (RM).
Se incluyen en este artículo 3 ejemplos de vídeos de RV en 360° en sala de endoscopia.
Letter to the Editor: Home Program for Acquisition and Maintenance of Microsurgical Skills During the COVID-19 Outbreak
2020, World Neurosurgery

View all citing articles on Scopus

: Supplementary digital content available online.

: Conflict of interest statement: The authors have no personal financial or institutional interest in any of the drugs, materials, and devices described in this article.

View full text

Doing More with LessVirtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery

Highlights

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

World Neurosurg

[The use of binocular microscopes in neurosurgery]

Wien Z Nervenheilkd Grenzgeb

The use of the binocular microscope in neurosurgery

Bibl Ophthalmol Suppl Ad Ophthalmol

The surgical binocular microscope in neurological surgery

Am Surg

Technique of fontanelle and persutural ventriculoscopy and endoscopic ventricular surgery in infants

Childs Brain

Doing More with Less
Virtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery