The impact of extended reality on surgery: a scoping review

Abstract

Purpose Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments to enhanced real-world environments. In the past two decades, XR-assisted surgery has seen an increase in its use and also in research and development. This scoping review aims to map out the historical trends in these technologies and their future prospects, with an emphasis on the reported outcomes and ethical considerations on the use of these technologies. Methods A systematic search of PubMed, Scopus, and Embase for literature related to XR-assisted surgery and telesurgery was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Primary studies, peer-reviewed articles that described procedures performed by surgeons on human subjects and cadavers, as well as studies describing general surgical education, were included. Non-surgical procedures, bedside procedures, veterinary procedures, procedures performed by medical students, and review articles were excluded. Studies were classified into the following categories: impact on surgery (pre-operative planning and intra-operative navigation/guidance), impact on the patient (pain and anxiety), and impact on the surgeon (surgical training and surgeon confidence). Results One hundred and sixty-eight studies were included for analysis. Thirty-one studies investigated the use of XR for pre-operative planning concluded that virtual reality (VR) enhanced the surgeon’s spatial awareness of important anatomical landmarks. This leads to shorter operating sessions and decreases surgical insult. Forty-nine studies explored the use of XR for intra-operative planning. They noted that augmented reality (AR) headsets highlight key landmarks, as well as important structures to avoid, which lowers the chance of accidental surgical trauma. Eleven studies investigated patients’ pain and noted that VR is able to generate a meditative state. This is beneficial for patients, as it reduces the need for analgesics. Ten studies commented on patient anxiety, suggesting that VR is unsuccessful at altering patients’ physiological parameters such as mean arterial blood pressure or cortisol levels. Sixty studies investigated surgical training whilst seven studies suggested that the use of XR-assisted technology increased surgeon confidence. Conclusion The growth of XR-assisted surgery is driven by advances in hardware and software. Whilst augmented virtuality and mixed reality are underexplored, the use of VR is growing especially in the fields of surgical training and pre-operative planning. Real-time intra-operative guidance is key for surgical precision, which is being supplemented with AR technology. XR-assisted surgery is likely to undertake a greater role in the near future, given the effect of COVID-19 limiting physical presence and the increasing complexity of surgical procedures.

Virtual Reality and Augmented Reality in Plastic and Craniomaxillofacial Surgery: A Scoping Review

“…One recent scoping review examined the role of VR and AR in a clinician-as-user, patient-specific manner, albeit with broader criteria than in this review: It included studies that examined any surgical application of any specialty, including those examining applications in medical education as well as experiments conducted with cadavers. Consistent with the findings of this review, the implementation of extended reality was reported to contribute to the surgical field by enhancing intraoperative spatial awareness and reducing the risk of iatrogenic injury [ 55 ]. In further alignment with this review’s findings, the authors concluded that there is a significant need for further studies—particularly requiring more data reported with respect to the quantification of the accuracy of operative plans and outcomes using these extended reality applications [ 55 ].…”

“…Consistent with the findings of this review, the implementation of extended reality was reported to contribute to the surgical field by enhancing intraoperative spatial awareness and reducing the risk of iatrogenic injury [ 55 ]. In further alignment with this review’s findings, the authors concluded that there is a significant need for further studies—particularly requiring more data reported with respect to the quantification of the accuracy of operative plans and outcomes using these extended reality applications [ 55 ].…”

Does Extended Reality Simulation Improve Surgical/Procedural Learning and Patient Outcomes When Compared With Standard Training Methods?

“…For time to task completion and technical scores, XR enhances procedural accuracy and surgical confidence by facilitating a deeper understanding of the patient's anatomy. 21 The integration of XR in surgical procedures holds potential therapeutic benefits, particularly for complex cases [18][19][20]54,55 because the learning curve is high. There is evidence that learning curves for complex procedures can be mitigated with repetition and motivation 56 and intelligent tutoring systems.…”

Application of Virtual Reality Systems in Bone Trauma Procedures

“…In orthopaedic trauma surgery, different modalities of reality technologies are currently available to support procedural teaching, practice, and patient-specific simulations, namely, virtual reality (VR), augmented reality, and mixed reality. These three reality modalities may sometimes be collectively described with the umbrella term extended reality [ 28 ] ( Figure 1 ). VR systems provide total visual immersion, movements, and interactions in an artificial, computer-generated environment that may incorporate artificial stimuli such as sounds or hand-operated controllers to improve the interactive experience [ 29 ].…”

“…While VR employs an entirely artificial computer-generated environment, augmented reality superimposes digital images onto physical environments in real-time. The term augmented virtual reality is also used distinctively in some literature to describe the real-time representation of physical world events in a virtual environment [ 28 ]. On the other hand, mixed reality utilises a digital display overlay in conjunction with interactive projected holograms, allowing the operator to explore the physical environment while simultaneously interacting with and controlling the digital material provided by the device.…”