Cyber surgery

Until fairly recently, surgeons were considered the journeymen of medical life. Not associated with the expensive university educations and academic learning of proper physicians, genuine doctors who needed to know how to diagnose ailments and prescribe cures. Rather, surgeons were semi-professionals, learning mainly by experience. Until the Age of Enlightenment, in fact, many European surgeons would even balance cutting limbs with cutting hair. A whisper of this history continues to this day – the red and white poles that grace many barber shops represent the bloody bandages sawbones once so infamously employed.

Now, of course, the reputation of surgery has essentially reversed. There’s a reason we colloquially imagine brain surgeons to be the cleverest people around, and why proud parents dream that their sons or daughters might one day take up a scalpel. The reason for this transformation, moreover, is obvious: training. Whereas they were once taken on as apprentices, like grubby tanners or brewers, the aspiring American surgeon can expect to study for over a decade, gaining a robust knowledge in biology and chemistry before they ever start operating. It goes without saying, meanwhile, that more complicated types of surgery require even more practice. To put it another way, it’s probably telling that the UK has a mere 400 heart surgeons.

Yet, if modern surgeons are a far cry from their fringe-chopping forebears, many of the same challenges persist. For, if modern surgeons can certainly practice their craft on animals and cadavers, there’s nothing like treating a genuine patient. And if they’re certainly better prepared than earlier generations of surgeons, any mistake can still cause problems. Between 2007 and 2017, for instance, patients in California state were subjected to 142 serious surgical errors. And though specific statistics are scarce, one 2012 study found that inexperienced surgeons may be more prone to distractions while operating, hardly surprising given the pressures involved. Even so, the situation is far from hopeless. By exploiting sophisticated digital platforms, surgeons can increasingly hone their skills before slipping on their scrubs – a change with important consequences for medicine right across the world.

VR you serious?

Digital models have been a part of industrial training for generations. As far back as the 1960s, for instance, pilots were using computers to practise take-offs and landings. Speak to Professor Anderson Maciel, however, and it becomes clear this hasn’t generally been true of surgery. “The older paradigm was ‘see one, do one, teach one,’” explains Maciel, an expert in digital training at the Federal University of Rio Grande do Sul in Brazil. “Even though trainees didn’t start with real patients on the first day, there were levels of simulation, depending on the resources available.” Indeed, Maciel continues, trainee surgeons have typically depended on a range of analogue training methods, spanning everything from fake rubber organs to human corpses and animals. From there, young doctors tended to learn by observation – before finally graduating to directing the show themselves.

That’s fine as far as it goes. But it equally makes sense that some insiders would get frustrated at the lack of hands-on experience presented by traditional medical training, something that ultimately goes beyond surgery specifically. For Dr Paul Kelly, an anaesthetist and digitalisation expert at Guy’s and St Thomas’ NHS Foundation Trust in London, these difficulties are obvious in a range of fields, from a lack of resources to an inability to insert sudden crises into training scenarios. Jag Dhanda has his own worries too. “It lacks valid scientific evaluation,“ argues Dhanda, an oral and maxillofacial consultant surgeon at London’s Queen Victoria Hospital, as well as a professor at Brighton and Sussex Medical School. “It’s also very expensive.” Certainly, this last point is reflected by the figures – one recent estimate suggests that the average American surgical education costs $80,000.

To be fair, these challenges have seen some doctors move fitfully towards digital training. But as Maciel stresses, that has sometimes involved just looking at computer screens, rather than having students try anything more proactive. But as the Brazilian continues, newer technology is increasingly introducing more fundamental changes to the field. “Virtual simulators represent a tremendous asset in overcoming the challenges of traditional surgical training,” he says. “When they are available, they are used as a new level of simulation, besides physical models, cadavers and animals. This allows for the possibility to repeat the training several times by several trainees with minimal additional cost, while cadavers, animals and supplies for physical simulators are expensive and can be used only once.”

Get your head(set) in the game

Travel to the Brighton and Sussex Medical School and you can witness something remarkable. There, Jag Dhanda by your side, you can experience a genuine operation, happening right there in front of you. You can see the flick of the scalpels, the drilling into bones, the shuffling of the patient on the bed. The catch, of course, is that you’re not really there at all. What Dhanda has done, instead, is to integrate live-streamed surgery onto VR headsets. Through a system he describes as “360° video”, the consultant brings genuine operations directly to surgical students, along the way creating an archive of content that can be used and reused.

Nor is the British doctor alone. On the contrary, systems like Dhanda’s, as well as more conventional videogame-like VR platforms, are changing the nature of surgical training. The numbers, as so often, are illuminating here. According to recent work by BlueWeave Consulting, the global industry for such platforms is predicted to enjoy CAGR of 42% through 2028. Nor is this explosion particularly hard to understand. Quite aside from Maciel’s financial considerations – 360° video and its cousins are obviously cheaper when you don’t need to source fresh cadavers – there are plenty of other advantages over traditional training too.

One is the fact that teachers can integrate danger into proceedings, with some systems forcing headset-wearing doctors to deal with emergencies like cardiac arrests. Another strength, Maciel notes, is that headsets can give students useful data via augmented reality (AR), with information like heart rates beamed right into their eyes. At the same time, there are signs that new technology might soon make VR training even more robust. A traditional problem of VR platforms is the fact that they’re by necessity, virtual – no matter how realistic the visual sensation, students aren’t actually practising with a real body. One solution, says Dhanda, has to do with the rising quality of the images themselves, especially for systems like his that rely on real-world footage. As he puts it: “Not only can you see the procedure, but you’ve also got multiple camera perspectives to see the fine anatomy.” That’s shadowed by other advances, designed to mimic the physicality of human flesh. As Maciel explains, his work in this area involves using sophisticated computers to “efficiently model tissue deformation and the interaction of instruments with the tissue”.

Keeping it real

Beyond these technical marvels, there’s increasing evidence that VR systems can bolster clinical outcomes. To explain what he means, Maciel uses the analogy of flight training. “Young surgeons,” he suggests, “can gain ‘hours of flight’ without leaving the ground.” That’s particularly useful, he emphasises, for complex and minimally invasive operations like laparoscopy – which without VR would take years of practice on real patients to master. These practical benefits are echoed by statistical improvements. As 2019 research by doctors at UCLA discovered, surgeons training in VR completed procedures 20% faster than their traditionally educated fellows. The same study found that VR training led surgeons to complete checklists of procedures far more accurately than ever before.

Given all this, at any rate, it’s no wonder that VR training is transcending the operating table to enter other areas of medical life. If nothing else, Paul Kelly explains, that’s happening in his own field of expertise. “From an anaesthetic perspective, we have run a number of virtual intubation training sessions with another fantastic platform from Medtronic,” he says, adding that his team has already purchased 15 headsets, hoping to start a multidisciplinary VR training programme shortly. And if VR looks ready to march across departmental boundaries, Dhanda hopes to carry the technology internationally. Easy to share online, and with headsets now costing less than a games console, his unique form of VR has supported oral surgeons in developing nations. Kenya and Sudan are just two of the countries Dhanda has worked in so far, with the consultant now offering a library of 400 videos to choose from. If only the rugged barbersurgeons of older generations could come back and watch them.