In the operating room, you don't often get a do-over. Every moment is vital and mistakes, while rare, can be costly. That's what makes training new surgeons so difficult. Surgeons might practice on plastic bones, but they have an entirely different feel to human ones. Cadavers, while more realistic, can cost up to $10,000 for acquisition, storage, and maintenance.

What we cannot do in the real world, however, can be achieved in the virtual one. That's the mission of FundamentalVR, a London-based company that uses virtual reality headsets and haptic controls to help train young doctors, gather data, and possibly change how the entire medical profession teaches surgery.

Flight Simulator for Surgeons

FundamentalVR, founded in 2012, has been developing its Fundamental Surgery VR software for four years, building on the success of products such as the Oculus Rift and the HTC Vive, which have made virtual reality affordable and accessible.

Alongside the headset is a haptic device that gives physical feedback, like the vibrating keypad on your smartphone. It looks like two styluses attached to a semi-circular hub. Each stylus can rotate, twist, and has a few inches of movement around the hub. But it can provide resistance, too, to simulate the differences between skin, ridged metal, rubber, and numerous other materials and textures. This gives surgeons in training a more realistic approximation of how it feels to cut skin or scrape away bones.

The entire array can be purchased for around $6,000, and while that might be expensive to the average consumer, it's a huge saving in the medical profession. The technology has already been adopted by the Mayo Clinic, UCLA, and NYU in the US, UCLH and St George's Hospital in the UK, and Sana in Germany.

It's not just cost that makes Fundamental Surgery such an attractive prospect; it's the fact that students can go through the motions over and over and over at no additional cost. One of the most vital skills a surgeon has is muscle memory. When putting screws into a spinal cord, it is essential they enter from exactly the right angle. When using a surgical reamer to grind away bones in knee, it's a tactile sensation that helps guide the surgeon. Visual information, like an X-Ray, is vital too, but that's precious extra time, not to mention exposure to radiation, which should be avoided if possible.

In Fundamental Surgery, students go through the same steps they would if they were practicing on a cadaver, but with green highlighted areas showing them the correct way to use the equipment and physical feedback when they touch bone or skin. CEO Richard Vincent describes this as a flight simulator for surgeons.

Much like you might "feel" turbulence if you practice flying a plane, haptics push back against your movements when sawing through bone to simulate density, but they'll quickly relent when they calculate that you've cut enough. Holding up the "saw" to the headset, you can even see a translucent veneer of blood. In the real world, you wouldn't be able to practice that again and again; in the virtual world, it's a simple matter of reloading the program.

Haptic feedback systems have their critics. One study found that "poor mechanical performance of the simulated haptic feedback is believed to have resulted in a negative training effect," and researchers say there might be an "uncanny valley" of sensations.

That said, other studies argue that "haptic feedback provides the greatest benefit to surgical novices in the early stages of their training." FundamentalVR's Total Hip Replacement (Posterior Approach) simulation was recently accredited by the Royal College of Surgeons in the UK, giving students six out of 50 Continuing Professional Development (CPD) points (equivalent to CME points in the US) a surgeon must maintain each year.

Data-Driven Surgery

It goes without saying that a surgeon has to be focused, but training your eyes to look at one specific area for what could be hours at a time, without distraction, is challenging. It's also difficult to measure, as a human surgeon cannot accurate read exactly where their trainee is looking at any given time.

Fundamental Surgery tracks all of this information, offering data on the time taken to complete a procedure, whether the student focused on the correct areas, the amount of guidance—in the form of digital overlays—that was needed, and more.

FundamentalVR stores an anonymized version of this data, which includes results from doctors at a range of skill levels, not just students, which could be used to detect trends.

At the moment, most of the data gathered about surgeries focuses on the outcome. Were there complications? Re-admissions? Fundamental Surgery, however, provides data from each step of the procedure. While that's not entirely translatable to real-world situations, you get granular information about what happened at a specific time.

Omar Sabri, a consultant surgeon and member of the FundamentalVR Global Medical Board, says that large data sets from practices like this could detect, for example, trainee doctors in the UK struggling with a particular part of a procedure where no difficulty exists in the US or Australia. With that sort of quantifiable information, doctors could then change teaching practices and try for higher success rates.

FundamentalVR is also hoping to make patient-specific simulations for surgeons to practice on, but Vincent says that's still a few years away. Eventually it's hoped that Fundamental Surgery will integrate DICOM data such as MRI or CAT scans, but at the moment that information is "messy" because it's scanning soft tissue in comparison to heavy bone.

That might become easier, though. Many data scientists are working on the automatic clean-up of that data using artificial intelligence. Once that's done it will be able to be put into the virtual cadaver, with machine learning being used to tell the different tissue types apart. Surgeons will then be able to rehearse a procedure the next day, or let students practice interesting cases that can be translated into a virtual reality environment.

It's not exactly brain surgery, but at the rate the tech is developing, it's not far off.

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