Surgeons and their patients are finding that virtual reality can relieve the pain and stress of operations—and it’s safer and cheaper than sedatives. For Mosaic , Jo Marchant travels to a Mexican mountaintop village to visit a clinic with a difference. The story is republished here under a Creative Commons license.

Ana Maria has never been to Machu Picchu. The 61-year-old always wanted to visit the mountain ruins, but she suffers from hypertension, and doctors warned that the extreme altitude could cause her blood pressure to rise dangerously high. Today, dressed in a white gown and hairnet, she will explore its ancient walls and pyramids for the first time.

She’s in a private medical clinic in Mexico City and laughs nervously as she’s wheeled into a windowless operating room. The surgeon takes a Sharpie and draws a large circle on her left thigh, paints on several layers of iodine, then injects a local anaesthetic into the skin. Inside the circle is a fatty lump, a lipoma around 6 cm across, which he is about to remove.

Ana will be awake for the operation, and she’s feeling scared. As the surgeon readies his scalpel, her blood pressure is 183/93, even higher than usual. Patients undergoing procedures like this often have to be sedated to cope with the pain and anxiety of being under the knife, but not today. Instead, José Luis Mosso Vazquez, who is supervising the operation, fits a sleek, black headset over Anna’s eyes and adjusts the Velcro straps.

The surgeon makes his first cut and the blood spills in a crimson stream down Ana’s leg. She’s surrounded by medical equipment—stools, trolleys, swabs, syringes, with super-bright surgical lamps suspended above the bed and her vital signs displayed on monitors just behind. But Ana is oblivious. She’s immersed in a three-dimensional re-creation of Machu Picchu. She begins her journey with a breathtaking aerial view of the ancient city clinging to the mountainside, before swooping down to explore the details of stepped terraces, moss-covered walls, and tiny stone huts.

Mosso watches her carefully. A 54-year-old surgeon at Panamerican University in Mexico City, he’s on a mission to bring virtual reality into the operating room, using the high-tech distraction technique to carry out surgeries that would normally require powerful painkillers and sedatives, with nothing more than local anaesthetic. He’s trying to prove that reducing drug doses in this way not only slashes costs for Mexico’s cash-strapped hospitals, but cuts complications and recovery times for patients, too.

But today, he’s not sure if his headset is going to be enough. He hopes the virtual reality will help Ana to avoid unnecessary medication, but if she becomes anxious during the surgery, her already-high vital signs might spike. He has prepared an intravenous line, ready to administer emergency medication if required.

The surgeon pulls a large, pearly glob of tissue from Ana’s thigh, his fingers easing under her skin as he carefully snips it free. Then he mops the blood and stitches the wound. The procedure has taken just 20 minutes, and there are smiles all round as Ana thanks the team. Because of the virtual reality, she says, she barely noticed the scalpel slicing her flesh: “I was transported. Normally I’m very stressed, but now I feel so, so relaxed.”

The monitors back up her story. Throughout the surgery, her blood pressure actually fell.

What if I use this on a patient?

In 2004, Mosso bought a Spider-Man game for his eldest son, and his life and career path changed. The game involved images projected onto a head-mounted display—an early form of virtual reality (VR). Mosso was struck by how immersed his son became in the game. “His Mom called him to go to dinner and he didn’t hear her, nothing. I thought, what if I use this on a patient?”

Like Mosaic stories? From time to time, Ars has republished the work of Mosaic (under Creative Commons) on everything from From time to time, Ars has republished the work of Mosaic (under Creative Commons) on everything from the inaccuracies of the calorie to the enigma of blood types . Now, we're helping them with a study to understand people’s views about science-related articles, and we would appreciate your opinion. If you’d like to be part of this online survey, please click here

Mosso began using the game during upper gastrointestinal endoscopies, in which a flexible tube with a camera on the end is fed through a patient’s throat into their stomach. The experience can be unpleasant and distressing. Patients often require sedation but Mosso encouraged them to play the Spider-Man game instead, to distract themselves.

He asked the patients to score their pain and anxiety during the procedure and in 2006 presented his results at the Medicine Meets Virtual Reality conference in California. The idea of using VR to reduce the distress of medical procedures was pioneered at the University of Seattle, Washington, where cognitive psychologist Hunter Hoffman and colleagues have developed a VR game called SnowWorld, to help patients endure wound care for severe burns. The researchers hoped that the illusion of being physically immersed in a three-dimensional computer-generated scene would move patients’ attention away from their real-world pain. It worked: Hoffman’s team has since shown in trials that SnowWorld reduces patients’ pain during wound-care sessions by up to 50 per cent, as well as reducing pain-related brain activity.

But there has been relatively little work in other medical contexts. At the 2006 conference, Mosso met Albert “Skip” Rizzo, a psychologist (and now director of medical VR) at the University of Southern California, who had been doing similar research with endoscopies. “He presented 10 cases,” says Mosso. “I presented 200.” Rizzo showed Mosso the expensive, state-of-the-art head-mounted displays he was using. “It was another world,” says Mosso. But then Rizzo revealed the equipment with which he had begun—it was the exact same Spider-Man game.

“In this moment my life changed,” says Mosso. “Skip saved me.” Impressed by Mosso’s work, Rizzo donated a headset to him and persuaded a colleague, Brenda Wiederhold of the Virtual Reality Medical Center in San Diego, to let Mosso use some virtual worlds she had developed specifically for pain relief.

Mosso returned to Mexico with his new equipment and started to use VR in a much wider range of situations, from childbirth to recovery from heart surgery. It helped to relax patients across the board, but some of his most successful results were in minor day surgery, procedures such as removing lipomas, cysts, and hernias, during which patients are awake but often sedated. He used a virtual scenario developed by Wiederhold called Enchanted Forest, in which users can explore rivers, lakes, trees, and mountains. (The virtual world has to be relaxing, notes Mosso. A shoot-em-up game, no matter how distracting, might increase the risk of uncontrolled bleeding if the excitement raised patients’ blood pressure.)

VR is now being studied by teams around the world to relieve pain in medical situations such as wound care and dentistry, as well as in chronic conditions such as phantom limb pain. But Mosso is still the only researcher to have published results on the use of VR during surgery. In one study of 140 patients he found that those using VR reported 24 per cent less pain and anxiety during surgery than a control group. He got similar results in a smaller randomized trial.

Offering patients VR also halved the amount of sedation they needed and in many cases avoided its use completely. That represents an important cost saving for the clinics in which Mosso works; sedative drugs such as fentanyl and midazolam are “very, very expensive,” he says. He estimates that this reduced the cost of surgery by around 25 per cent, although he hasn’t yet crunched the data to give an exact figure. Cutting drug doses should also reduce complication risks and recovery times for patients. Mosso is planning further trials to test this, but in general, he says, patients can go home an hour after surgery if they receive only local anaesthetic, whereas those who are sedated often need a whole day to recover.

“It cuts down on the cost, on the recovery time, and on the complications,” says Wiederhold. “It’s incredible. We still have not done that here in the US.” Gregorio Obrador, dean of medicine at Panamerican University, is impressed, too. At first, “I thought it was a little goofy,” he admits. “I’m accustomed to giving pain medication.” But after looking at the literature on VR and pain relief, “I’m convinced that it does work.”

Overall, Mosso has now carried out more than 350 surgeries using VR and says he’d love to see it used as a routine component of pain relief in operating rooms. Offered alongside medication, he thinks the technology could transform how patients are treated during a wide range of procedures. But he has a bigger vision. What if VR could be more than an alternative to sedation during hospital surgeries? Could it help him to bring surgery to patients where sedation isn’t possible, where there are no hospitals at all?

Forgotten

Mosso’s Jeep Cherokee is full to bursting. Tents, plastic food boxes, surgical equipment, medication, sanitary products, and bags filled with clothes, sweaters, and shoes are squeezed into every available space inside and tied precariously to the roof. On the back seat are Mosso’s wife, Veronica—a gynaecologist—their youngest son, Olivier, and, to keep the nine-year-old entertained, two baby iguanas recently captured from the forest near Acapulco, confined for the journey in a green net bag.

There’s a long drive ahead. We are going to El Tepeyac, an isolated village hundreds of kilometres away in the mountains of Guerrero state. It’s home to an indigenous Me’phaa community (often called Tlapaneco by outsiders), one of Mexico’s poorest. “They have been forgotten,” says Mosso. “They live with cold, on top of the mountain. They don’t have hospitals, clinics, nothing.”

As the high-rise blocks of Mexico City give way to sprawling shanty towns and then forested mountains, Mosso tells me about his father, Victorio. He was born close to El Tepeyac but left when he was 13, eventually becoming a teacher near Acapulco. He returned briefly to his childhood home after getting married, but never visited again until Mosso took him 40 years later. They found Victorio’s youngest brother, Faustino. At first, neither brother recognized the other. “They said ‘You look too old!’” recalls Mosso. “Then they were hugging, crying, a lot of emotions. It was the first time I saw my father cry.”

Mosso was shocked by the poverty he saw, with dwellings that he felt could barely be described as houses. The villagers asked him to examine a patient, an old woman with a fever who was lying in a puddle on the floor (there had been a recent flood, and it was the only place close to the fire). She had pneumonia; Mosso told them there was nothing he could do. “She was my aunt,” he says. “It was the last time I saw her. She died a few weeks later.” He pauses, eyes fixed on the road. “That’s why I go back. Because of my aunt.”

In 2000, Mosso and Veronica began to travel to El Tepeyac every few months. They helped the villagers to build and stock a basic medical clinic, and they carried out simple surgeries. But a few years ago their trips stopped, due to a sharp rise in violence from the country’s drug cartels. These organized criminal groups have been active across Mexico since the 1990s, producing heroin from poppies grown in the mountains here and exporting it to the US and Europe. Any violence was traditionally directed mostly at the authorities and each other, but since 2009 the cartels have increasingly targeted the general population with extortion and kidnappings.

The threat of violence is now routine for many Mexicans; the news here is filled with beheadings, mutilations, and disappearances. On the freeway in the outskirts of Mexico City the day before, we had passed a group of four men, calmly crossing on foot between the busy traffic. One of them carried a young woman over his shoulder, either dead or unconscious, her dark hair spilling down past his hips. Mosso shrugged; for him the sight was nothing unusual. He works weekends at a hospital in this area and says he once had to order his surgical team to flee the operating room when a gunman entered the building, intent on killing their patient.

But the security situation is particularly bad in Guerrero, which is the country’s most violent state, with one of the highest murder rates in the world. According to a 2015 report by anthropologist Chris Kyle of the University of Alabama, Birmingham, illegal roadblocks, carjackings, and kidnappings are routine here. The police have lost control, Kyle says, and there is “near complete impunity” for the perpetrators. In 2009, Mosso and Veronica reluctantly decided that it was too dangerous to travel. “We were coming to El Tepeyac four times a year,” he says. “When the narc began, no more.”

But he’s desperate to see his family and worried about the health of the villagers. So although the security situation hasn’t improved, he is now attempting the trip again. The obvious route from Mexico City is to take the highway via Guerrero’s capital, Chilpancingo, to Tlapa de Comonfort, the nearest town to El Tepeyac. But the road from Chilpancingo to Tlapa—the main route for transporting opium out of the region—is “hell,” Mosso says, with many shootings and kidnappings. Instead we take a roundabout route through the states of Morelos and Puebla. We travel by daylight and eat on the move, making just one brief stop, in a deserted lay-by, during the nine-hour drive.

His caution pays off; the only sign of trouble is three cars traveling in convoy—“When you see vehicles driving together like that, it’s the narc,” Mosso notes as we pass—and once we reach the steep streets of Tlapa, he visibly relaxes. In this largely indigenous area, self-organized community police groups have been relatively successful in limiting the violence of the cartels. From Tlapa, the road gets higher and rougher as the sun sets, eventually becoming a narrow, winding track of mud and stones.

We arrive to find El Tepeyac in darkness; the only power line was recently blown down by a storm. The villagers line up to meet us with flashlights, wide eyes, and smiles looming out of the black. The welcome is a little awkward—many of them don’t speak Spanish, and Mosso doesn’t speak Me’phaa—until they direct us to a long, plastic table beneath a high shelter and feed us chicken soup and tortillas, freshly cooked over a fire, with steaming lemon tea.