How surgeons are helped by immersive technologies

Dr. Claudette Lajam, chief safety officer and adult reconstructive surgeon at NYU Langone Orthopedics, explains why touch is so important and why medical institutions are at the forefront of advanced immersive technologies that are providing medical educators with new ways to help surgeons improve patient outcomes. 

While we use all five senses to experience the world, the sense of touch is one to which we give little thought. However, touch integrates with the other senses in complex and powerful ways – every second of every day. We receive innumerable signals from touch; the glide of fabric across the skin, a breeze on the face, the touch of a keyboard, the resistance of water in a lake.

“Touch,” or somatosensation, is divided in three parts: tactile, proprioceptive, and temperature. “Haptics” includes tactile and proprioceptive feedback. The field of haptics in technology was created to replicate these senses. Research has shown that the human finger can discriminate between surfaces patterned with ridges as small as thirteen nanometres in amplitude, where one sheet of paper has a thickness of 100,000 nanometres. This is astounding when we consider trying to replicate this through technology.

In surgery, touch is crucial to the surgeon’s ability to learn and carry out tasks. Surgery is a multi-sensory skill, where successful outcomes rely on the ability of the surgeon to experience and process somatosensory feedback. What the surgeon sees interfaces with tactile and proprioceptive feedback to allow her to perform and adjust movement during surgery.

In many instances, haptic feedback guides the surgeon’s actions during a procedure. For example, during a total knee replacement, the surgical saw is used to resect bone. Haptic feedback allows the surgeon to feel changes in resistance between the layers of harder and softer bone, and to feel when she has gone through the bone, so she can prevent injury to nerves, vessels, and soft tissue behind this layer. These layers of bone cannot be seen – they must be felt.

Traditional surgical training involves years of classroom study, surgical observation, and hands-on training on real patients through graduated responsibility. While training on real patients is extremely important, it involves both risk and cost. Thus, technology, such as video, text, imagery, role-play and digital rehearsal systems are employed. These non-tactile experiences have value but lack tactile and proprioceptive feedback which is so important.  This haptic advantage, which allows surgeons to develop critical muscle memory, has only recently started to become available.

The development of immersive technologies provides exciting new capabilities. Teaching hospitals and institutions are incorporating VR haptic solutions into their training programs with flight simulator type machines. This acceleration is being driven by research into the value of haptics in surgical simulations where the results have been promising.  

In cardiology, Halabia and colleagues noted that haptics “increases accuracy and reduces the time taken to perform tasks.” A study into robotic surgery demonstrated that a lack of haptics was a major inhibitor to skills development and in two studies of different flat screen simulators where haptic feedback could be disabled, the surgical trainees learning to perform tasks using haptics were faster and became more accurate.

But while studies have shown surgical haptic simulations can improve physicians’ cognitive, psychomotor, and technical performance, less than 0.5% of the world’s surgeons currently have access to surgical simulations. This is not surprising when cost can exceed $100,000, with up to $25,000 a year for maintenance. Moreover, most systems are large, and cannot be moved once established.         

There is no doubt that haptics are part of the future of surgical training. This is why surgeons like me have partnered with technology companies to create platforms that realistically mimic the somatosensory feedback associated with using various tools on different tissue variants. I work with FundamentalVR, which is unique, since it provides this incredible haptic technology at a cost that is accessible to even the smallest training programs or practices.

This is a fun and informative journey for me – to work with engineers and translate the various sensations experienced during surgery, and to build a virtual anatomical database of how a human body feels and reacts. This engine is called the Surgical Haptic Intelligence Engine and it has been designed to be hardware agnostic able to work with any current or future haptic device of VR headset. The resulting Fundamental Surgery can be deployed using any laptop and readily available equipment.

This democratises the haptic experience. Any surgeon, anywhere in the world, can use it with an appropriate laptop and widely available VR equipment. This is already deployed at world leading institutions including the Mayo Clinic and UCLA in the US, UCLH and St Georges in the UK and Sana in Germany, and we expect to bring it to many other Institutions.

Medical professionals and institutions are often accused of being slow adopters of technology. This is driven by the need for precision and to be clinically credible. Surgery is not gaming; what is acceptable feedback during a game won’t cut it when wielding a scalpel. When it comes to the use of improving and fine-tuning haptics, the medical community now leads the way.