Virtual Reality Simulation of Airway Management Post-Cleft Palate Surgery: A Model for Sustainable and Equitable Education.

BACKGROUND: The effectiveness of virtual-reality (VR) simulation-based training in cleft surgery has not been tested. The purpose of this study was to evaluate learners' acceptance of VR simulation in airway management of a pediatric patient post-cleft palate repair. METHODS: This VR simulation was developed through collaboration between BioDigital and Smile Train. 26 medical students from a single institution completed 10 min of standardized VR training and 5 min of standardized discussion about airway management post-cleft palate repair. They spent 4-8 min in the VR simulation with guidance from a cleft surgery expert. Participants completed pre- and post-surveys evaluating confidence in using VR as an educational tool, understanding of airway management, and opinions on VR in surgical education. Satisfaction was evaluated using a modified Student Evaluation of Educational Quality questionnaire and scored on a 5-point Likert scale. Wilcoxon signed-rank tests were performed to evaluate responses. RESULTS: There was a significant increase in respondents' confidence using VR as an educational tool and understanding of airway management post-cleft palate repair after the simulation (P < .001). Respondents' opinions on incorporating VR in surgical education started high and did not change significantly post-simulation. Participants were satisfied with VR-based simulation and reported it was stimulating (4.31 ± 0.88), increased interest (3.77 ± 1.21), enhanced learning (4.12 ± 1.05), was clear (4.15 ± 0.97), was effective in teaching (4.08 ± 0.81), and would recommend the simulation (4.2 ± 1.04). CONCLUSION: VR-based simulation can significantly increase learners' confidence and skills in airway management post-cleft palate repair. Learners find VR to be effective and recommend its incorporation in surgical education.

Internet-based Digital Simulation for Cleft Surgery Education: A 10-year Assessment of Demographics, Usage, and Future Directions.

Background: In October 2012, an open-access, multimedia digital cleft simulator was released. Its purpose was to address global disparities in cleft surgery education, providing an easily accessible surgical atlas for trainees globally. The simulator platform includes a three-dimensional surgical simulation of cleft care procedures, intraoperative videos, and voiceover. This report aims to assess the simulator's demographics and usage in its tenth year since inception. Finally, we also aim to understand the traction of virtual reality in cleft surgical education. Methods: Usage data of the simulator over 10 years were retrospectively collected and analyzed. Data parameters included the number of users, sessions, countries reached, and content access. An electronic survey was emailed to registered users to assess the benefits of the simulator. Results: The total number of new and active simulator users reached 7687 and 12,042. The simulator was accessed an average of 172.9.0 ± 197.5 times per month. Low- to middle-income regions accounted for 43% of these sessions. The mean session duration was 11.4 ± 6.3 minutes, yielding a total screen time of 3022 hours. A total of 331 individuals responded to the survey, of whom 80.8% found the simulator to be very useful or extremely useful. Of those involved in education, 45.0% implemented the simulator as a teaching tool. Conclusions: Global utilization of the simulator has been sustained after 10 years from inception with an increased presence in low- to middle-income nations. Future similar surgical simulators may provide sustainable training platforms to surgeons in low- and high-resource areas.

A Real-Time Local Flaps Surgical Simulator Based on Advances in Computational Algorithms for Finite Element Models.

BACKGROUND: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. METHODS: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. RESULTS: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. CONCLUSIONS: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general.

Step-based cognitive virtual surgery simulation: an innovative approach to surgical education.

BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created a complex, real-time, step-based simulation platform for plastic surgery education. These simulators combine live surgical footage, interactive 3D visualization, text labels, and voiceover as well as a high-yield, expert-approved testing mode to create a comprehensive virtual educational environment for the plastic surgery resident or physician.

The biodigital human: a web-based 3D platform for medical visualization and education.

NYU School of Medicine's Division of Educational Informatics in collaboration with BioDigital Systems LLC (New York, NY) has created a virtual human body dataset that is being used for visualization, education and training and is accessible over modern web browsers.

Integration of surgical simulation in plastic surgery residency training.

BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created an interactive, step-based latissimus musculocutaneous flap simulator. Preliminary testing of fourteen residents (PGY1-6) demonstrates that simulator training results in significant improvement in an objective assessment of surgical knowledge (p < 0.0006, pre-training score: 81.0%, post-training score 92.7%). This study is the first in the field of plastic and reconstructive surgery to demonstrate objective improvement in surgical knowledge as a result of simulator training, suggesting the potential effectiveness of simulators for a panopoly of breast reconstruction options.

Simulating video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation.

OBJECTIVE: Current video-assisted thoracoscopic surgery training models rely on animals or mannequins to teach procedural skills. These approaches lack inherent teaching/testing capability and are limited by cost, anatomic variations, and single use. In response, we hypothesized that video-assisted thoracoscopic surgery right upper lobe resection could be simulated in a virtual reality environment with commercial software. METHODS: An anatomy explorer (Maya [Autodesk Inc, San Rafael, Calif] models of the chest and hilar structures) and simulation engine were adapted. Design goals included freedom of port placement, incorporation of well-known anatomic variants, teaching and testing modes, haptic feedback for the dissection, ability to perform the anatomic divisions, and a portable platform. RESULTS: Preexisting commercial models did not provide sufficient surgical detail, and extensive modeling modifications were required. Video-assisted thoracoscopic surgery right upper lobe resection simulation is initiated with a random vein and artery variation. The trainee proceeds in a teaching or testing mode. A knowledge database currently includes 13 anatomic identifications and 20 high-yield lung cancer learning points. The "patient" is presented in the left lateral decubitus position. After initial camera port placement, the endoscopic view is displayed and the thoracoscope is manipulated via the haptic device. The thoracoscope port can be relocated; additional ports are placed using an external "operating room" view. Unrestricted endoscopic exploration of the thorax is allowed. An endo-dissector tool allows for hilar dissection, and a virtual stapling device divides structures. The trainee's performance is reported. CONCLUSIONS: A virtual reality cognitive task simulation can overcome the deficiencies of existing training models. Performance scoring is being validated as we assess this simulator for cognitive and technical surgical education.

Creating a virtual surgical atlas of craniofacial procedures: Part I. Three-dimensional digital models of craniofacial deformities.

BACKGROUND: Three-dimensional digital animation can enable surgeons to create anatomically accurate, virtual models of normal and pathologic human anatomy. From these models, surgical procedures can be digitally performed, recorded, and distributed as a teaching tool or as a virtual surgical atlas. The idea of a virtual surgical atlas has recently become a part of contemporary surgical teaching. In the field of craniofacial surgery, no such educational tool exists. Presented is the first part of the creation of a virtual atlas of craniofacial surgical procedures: the three-dimensional digital modeling of pathologic deformities commonly treated by craniofacial surgeons. METHODS: Three-dimensional craniofacial models were constructed using Maya 8.5. A skeletally "normal" craniofacial skeleton was first produced from a preexisting digital skull using Bolton tracings as a reference. The remaining soft-tissue elements were then added to create an anatomically complete three-dimensional face. The "normal" model was then deformed in Maya to produce specific craniofacial deformities using computed tomographic scans, cephalograms, and photographs as a reference. One of the craniofacial deformity models was created directly from computed tomographic data. RESULTS: One model of the normal face and eight pathologic models of craniofacial deformities were created: microgenia, micrognathia, prognathia, temporomandibular joint ankylosis, maxillary hypoplasia, Crouzon syndrome with and without the need for cranial vault expansion, and bicoronal craniosynostosis. CONCLUSIONS: For the first time, anatomically accurate three-dimensional digital models of craniofacial deformities have been created. The models are the first step in the creation of a virtual surgical atlas of craniofacial procedures.

Creating a virtual surgical atlas of craniofacial procedures: Part II. Surgical animations.

BACKGROUND: Craniofacial surgery can be challenging to teach and learn. To augment the intraoperative learning experience for surgical trainees and to provide a resource for practicing craniofacial surgeons to review uncommonly performed procedures before entering the operating room, a series of three-dimensional animations were created encompassing the most commonly performed craniofacial procedures. METHODS: Previously created three-dimensional craniofacial digital models were used to create digital animations of craniofacial surgical procedures using Maya 8.5. Digital models were altered systematically within Maya to recreate the ordered steps of each craniofacial procedure. Surgical tools were imported into Maya for use in the animations using computer-aided manufacturing files obtained directly from the manufacturer. RESULTS: Nine craniofacial procedures were animated: genioplasty, bilateral sagittal split osteotomy, intraoral vertical ramus osteotomy, Le Fort I osteotomy, unifocal mandibular distraction, mandibular transport distraction, fronto-orbital advancement with cranial vault remodeling, Le Fort III advancement/distraction, and monobloc advancement/distraction. All major surgical steps are demonstrated, including exposure, execution of the osteotomy, displacement of the bone composite, and the predicted morphologic changes to the craniofacial contour. Throughout the surgical animation, the view of the surgeon in the operating room is incorporated to reproduce the vantage of the surgeon, and the overlying tissue is rendered transparent to illustrate critical underlying anatomical relationships. CONCLUSIONS: The first virtual surgical atlas of craniofacial procedures is presented. These animations should serve as a resource for trainees and practicing surgeons in preparation for craniofacial surgical procedures.

Real-time complex cognitive surgical simulator with testing.

One of the greatest challenges facing surgical education is the inability to effectively test a surgeon's cognitive knowledge of a complex open surgery procedure. Cognitive knowledge is tested by paper, and more recently, computer-based and oral exams. Although these tools are used for testing in surgical education, they have been limited by providing a two-dimensional static representation of complex and dynamic, three-dimensional procedures.A three-dimensional interactive surgical simulator that will engage the surgeon, ask questions, test competency and provide feedback has the potential to revolutionize surgical education. Internet connectivity allows for rapid deployment of surgical modules, networked testing formats, data aggregation, comparative analysis and guided tutorials. Combined with the approval of a surgical society, this platform has the potential to set measurable quantitative surgical standards.

Local flaps: a real-time finite element based solution to the plastic surgery defect puzzle.

One of the most fundamental challenges in plastic surgery is the alteration of the geometry and topology of the skin. The specific decisions made by the surgeon concerning the size and shape of the tissue to be removed and the subsequent closure of the resulting wound may have a dramatic affect on the quality of life for the patient after the procedure is completed. The plastic surgeon must look at the defect created as an organic puzzle, designing the optimal pattern to close the hole aesthetically and efficiently. In the past, such skills were the distillation of years of hands-on practice on live patients, while relevant reference material was limited to two-dimensional illustrations. Practicing this procedure on a personal computer [1] has been largely impractical to date, but recent technological advances may come to challenge this limitation. We present a comprehensive real-time virtual surgical environment, based on finite element modeling and simulation of tissue cutting and manipulation. Our system demonstrates the fundamental building blocks of plastic surgery procedures on a localized tissue flap, and provides a proof of concept for larger simulation systems usable in the authoring of complex procedures on elaborate subject geometry.

A virtual reality atlas of craniofacial anatomy.

BACKGROUND: Head and neck anatomy is complex and represents an educational challenge to the student. Conventional two-dimensional illustrations inherently fall short in conveying intricate anatomical relationships that exist in three dimensions. A gratis three-dimensional virtual reality atlas of craniofacial anatomy is presented in an effort to address the paucity of readily accessible and customizable three-dimensional educational material available to the student of head and neck anatomy. METHODS: Three-dimensional model construction was performed in Alias Maya 4.5 and 6.0. A basic three-dimensional skull model was altered to include surgical landmarks and proportions. Some of the soft tissues were adapted from previous work, whereas others were constructed de novo. Texturing was completed with Adobe Photoshop 7.0 and Maya. The Internet application was designed in Viewpoint Enliven 1.0. RESULTS: A three-dimensional computer model of craniofacial anatomy (bone and soft tissue) was completed. The model is compatible with many software packages and can be accessed by means of the Internet or downloaded to a personal computer. As the three-dimensional meshes are publicly available, they can be extensively manipulated by the user, even at the polygonal level. CONCLUSIONS: Three-dimensional computer graphics has yet to be fully exploited for head and neck anatomy education. In this context, the authors present a publicly available computer model of craniofacial anatomy. This model may also find applications beyond clinical medicine. The model can be accessed gratis at the Plastic and Reconstructive Surgery Web site or obtained as a three-dimensional mesh, also gratis, by contacting the authors.

Designing a virtual reality model for aesthetic surgery.

BACKGROUND: Aesthetic surgery deals in large part with the manipulation of soft-tissue structures that are not amenable to visualization by standard technologies. As a result, accurate three-dimensional depictions of relevant surgical anatomy have yet to be developed. This study presents a method for the creation of detailed virtual reality models of anatomy relevant to aesthetic surgery. METHODS: Two-dimensional histologic sections of a cadaver from the National Library of Medicine's Visible Human Project were imported into Alias's Maya, a computer modeling and animation software package. These two-dimensional data were then "stacked" as a series of vertical planes. Relevant anatomy was outlined in cross-section on each two-dimensional section, and the resulting outlines were used to generate three-dimensional representations of the structures in Maya. RESULTS: A detailed and accurate three-dimensional model of the soft tissues germane to aesthetic surgery was created. This model is optimized for use in surgical animation and can be modified for use in surgical simulators currently being developed. CONCLUSIONS: A model of facial anatomy viewable from any angle in three-dimensional space was developed. The model has applications in medical education and, with future work, could play a role in surgical planning. This study emphasizes the role of three-dimensionalization of the soft tissues of the face in the evolution of aesthetic surgery.

Applications of virtual reality in aesthetic surgery.

BACKGROUND: Virtual reality has a long history in plastic and reconstructive surgery, with uses ranging from anatomical demonstration to craniofacial surgical planning. The purpose of this article is to add to the literature a computer graphics-based resource for aesthetic surgery. METHODS: Deformation tools, virtual cameras, and other components of Alias's Maya 4.0 were used to perform virtual surgical procedures on a detailed model of superficial facial anatomy. This three-dimensional model of superficial facial anatomy, derived from the National Library of Medicine's Visible Human Project, was also "aged" in Maya at key depths of anatomical dissection. Adobe's After Effects 5.5 was used for animation postproduction work for all animations. RESULTS: Three-dimensional computer animations were developed to illustrate techniques in aesthetic surgery. Another animation was created that simulates facial aging at various levels of anatomical dissection. CONCLUSIONS: Computer modeling and animation have the potential to play an important role in education, surgical planning, development, and other aspects of aesthetic surgery.

Computer-generated three-dimensional animation of the mitral valve.

OBJECTIVE: Three-dimensional motion-capture data offer insight into the mechanical differences of mitral valve function in pathologic states. Although this technique is precise, the resulting time-varying data sets can be both difficult to interpret and visualize. We used a new technique to transform these 3-dimensional ovine numeric analyses into an animated human model of the mitral apparatus that can be deformed into various pathologic states. METHODS: In vivo, high-speed, biplane cinefluoroscopic images of tagged ovine mitral apparatus were previously analyzed under normal and pathologic conditions. These studies produced serial 3-dimensional coordinates. By using commercial animation and custom software, animated 3-dimensional models were constructed of the mitral annulus, leaflets, and subvalvular apparatus. The motion data were overlaid onto a detailed model of the human heart, resulting in a dynamic reconstruction. RESULTS: Numeric motion-capture data were successfully converted into animated 3-dimensional models of the mitral valve. Structures of interest can be isolated by eliminating adjacent anatomy. The normal and pathophysiologic dynamics of the mitral valve complex can be viewed from any perspective. CONCLUSION: This technique provides easy and understandable visualization of the complex and time-varying motion of the mitral apparatus. This technology creates a valuable research and teaching tool for the conceptualization of mitral valve dysfunction and the principles of repair.