Virtual reality in neurosurgery: development of an educational module focused on intracranial pressure sensor insertion

Overview

Virtual reality represents an interactive, artificially created environment isolated from the real world. This unique technology, through immersion and gamification, has effectively complemented the education of therapeutic procedures and surgical techniques over the past decade. Based on positive experiences with the use of virtual reality in rehabilitation, our team decided to develop an educational model for a relatively straightforward neurosurgical procedure: the insertion of an intracranial pressure sensor. This report discusses the development of the module and the initial experiences with its testing in education. The module combines a realistically designed environment with virtual assistance and the possibility of online supervision by instructor. Its simple controls allow for safe and freely repeatedly practiced operations. Immersion and gamification appear to be key diff erentiators for better retention of information during training, thereby improving the educational process compared to other techniques. This has been confi rmed during module testing by healthcare professionals from the development team and students from the faculty of medicine and higher medical school. We anticipate that the application of this module in surgical training could effectively complement existing teaching methods and potentially accelerate the learning curve for the given procedure in the future.

Keywords:

virtual reality – neurosurgery – Immersion – intracerani pressure – training techniques

Introduction

Currently, virtual reality (VR) technologies are used as an adjunct in, for example, rehabilitation [1,2], diagnostics [3,4] and neurosurgery [5]. Special goggles with sensors allow the illusion of a realistic and controlled 3D environment, providing students with the opportunity to safely and effectively practice various procedures and techniques without the need for additional aids such as cadavers or 3D printed models [6,7]. The immersive approach offered by virtual reality allows students to be fully immersed in the simulated environment, thus greatly improving the memorization and practical skills acquired during the learning process [8,9].

Based on this knowledge, our multidisciplinary team of healthcare professionals and technicians created a training module to practice a standardized and relatively simple procedure -⁠ intracranial sensor application. This type of surgery is most commonly used in comatose patients to monitor severe changes in brain tissue, most often caused by trauma, where no other surgical intervention is indicated. The application of the sensor, due to the severity of the patient's condition, requires rapid and precise mastery of the entire surgical procedure. Simulating the procedure using VR technology can enhance its quality, which has a positive impact on the patient.

 

Methodology

The app was designed based on the positive experience for the Meta Quest 3 headset, which features simple controls, high resolution, low weight and ergonomic, motion-sensing controls. The device has sufficient power and allows up to 2 hours of smooth interaction with the app, ensuring the most realistic training environment. The actual training of the operation then takes place using 3D glasses that combine text-based tables with virtual assistance and the possibility of online control by the teacher.

The development of the training module took place in three successive phases.

In the first phase of developing the training module, the medical team broke the exercise down into key steps that allowed the technicians to understand and model each phase of the operation. These steps included preparing the patient in the operating room, the actual procedure involving trepanation of the skull from a short incision at Kocher's point anteriorly, fixation of the screw in the skull bone, and insertion of a sensor with a connection to a monitor displaying intracranial pressure readings. These phases of the operation were recorded using cameras, with the recordings serving as reference material for the development of detailed 3D models that simulate as closely as possible the real conditions in the operating room (Figure 1).

The second phase of development involved 3D modelling and texturing using Blender on the Unity cross-platform software. This allowed us to create detailed and realistic models of the organs, instruments and operating environment. Emphasis was placed on the accuracy and fidelity of the models so that users could practice their surgery in the most realistic representation of the operating room and the necessary instrumentation. To achieve a high-quality representation, we provided the models with textures that simulate the realistic appearance of the operating room environment and instruments. The texturing involved the use of advanced techniques to simulate reflections, shadows, and other visual effects (Figure 2).

In the third phase of development, engineers used the XR Interaction Toolkit development platform to implement interactive elements such as operational tools that connect users to 3D models in a VR environment. An intuitive and user-friendly interface was created to make it easier to control the instrumentation and navigate during the operation training. Users can manipulate the virtual instruments, perform operations and receive real-time feedback. During practice, the student is guided step-by-step using text-based help (Fig. 3) supplemented by visual assistance in the virtual environment. A green arrow, the so-called virtual assistance, on the goggle screen together with the text indicates the instrument on the instrument table to be used by the student (Figure 4). When grasped by the virtual hand, the instrument is highlighted in green and automatically placed in the correct position in the operating field (Fig. 5). If the tool is used correctly, its color changes to blue, allowing the student to continue the operation. In case of incorrect placement, the instrument will return to its original position on the instrument table and the procedure must be repeated with the help of virtual assistance. In this way, the whole teaching process is carried out (Figure 6).

 

Results

After basic finalization, the module was tested by a team of doctors and nurses from the multidisciplinary team and also by medical and non-medical students. Participants involved particularly appreciated the following aspects:

• Easy and intuitive control using 3D glasses with controllers in a realistic operating room environment, without the need for additional special aids or teaching spaces.
• The ability to safely and repetitively practice performance in a controlled environment, eliminating the risk of mishandling that could lead to damage to equipment loaned for training.
• The possibility of expert guidance by an instructor with instant online interaction using a PC or 3D glasses.
• Reduction of teaching costs due to the affordable price of the equipment, i.e. 3D glasses and controllers.

 

The main risk of teaching in VR lies in the lack of a well-developed operation scenario and poor technological execution. Students with vestibular disorders cannot participate in VR training due to potential complications such as nausea and headaches. The risk associated with scenario design and application development was reduced by the collaboration of a multidisciplinary team.

 

Discussion

The authors Chan et al [10] point to the considerable potential of virtual reality in transforming neurosurgical education. The importance of this technology in medicine is also confirmed by Iop et al [11], who highlight that VR allows physicians to safely experiment with different techniques and scenarios, which promotes innovation in surgery and improves the overall quality of care. A key factor in the effectiveness of learning through VR is the so-called immersiveness, i.e. the ability of the brain to perceive the simulated environment as real and to respond appropriately to it. By eliminating external stimuli, VR allows full concentration on the task, which, combined with gamification elements, improves memorization and accelerates the learning process [12,13]. In the development of learning modules, emphasis is placed on designing multimodal virtual environments, such as operating room simulations, and creating immersive scenarios that realistically simulate surgical procedures. A large role is also played by a user-friendly training method that includes gamification of training, similar to rehabilitation in VR [1,2]. Gamification in VR represents the use of game elements to enhance participant engagement and motivation during training. Through this, learners can interactively practice skills in an environment that simulates real-life situations, which facilitates knowledge acquisition and improves the ability to respond to different scenarios in practice. No other technology offers such a comprehensive learning method [8]. This experience was confirmed by the students who tested the module we created.

Fiani et al [14] highlight that VR provides detailed visualization of anatomical structures, which is essential for accurate surgical planning and reducing the risk of complications. According to Kozel et al [3], Školoudík et al [4], Gosal et al [5] and Mishra et al [15], realistic simulations in VR significantly improve surgical skills. Our initial experience shows that teaching through the developed intracranial pressure (ICP) sensor insertion module can significantly enhance the practical skills of healthcare professionals, which is in line with the findings of Vayssiere et al. [6] and Knafo et al. [16].

Colombo et al. [17] reported that VR contributes to increase the accuracy and safety of operations. In line with international experience, we can confirm that one of the main benefits of VR in neurosurgical training is the possibility of repeated practice without risk to patients, allowing physicians to acquire the necessary skills in a controlled environment. However, we cannot yet confirm the results of Roh et al. [18], who found that VR trainees achieve higher accuracy and efficiency in simulated procedures more quickly. Thus, realistic simulations have been shown to improve residents' skills.

Authors Arjun et al. [9], Chan et al. [10], Bernardo [12], Fiani et al. [14] and Paro et al. [19] emphasize that VR increases physicians' confidence in their own abilities and preparedness for real-world clinical situations, which is crucial for the successful performance of neurosurgery. This approach allows physicians to experiment with different techniques and scenarios without risk to patients, which can lead to innovations in surgical procedures and possibly reduce costs compared to robotic systems. We are unable to substantiate these claims at this time.

In the future, we are considering extending the module to include scenarios simulating common complications during intracranial sensor insertion, such as bleeding. Such an extension would add realistic training to the module, where students practice reacting to crisis situations, thus better preparing them for similar challenges in a real clinical setting. This element could significantly increase their preparedness and ability to respond effectively during challenging interventions.

 

Conclusion

The developed ICP sensor insertion module demonstrates that learning through VR technology, which uses immersivity and gamification, offers a realistic, safe and infinitely repeatable simulation of surgical procedures compared to traditional methods. This approach does not require demanding teaching spaces or special equipment, which greatly increases its effectiveness. Our early experiences, which are in line with the literature, confirm the significant potential of VR in medical education. These positive results motivate us to continue developing additional learning modules that will further expand the possibilities of neurosurgical simulation.

 

Ethical aspects

The study was conducted in accordance with the 1975 Helsinki Declaration (and its 2004 and 2008 revisions).

 

Grant support

The project was supported by the Operational Programme Fair Transformation of the State Environmental Fund of the Czech Republic within the project Life & Environment Research Center Ostrava (LERCO) with reg. no. CZ.10.03.01/00/22_003/0000003. All rights under intellectual property protection regulations are reserved.

 

Conflict of interest

The authors declare that they have no conflict of interest in relation to the subject of the study.