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Surg Open Sci
Surg Open Sci
Surgery Open Science
2589-8450
Elsevier

S2589-8450(24)00114-3
10.1016/j.sopen.2024.08.004
Brief Communication
Could virtual reality be a solution in surgical trainings in resource-restricted settings? A perspective
Sibomana Olivier oliviersibomana917@gmail.com
⁎
Olis Health5.0, Smart Health Research, Kigali, Rwanda
Department of General Medicine and Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
⁎ Department of General Medicine and Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. oliviersibomana917@gmail.com
26 8 2024
9 2024
26 8 2024
21 1416
21 8 2024
22 8 2024
© 2024 The Author
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Surgical conditions account for 11 % of the global burden of disease, with over 313 million surgical procedures performed worldwide each year. This underscores the critical need to train more surgeons, particularly in low- and middle-income countries (LMICs), where disparities in access to surgical services persist due to a limited number of trained professionals. However, in resource-restricted settings, surgical education is often hampered by ethical, logistical, and financial challenges associated with the use of cadavers, leading to significant skill gaps that can negatively impact patient outcomes and exacerbate healthcare disparities. The advent of advanced technologies, such as Virtual Reality (VR), offers a promising alternative for enhancing surgical training. This paper explores the potential of VR to revolutionize surgical education in resource-constrained environments and addresses key considerations for its effective implementation.

Keywords

Virtual reality
Surgical education
Global surgery
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pmcIntroduction

Surgical education is a critical component of healthcare systems worldwide, as it directly influences the quality of care provided to patients. With an estimated 11 % of the global burden of disease attributed to conditions that can be treated surgically [1], the need for well-trained surgeons is immense. Each year, millions of lives are saved or significantly improved through surgical interventions, ranging from simple routine procedures to complex operations. According to the Lancet Commission on Global Surgery, over 313 million surgical procedures are performed globally each year [2], highlighting the crucial role of surgery in addressing the healthcare needs of populations. However, disparities in surgical training, particularly in low-resource settings, pose a significant challenge to ensuring equitable access to safe and effective surgical care.

The provision of high-quality surgical training is severely limited in many resource-constrained settings due to ethical, logistical, and budgetary obstacles. Because of the significant expenses associated with their acquisition, maintenance, and storage, traditional training methods—especially the use of cadavers—are sometimes unaffordable. Furthermore, cultural and ethical considerations may make it harder for cadavers to be used in medical schools, which limits the opportunity for future surgeons to obtain practical experience [3]. These restrictions add to a large skill gap in surgery, which can worsen patient outcomes and increase healthcare disparities in settings with limited resources.

The need for efficient surgical training is rising as medical treatments continue to advance and become more complex. Insufficient training has the potential to cause healthcare workers to lack confidence and competence, which can ultimately affect the standard of care given to patients. In light of these difficulties, alternative training approaches that are both practical and efficient are desperately needed especially in environments with limited resources. The potential of cutting-edge technology, such virtual reality (VR), to completely transform surgical education, has drawn more attention surgery – teaching institutions. This paper presents Virtual Reality as the potential tool to transform surgical education especially in resource-constrained environments. It also highlights important considerations that must be addressed when using VR technology in surgical education.

Why should VR be considered as the potential alternative?

While cadaveric material remains fundamental to medical education, particularly in surgical fields, challenges in body availability and legislative shortcomings have led to both educational and financial burdens. Universities often face the high costs of importing anatomical specimens from abroad, spending thousands of euros to facilitate dissection for training purposes. Similarly, medical students and practitioners seeking comprehensive surgical or anatomical education frequently incur substantial personal expenses to travel to countries where cadaver dissection is well-regulated and integrated into curricula [3]. Although irreplaceable, cadaver-based education is linked to significant financial and ethical challenges. To address these issues, Virtual Reality (VR) offers a sustainable solution that can enhance surgical training, not only in resource-constrained settings but also in resource-rich environments, to augment trainees' skills. Table 1 compares Virtual Reality versus cadaveric-based practice in surgical trainings.Table 1 VR versus cadavers in surgical trainings.

Table 1Aspect	Virtual reality (VR)	Cadavers	
Cost	- Low recurring costs.	- High ongoing costs for procurement, preservation, and storage.	
Accessibility	- Widely accessible once infrastructure is in place.
- Scalable across multiple locations.	- Limited availability, especially in low-resource settings.
- Cultural and ethical barriers in some regions.	
Repetition & practice	- Unlimited practice opportunities: Procedures can be repeated indefinitely.	- Limited use; once a procedure is performed, repetition is not possible.	
Ethical considerations	- No ethical concerns related to use.	- Ethical and cultural concerns in body donation and use.	
Educational value	- Highly interactive and customizable learning environment.
- Safe environment for making and correcting mistakes.	- Essential for understanding human variation and real-life surgical complexities, but not interactive and customizable.
- Unsafe environment for making and correcting mistakes.	
Long-term sustainability	- Sustainable with low ongoing costs.
- Easily updated and maintained.	- Requires continuous investment in body acquisition and maintenance.	
Regulatory and legal issues	- Fewer regulatory barriers compared to cadavers.	- Subject to strict regulations and legal requirements for use.	

Cost considerations are paramount in evaluating training methods. William K. et al. compared skill acquisition in immersive Virtual Reality (VR) with cadaver laboratory sessions for reverse total shoulder training, finding no significant differences in skill acquisition. However, the average cost for VR hardware and a one-year software license was $4900, while a single cadaver lab session cost $1268.20 per resident [4]. Basing on that, the expense of four cadavers, which would be insufficient for even a month of training of all surgical trainees, would cover the cost of VR for an entire year, allowing repeated usability and accessibility to all trainers. Similarly, Haerling Katie's cost-utility analysis revealed that virtual simulation had a more favorable cost-utility ratio of $1.08 compared to $3.62 for mannequin-based simulation [5]. These findings position VR as a cost-effective solution, particularly in financially constrained settings.

With its immersive, dynamic, and highly adaptable learning environment, virtual reality presents a possible substitute for conventional surgical teaching techniques. Virtual reality simulations can be customized to match the needs of individual learners and, unlike cadavers, VR can be used repeatedly. With virtual reality (VR), surgical trainees can practice a broad range of techniques in a safe setting where errors can be made and fixed without endangering actual patients [3,6]. This makes VR a desirable alternative for surgical training due to its capacity to accurately and safely replicate complicated surgeries, which is important especially in environments with restricted cadaver access.

When it comes to ethical, legal, and regulatory issues, virtual reality offers an appealing substitute of cadavers in surgical education. VR is not as legally constrained as cadaver-based training, which is subject to stringent rules around body donation, transportation, and use. In some cultures, due to societal and religious beliefs on death and the handling of human bodies, the procurement of cadavers is heavily regulated and sensitive. Those cultures place a strong emphasis on ancestor reverence and the sacredness of the body after death, leading to fewer body donations [7]. VR can systematically resolve ethical issues related to the use of human bodies, honoring cultural and religious convictions while offering reliable and excellent surgical training ground.

Virtual reality presents as the alternative way to be used in surgical education in cadavers-resource-restricted settings. However, there are important considerations that must be addressed when using VR in surgical education. First, VR to be used must be checked if their quality and realism accurately reflect surgical procedures to ensure effective skill transfer. If they don't, trainees may not acquire the necessary competencies. Secondly, instructors must be sufficiently educated to integrate VR into the curriculum and maximize its educational benefits. it is also important to assess the hardware and software costs associated with VR technology, and compare them with expense associate with cadavers, to make sure that it is a financially viable option for educational institutions. Additionally, in order to guarantee continuous training, technical concerns including user support, device upkeep, and software updates must be handled. Finally, ethical concerns about data privacy and user permission must be taken into account in order to safeguard trainees' private information and uphold regulatory compliances.

Conclusion

Real cadavers play an irreplaceable role in surgical education, offering unmatched realism and the opportunity to understand human anatomy in depth. However, where access to cadavers is limited, it is imperative that surgical trainees are not confined to theoretical knowledge alone. Virtual Reality (VR) presents a viable alternative to bridge this gap. Beyond its lower associated costs, VR provides a customizable learning environment with fewer regulatory and ethical concerns. While VR has been primarily discussed as a solution for resource-constrained settings due to its cost-effectiveness, it can also complement cadaver-based training in resource-rich environments, enhancing the practical skills of emerging surgeons. In both contexts, VR can significantly contribute to the development of competent and confident surgical professionals.

Funding source

No funding was received.

Ethical approval statement

No ethical approval was needed since there was no involvement of human or animal subject.

CRediT authorship contribution statement

Olivier Sibomana: Conceptualization, Formal analysis, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Alimoglu O. Colapkulu N. Global surgery: improving health in low-income countries Bangladesh J. Med. Sci. 20 3 Apr. 2021 3 10.3329/bjms.v20i3.52789
2 Meara J.G. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development Lancet 386 9993 Aug. 2015 569 624 10.1016/S0140-6736(15)60160-X 25924834
3 Bolino G. Fineschi V. Cecannecchia C. D’Antonio G. Frati P. The practice of teaching and scientific research on cadaveric material remains crucial for medical education Clin. Pract. 13 5 Oct. 2023 5 10.3390/clinpract13050095
4 Crockatt W.K. Confino J.E. Kopydlowski N.J. Jobin C.M. Levine W.N. Comparing skill acquisition and validity of immersive virtual reality with cadaver laboratory sessions in training for reverse total shoulder arthroplasty JBJS Open Access 8 3 Sep. 2023 e22.00141 10.2106/JBJS.OA.22.00141
5 Haerling K.A. Cost-utility analysis of virtual and mannequin-based simulation Simul. Healthc. 13 1 Feb. 2018 33 10.1097/SIH.0000000000000280 29373382
6 Gilliland A. Immersive virtual reality training and surgical skill: a systematic review &amp; recommendations for future research medRxiv Jun. 17, 2024 10.1101/2024.06.17.24309027
7 Trandzhiev M. The evaluation of virtual reality neuroanatomical training utilizing photorealistic 3D models in limited body donation program settings Cureus 16 Mar. 2024 10.7759/cureus.55377
