Chapter Three

VR Application in
Surgical Domain

37
 Chapter Three
VR Application in Surgical Domain
This chapter surveys the state of the applications of virtual environments
cosmetic surgery and related technologies for health care. Applications of
these technologies are being developed for health care

Section 1: Health-Care Applications of Virtual Environments and Related

Technologies -- describes applications of virtual environments and related
technologies in health-care related areas. The areas discussed are cosmetic
surgical procedures, surgical training.

Section 2: Discussion Benefit of the virtual environment systems returning

to health care and Researcher VIEW.

3.1 Virtual Surgery

Virtual surgery, in general, refers to using VR Techniques of

simulating surgery procedures in order to enable Surgeons improve surgery
plans and practice surgery process on 3D models. Such simulator surgery
results can be evaluated before the actual surgery. Consequently, the
surgeon could gain a better and clear picture of the outcome of the surgery.
For example, if the surgeon finds some errors, many iterations of the
simulated surgery can be done to finalize the parameters to achieve better
surgical results. Furthermore, the surgeon can view the anatomy from wide
range of angles, which cannot be done on a real patient in the surgery, that
would enable the surgeon correct the incision, cutting, gain experience and
therefore improve both the surgical skills and results.

The virtual surgery is based on the patient specific model, so when

the real surgery takes place, the surgeon is already familiar with all the
specific operations that are to be employed.

3.1.1 Virtual Reality Applications In Surgery

The highly visual and interactive nature of virtual surgery has proven
to be useful in understanding complex 3D structures and for training in
visuo-spatial tasks. The scope of VR applications in surgery covers a
number of major areas and applications including:

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  Training and Education.

 Surgical Planning.

 Image Guidance.

 Tele-surgery.

3.1.1.1 Training And Education

The similarities between pilots and surgeons responsibilities are

striking; both must, be ready to manage potentially life-threatening
situations in dynamic, unpredictable environments. The long and successful
use of flight simulation in air and space flight training has inspired the
application of this technology to surgical and education.

Traditionally, textbook images or cadavers were used for training

purposes, the former ie textbook images, limiting one’s perspective of
anatomical structures to 2D plane and the latter, cadavers; limited in supply
and generally allowing one-time use only. Today VR simulators are
becoming the training methods of choice in medical schools. Unlike
textbook examples, VR simulators allow users to view the anatomy from a
wide range of angles and “fly through” organs to examine bodies from
inside.

The experience can be highly interactive allowing students to strip

away the various layers of tissues and muscles to examine each organ
separately. Unlike cadavers, VR models enable the user to perform a
procedure countless times. Perhaps because of the number of
complications resulting from the uncontrolled growth of laparoscopic
procedures in early 1990’s many groups have pursed simulation of
minimally invasive and endoscopic procedures. Advances in tissue
modeling, graphics and haptic instrumentation have enabled the
development of open abdominal and hollow-tube anastomosis simulators.
Initial validation studies using simulators have shown differences between
experienced and novice surgeons, that training scores improve overtime
and that simulated task performances is correlated to actual task
performances.

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Computer-based training has many potential advantages:

• It is interactive.

• An instructor presence is not necessary, so student’ can practice in their

free moment.

• Changes can be made that demonstrate variation in anatomy or disease

state.

• Simulated position and forces can be recorded to compare with

established performance matrices for assessment and credentialing.

• Students could also try different technique and loot at tissues from
perspective that would be impossible during real operations.

3.1.1.2 Surgical Planning

In traditional surgery planning, the surgeon calculates various

parameters and procedure for surgery from his earlier experience and
imagination. The surgeon does not have an exact idea about the result of
the surgery after it has been performed. So the result of the surgery depends
mainly on human factors. This leads to lots of errors and even to the risk of
losing the life of the patients. The incorporation of the virtual reality
techniques helps in reducing the errors and plan the surgery in the most
reliable manner.

‘The virtual reality technology can serve as useful adjunct to

traditional surgical planning techniques. Basic research in image processing
and segmentation of computed tomography and magnetic resonance scans
has enabled reliable 3D reconstruction of important anatomical structures.
This 3D imaging data have been used to further understand complex
anatomical relationships in specific patient prior to surgery and also to
examine and display the microsurgical anatomy of various internal
operations.

3D reconstruction has proven particularly useful in planning

stereostatic and minimally invasive neurosurgical procedures. Modeling of
deformable facial tissues has enabled simulations of tissue changes and the
postoperative outcome of craniofacial surgery. Other soft tissue application

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includes planning Liver resection on a 3D deformable liver model with aid
of a virtual laparoscopic tool.

3.1.1.3 Image Guidance

The integration of advanced imaging technology, image processing

and 3D graphical capabilities has led to great interest in image guided and
computer-aided surgery. The application of computational algorithm and
VR visualization to diagnostic imaging, preoperative surgical planning and
intra-operative surgical navigation is referred to as Computer Aided
Surgery. Navigation in surgery relates on stereotactic principles, based on
the ability to locate a given point using geometric reference. Most of the
work done in this field has been within neurosurgery. It also proved useful
in Robotic Surgery, a new technique in which surgeon remotely manipulate
robotic tool inside the patient body.

3.1.1.4 Telesurgery

Tele-surgery allows surgeons to operate on people who are

physically separated from themselves. This is usually done through a
master-slave robot, with imaging supplies through video cameras
configured to provide a stereoscopic view. The surgeon relies on a 3D
virtual representation of the patient and benefit from dexterity enhancement
afforded by the robotic apparatus’ prototype tele manipulator has been used
to successfully perform basic vascular and urologic procedures in swine’s.

3.1.2Virtual Surgery Simulation

3.1.2.1 3d Image Simulation

The first step in this is to generate a 3D model of the part of the body
that undergo surgery simulating human tissues-beat tooth enamel, skin or
blood vessels-often starts with a sample from a flesh and blood person that
is we should have a 3D model of the part of the body. Using computer
graphics we first construct a reference model. Depending on this
simulation needed, anatomical images can be derived from a series of
patient’s Magnetic Resonance Images (MRI), Computed Tomography (CT)
or video recording, which are 2D image. These images are segmented using
various segmentation methods like SNAKE’. The final model is obtained

41
by deforming the reference model with constraints imposed by
segmentation results. The image is digitally mapped on to the polygonal
mesh representing whatever part of the body on organ is being examined.
Each vortex of the polygon is assigned attributes like color and reflectivity
from the reference model.

For the user to interact with the graphics there must be software
algorithms that can calculate the whereabouts of the virtual instrument and
determines whether it has collided with a body part or anything else.
Advances in medical graphic allows ordinary medical scan of a
patient anatomy be enhanced into virtual 3D views-a clear advantage for
surgeon who preparing to do complicated procedures. Scans from MRJ and
CT produces a series of things slices of the anatomy divided into volume
data point or voxels, these slices are restacked and turned into 3D images
by a computer. These 3D images are color enhanced to highlight, say bone
or blood vessels.

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3.1.2.2 Touch Simulation

The second step in the simulation of surgery is simulating haptic-

touch sensation. Physicians rely a great deal on their sense of touch for
everything from routine diagnosis to complex, lifesaving surgical
procedure. So haptic , or the ability to simulate touch, goes a long way to
make virtual reality simulators more real.

It also add a layer of technology that can stump the standard

microprocessor. While the brain can be tricked into seeing seamless motion
by flipping through 30 or so images per second, touch signals need to be
refreshed up to once a millisecond. The precise rate at which a computer
must update a haptic interface varies depending on what type of virtual
surface is encountered-soft object require lower update rates than harder
objects.

A low update rate may not prevent a users surgical instrument from sinking
into the virtual flesh, but in soft tissues that sinking is what is expected. If
we want something to come to an abrupt stop that is in the case of born,
etc. it requires a higher update rates than bumping into something a little
squishy like skin, liver etc.

For simulating touch sensation, we have to calculate the forces

applied to cut, prodded, puncture the various tissues. Also how they react
or behave when cut, prodded, punctured using surgical instruments. First
we have to make physical models of various tissues. The major difficulty in
modeling organs is the physical behavior as they have all kinds of
complexities-they are anisotropic, non-homogeneous and nonlinear. In
addition, a great deal more physical measurement of tissues will be needed
to make realistic haptic maps of complicated parts of the body such as
abdomen.

Physical model is made assuming that tissues are polygon meshes

that interact like an array of masses connected by springs and dampers. The
parameter values are derived using complex nonlinear equations. The
reaction forces are also calculated.

In coming years, VR designers hope to gain a better understanding of

true mechanical behavior of various tissues and organs in the body.

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If the haptic device is to give a realistic impression of say pressing the skin
on a patient’s arm, the mechanical contributions of the skin, the fatty tissue
benefit, muscle and even bone must be summed up. The equations to solve
such a complex problem are known, but so far the calculations cannot be
made fast enough to update a display at 30Hz, let alone update a haptic
interface at 500-1000Hz.

3.1.2.3 Virtual Surgery Simulator

The VR simulator basically consists of a powerful PC which runs the

software and an interfacer- haptic interfacer- for the user to interact with
the virtual environment. Usually the haptic interfacer works on force
feedback loop.

The force feedback systems are haptic interfaces that output forces
reflecting input forces and position information obtained from the
participant. These devices come in the form of gloves, pens, joystick and
exoskeletons.

Figure 2.9 a haptic feedback loop

The figure (2.9) shows a haptic feedback loop, how human sense of
touch interacting with a. VR system. A human hands moves the end

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effecter-shown here with hemostat-of a haptic device causing the device to
relay its position via sensors to a computer running a VR simulation.

The computer determines what force should oppose that collision and
relays force information to actuators or brakes or both, which push back
against the end effecter. In the left hand loop, forces on the end effecter are
detected and relayed to user’s brain. The brain, for example, commands the
muscle to contract, in order to balance or overcome the force at the end
effecter.

3.1.3 Advantages of using virtual reality in surgery

Virtual reality simulation is becoming a standard part of the surgeon’s

training , Although virtual surgery will not replace current hands-on
teaching about new surgical procedures,

 it will give surgeons a chance to learn complex anatomy inside-out

and gain extra practice before their first patient is scheduled.

 “It will give them the time to do an advanced procedure in a

completely free environment,” Dr. Silverstein says. The technology
also will test surgical skills. The UIC virtual surgery laboratory is
exploring the possibility of developing reliable simulation models for
evaluating whether surgeons perform the steps of a procedure in the
right order and in an appropriate length of time. Models one day may
include challenging clinical scenarios that test whether surgeons
choose the right surgical approach to a problem or adapt to changing
patient dynamics. Pretreatment planning will take virtual reality
simulations to a different plane.

 “It will allow us to create a distributed, collaborative environment to

look at and manipulate radiologic data. It will simulate standing at
this spot, looking at this patient, right under these vessels and seeing
what the anatomy looks like around there,” Dr. Silverstein explains.
Virtual reality in the operating room will augment the limited
visualization surgeons have with minimally invasive techniques by
providing patient- derived data to surgeons by means of a pair of
glasses that project anatomical images to a tiny triangular space in
each lens.

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  “This will have tremendous impact on the crowded operating room
by bringing all those monitors and screens down to where they
belong—in front of the surgeons’ eyes—without blocking the rest of
their view,” Dr. Silverstein says.

3.1.4 The future of Virtual reality surgery

part of the typical surgical routine, surgeons slap X-ray films, computed
tomography slices, and even three-dimensional image reconstructions on
light boxes along the walls of the operating room so they can step away
from the operating table whenever they need to review where a particular
structure lies. Is it just beyond the curve of that vessel, just past that turn in
the bone, just behind that bit of tissue?

 But what if surgeons didn’t have to walk away from the table?

 What if they could view anatomy in three dimensions through stereo

video displays in a pair of goggles much like a pair of bifocals?

Better yet

 What if they could turn the display in any direction or orientation

and look at actual three-dimensional images of anatomy
superimposed over the operative field from their particular point of
view?

a) Surgeons then would be able to save considerable amounts of time.

They wouldn’t have to spend.

an hour with an ultrasound probe double-checking the position of major

vessels during liver resection. They would know exactly where to place
their ports while performing living-related donor nephrectomy. They could
spot a tumor in the adrenal gland without having to interrupt the operation
at critical moments to check anatomic images.

b) “Surgeons would be able to see much more clearly and do things in

more efficient and intelligent ways.

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Knowing exactly what they were going to find and exactly where they were
going in and coming out, they would be better able to make all the small
decisions of an operation,” says Jonathan Silverstein, MD, FACS, assistant
professor of surgery and health care informatics at the University of Illinois
at Chicago (UIC). This is the future of virtual reality surgery as Dr.
Silverstein sees it, and it’s not that far away. Indeed, some elements of
virtual reality surgery already are in place at UIC:

i) Surgical residents are using virtual reality technology to study the

three-dimensional anatomy of the temporal bone

3.2 Health-Care Applications of Virtual Environments And Related

Technologies

The terminology and categories used in this section are an amplification of

schema for health-care applications of virtual environments and related
technologies The following categories of applications are discussed:

• Surgical procedures (remote surgery or telepresence, augmented --

or enhanced -- reality surgery, and planning and simulation of procedures
before surgery .

• Surgical training

3.2.1 Surgical Procedures

Telepresence applications link research in robotics and virtual

environments. Telepresence systems are used in medicine to manipulate
equipment at remote sites. The surgeon or other medical practitioner has
the sense of actually being at the site performing the procedure

3.2.1.1 Remote Surgery or Telepresence

SRI International's Green Telepresence Surgery System was designed to

allow surgeons to participate in battlefield operations from sites removed
from the front line. The system consists of the "remote operative site and a

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surgical workstation...[that includes] 3-D vision, dexterous precision
surgical instrument manipulation, and input of force feedback sensory
information." The surgeon operates on a virtual image, and a robot on the
battlefield reproduces the surgeon's movements. This one-to-one coupling
between the surgeon and the machine has been demonstrated to work from
150 yards away with a fiber-optic connection. The next goal for the
military is to replace the fiber-optic connection with a wireless signal . As
promising as this system is, it will take about 3 years for it to be approved
for investigational trials on humans , personal communication.

The use of virtual environments and remote surgery opens up new

possibilities. Besides the military and the academic examples discussed
above, other civilian uses are possible. A specialist could assist a local
surgeon by remote connection, or surgery could be performed, via a
medical center, in a rural setting, a ship at sea, an airplane in flight, or even
a space station. Besides solving the distance problem, telepresence offers
other benefits, such as minimizing the exposure of surgeons to diseases and
reducing potential costs as a result of reduced trauma surgery. Augmented
surgery includes fusing computer images with real time images or
superimposing them on the body using video technology or using robots
directed by surgeons physically present in the operating room.
Table 3.1. Applications for Augmented Reality Surgery

Technique Technique
Cholecystectomies (gall bladder)
Endoscopic surgery
removal
Robots used locally Orthopedics, joint replacement
Fusing scanned images and real time Brain surgery: MRI overlaid on a
video image video image of the patient's head

3.2.1.2 Technique Examples

Endoscopic surgery Cholecystectomies (gall bladder) removal obots used

locally Orthopedics, joint replacement fusing scanned images and real time

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video image Brain surgery: MRI overlaid on a video image of the patient's
head .

Traditionally, surgery is performed by making incisions and directly

interacting with the organs and tissues. Recent innovations in video
technology allow direct viewing of internal body cavities through natural
orifices or small incisions. As with remote surgery, the surgeon operates on
a virtual image. The manipulation of instruments by the surgeon or
assistants can be direct or via virtual environments. In the latter case, a
robot reproduces the movements of humans using virtual instruments. The
precision of the operation may be augmented by data/images superimposed
on the virtual patient. In this manner the surgeon's abilities are enhanced.

Surgical practice, particularly in orthopedics, presents excellent

opportunities for robotic and computer-based technologies to improve
clinical techniques. Procedures such as total joint replacements are
performed in large volumes and at significant cost. The clinical success of
these procedures is very dependent on the proper placement and fit of the
implants within bony structures. Important contributions to surgical
planning and execution can be made by surgical robots and pre-operative
planners that utilize computer simulations. Use of robotic assistants
significantly augments the skill of the surgeon.

3.2.1.3 Planning and Simulation of Procedures before Surgery

Virtual environment technology can also be used to improve the way

surgeons plan procedures before surgery. When used to simulate a
procedure on a particular patient, the technology can be used to integrate
the information provided by diagnostic sensors into a realistic model of the
actual environment in which the surgeon will perform the proposed
procedure . The realistic model or surgical simulator "must have accurate
detail and must be highly interactive. Specifically, the image must be
anatomically precise and the organs must have natural properties such as
the ability to change shape with pressure and to behave appropriately in
gravity. All the body parts represented must be able to be manipulated by
grasping, clamping, or cutting, and they must be able to bleed or leak fluids

49
Virtual environments can make a critical contribution to the planning of a
surgical procedure (see Table 2). For example, "Netra has been used for
various precision, computer-assisted surgical procedures. Neurosurgeons
use Netra to plan precision biopsies, laser-guided tumor resections, surgery
for Parkinson's Disease and other motor disorders, and surgical
implantation of electrode arrays for epilepsy. What is unique with this
system is its user interface. Users manipulate objects, such as a doll's head,
to cause movement of the virtual image on the monitor.
Table 3.2 .Applications for Planning and Simulation of Procedures
Before Surgery
Technique Examples Who/Where
Plastic surgical
Virtual reality face Dr. Joseph Rosen,
procedure and
model with deformable Dartmouth University
demonstration of final
skin Medical Center
outcome
Tendon transplant
surgery and walking
Virtual leg model Dr. Scott Delp
the repaired leg to
predict consequences
Creating 3-D images Cranio-facial Dr. Altobelli, Brigham
from a CT scan dysostosis repair Women's Hospital
Biopsies, laser-guided
tumor resections,
Netra system, used for
surgery for Parkinson's University of Virginia,
various precision
disease and other motor Department of
computer-assisted
disorders, surgical Neurosurgery
surgical procedures
implants of electrode
arrays for epilepsy

Simulators are being developed for all types of surgery. Many of them are
used for planning particular procedures. Dr. Altobelli's (Brigham Women's
Hospital) system "creates 3-D images from the CT scan of a child with
bony deformities of the face (cranio-facial dysostosis); using the model
created from the CT scan, the bones can be correctly rearranged to
symmetrically match the normal side of the face." The procedure can be
practiced repeatedly .

Some of the simulations designed for planning a procedure also include a

predictive component. Data that could be used to correct a condition is

50
introduced into the model and the results of the proposed actions are
calculated and visualized. For example, Dr. Joseph Rosen's (Dartmouth
University Medical Center)

Virtual reality model of a face with deformable skin...allows the practicing

of a plastic surgical procedure and demonstrates the final outcome. Another
example virtual model of a lower leg upon which he can practice a tendon
transplant operation and then 'walk' the leg to predict the short and long
term consequences of the surgery.

An application allowing evaluation of the probable results of a procedure is

being developed by the Fraunhofer Institute for Industrial Engineering and
the Orthopaedic University Clinic Heidelberg. They have "developed an
application for the planning of osteotomy operations. The surgeon, with the
aid of tracked shutter-glasses and a 6D input device, is able to view and
rotate the femur and the hip joint." Using a simulated X-ray of the bones,
the medical practitioner can determine the angle, allow the computer to
perform the surgery, and view the simulated results on the screen .
Planning for surgery is always important. With computer-assisted surgical
planning, an exact picture can be drafted "of the relative positions of the
cartilages, the abrasion of the cartilage and the position of the femur in the
hip joint, [to help] determine the alteration parameters. The planning of an
osteotomy can be optimized by using a 3D image because the operator is
more able to evaluate the result. An increase in the rate of successful
operations is conceivable". In the future, the application should serve in the
planning of patient-specific osteotomies requiring tomographic data from
the relevant bones and cartilage

Simulation techniques for improved preoperative planning are of value for

orthopedic surgery with or without a robot. It is

Useful for a surgeon to realistically simulate surgery beforehand to help

determine what implant size to use* and what would be its optimal
position. Existing planners *permit the surgeon to template the implant
based upon 3D geometry,

the problems:

51
  don't give indication of the consequences of the proposed surgery
on the initial stability of the system,
 the presence of implant-bone interface gaps, and the changes in the
mechanical environment that are induced in the bone. The inclusion
of biomechanical simulations would permit the surgeon to make
appropriate changes in the initial surgical a plan,
 changing such parameters as the implant placement, specifics of the
bone preparation and type and size of implant.
 Without a robotic tool, however, there is no method for a surgeon to
accurately implement a preoperative plan. For example, the
simulation may help indicate an
 'Optimal' bone cavity shape and implant location, but the surgeon
will be unable to accurately perform this plan without a robotic
device. In this manner, surgical robots actually improve the clinical
usefulness of realistic surgical simulations

The predictive element is important not only for the medical team, but also
for the patient's family. It can serve as a model on which to base informed
consent of the patient and his or her family . Further, these simulation
applications could be used for medical education and training.

3.2.2 Surgical Training

The use of computers in medical schools is increasing. Table 3.3 lists

some examples of applications of virtual environments and related
technologies for surgical training.

In medical research, there is a shortage of cadavers; for students, being

able to summon a detailed, lifelike computer image of a human body is
a workable replacement. To improve training, companies are developing
3-D computer simulations of medical and surgical procedures.
According to Jon Merrill, "these 3-D simulations allow rather more
realistic training than do cadavers... . If a trainee pinches a nerve or
slices through a blood vessel in a cadaver, nothing happens. Dead tissue
is usually harder, color is changed, and arteries no longer pulsate. Once
something is cut in a cadaver, it cannot be reattached. But in digital
format, procedures can be repeated ad infinitum and stored for later

52
 group analysis. Some organs can also be made transparent, 'crisis' drills
can be created, and various types of organs can be modeled"

A system built at Talisman Dynamics, Inc. simulates the rather rare

open cholecystectomy procedure. Because the laparoscopic procedure is
being addressed by a variety of applications for medical training,
Talisman felt that a simulation of the open procedure would lend itself
to an overview of the abdominal anatomy in 3-D context that could be
useful in anatomical education. Simulating the open procedure allowed
the developers "to simulate a large number of different tools and
interactions, and to provide a comprehensive spatial context
Table 3.3 Applications for surgical Training
Technique Examples Who/Where
The virtual abdomen (liver
Virtual reality laparoscopic
and gall bladder) are
surgery simulator, consisting
graphically displayed upon
of a torso into which the
the video monitor, and the Woods and D. Hon
handles of laparoscopic
apprentice surgeon practices
instruments are mounted and
specific laparoscopic
providing force feedback
procedures.
Allows the trainee to guide a
balloon catheter through a
Heart catheterization hollow guiding wire to the
High Techsplantations
simulation including obstruction, inflate the
Inc., Rockville, MD
feedback balloon to expand the artery,
and restore regular blood
flow.
Created for the immersive, Richard M. Satava,
traditional helmet-mounted Advanced Research
Virtual abdomen
display (HMD) and Project Agency,
DatagloveTM. Arlington, VA
Will lead to a virtual reality MusculoGraphics, Inc.,
Limb trauma simulator
environment. Evanston, IL
Simulating surgery complete
Simulates surgery on the Georgia Institute of
with feedback on the force
human eye. Technology, Atlanta
being exerted

The following are examples of additional issues being addressed by

simulators recently or currently under development:

53
 A limb trauma simulator is being developed and is expected to lead
to a virtual reality environment .

 Georgia Institute of Technology in Atlanta is trying to simulate

surgery on the human eye, complete with feedback on the force
being exerted.

 The National Institute for Cancer Research in Genoa, Italy, has

developed a virtual reality microsurgical simulator for surgeon
training. They want to create a microsurgical training simulator that
simulates the suturing of two parts of a vessel under a stereo
microscope.

 The National Cancer Center of Tokyo has developed a Surgical

Simulation Support System. The surgical procedure simulated is a
neurosurgical operation in which a neoplasm of the brain is resected
without photomicroscopy

 Researchers at the Ohio State University Hospital, Immersion

Corporation, and the Ohio Supercomputer Center are collaborating
"to create and test a virtual simulator for training residents in the use
of regional anesthesiology. Specific issues and difficulties of the
epidural technique were used to develop a pilot system. Limitations
of physical models such as mannequins include lack of patient
variance, inaccurate representation of biological tissue, and physical
wear from repeated use.

 "Triage is a protocol to assess patient conditions and to decide on

medical treatment in mass casualty situations. Education and training
on triage protocols can be facilitated with computer-based training
facilities, like interactive video. [Virtual environment] training and
simulation systems can give the human an experience which is near
to reality... . In a [virtual environment] training system, mass
casualty triage in combat situations can be simulated. There is,
however, some more research required towards deformation
modeling and real-time database management. Present display
devices have a resolution in terms of image size that is critical to
medical applications.

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 3.3 Benefit of the virtual environment systems returning to health
care

Virtual environments and related technologies add value to health care

in the areas of cost savings, improved services, and savings in material
resources.
Table 3.4 summarizes examples of value added in these three areas.

Value
Examples
Added
Trauma units in emergency rooms could improve
operating efficiency and reduce costs by using
Cost savings telepresence. Doing so would conserve resources by
limiting the need for part-time specialists to be
physically present in trauma units.
Simulations allow surgeons to develop new techniques, to
practice unfamiliar techniques, and to predict results of
particular surgical procedures.
The success of joint replacement depends on the proper
placement and fit of implants within bony structures.
Surgical robots and preoperative planners using computer
Improved
simulations can improve surgical techniques and
services
accuracy.
Advantages offered by telepresence systems include
enhancing task performance in remote manipulation;
allowing controlled application of extremely large or
small forces; improving operator perception of the task;
and facilitating manipulation in hazardous environments.
Savings in
The use of simulators saves precious resources such as
material
cadavers and animals.
resources

3.4 The Researcher View:

55
After in-depth study of the majority of VR application in healthcare and
surgical domain and found that there are some problems in these
applications will be explained as follows:

Many of the current virtual environment applications in health care have

problems that limit their effectiveness. Some of these limitations are due
to the state of the art of the supporting technologies.

 As noted earlier, the sense of smell in virtual environment systems

has been largely ignored. Smells are extremely important. Not only
do they help distinguish specific substances, but also they give a
sense of reality to a situation. The absence of odor is a serious
limitation of current telepresence and training systems.

 Another major research problem relates to overlaying ultrasound

images on live video that is then viewed in a head-mounted device
application. The research issue to be addressed is the alignment of
images in real time .

 The senses of vision and touch are the two main feedback
mechanisms used by surgeons when performing a surgical
procedure. Improved cameras, HDTV, head mounted displays, and
stereoscopes have advanced the sensing and displaying of vision;
however, there have been few developments in the area of tactile
feedback. The ability to feel tissue is a valuable tool. Procedures that
require palpitation, such as artery localization and tumor detection,
are extremely difficult when the only form of haptic exploration is in
the form of forces transmitted through long, clumsy instruments. The
ability to remotely sense small scale shape information and feel
forces that mesh with natural hand motions would greatly improve
the performance of minimally invasive surgery and bring a greater
sense of realism to virtual trainers"

 According to experiments conducted by the British Defense

Research Agency virtual reality can make you sick [This confirms]
what some users of [virtual reality] headsets have long suspected.
that 89 of 146 otherwise healthy adults suffered temporary nausea,
dizziness, or impaired vision after using a [virtual reality] helmet-

56
 mounted display (HMD) for just 20 minutes. Eight became so
nauseated they could not finish the 20-minute period First, [virtual
reality] systems usually have a lag time between when the user
moves and when the display is updated; users, accustomed to this
lag, may become confused when they take the helmet off. Moreover,
[virtual reality] creates an illusion of three dimensions, even though
the screen actually remains at a fixed distance from a wearer's eye.
This may disrupt depth perception later.

Virtual reality systems used for interfacing to "training equipment

requires the user to be isolated from the real world and surrounded by
the virtual world generated by the computer. This is normally achieved
using a head mounted display...One of the challenges for a virtual
environment is to allow the user to move freely between the virtual and
the real worlds.

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