This Visionary VR Surgical Simulation Could Reduce Doctors’ Radiation Risk

August 8, 2019 Kimberly Holland

Training to be a surgeon is hard—no surprise there. But should medical training also come with a significant risk of physical harm? Urologists, for instance, are exposed to high levels of radiation while performing even minimally invasive procedures such as percutaneous nephrolithotomy (PCNL), a process for removing large kidney stones.

In both training and the actual operation, radiation from the X-ray machine guiding surgeons can have a cumulative effect, and urologists have to monitor their total exposure rates yearly. They can, and often do, reach the upper limits, which constrains their ability to work and makes training other surgeons difficult.

To address these concerns, Ben Sainsbury leveraged his career experience in gaming and virtual reality (VR) to improve urologists’ techniques and learn from others. Sainsbury and his partner, urologist Dr. Rajiv Singal, founded Marion Surgical. As members of the Autodesk Residency Program, Marion Surgical works out of the Autodesk Technology Centre in Toronto to create a surgical-simulation platform using augmented reality (AR), VR, and haptic technology for surgeons and residents to practice PCNL in realistic virtual operating rooms.

“In the past, a lot of medical schools used the method of ‘see one, do one’ and get a good score on a test,” Sainsbury says. “So if you do well on a test, then your supervisor says, ‘You did it just like me.’ You were certified. But that’s the old way. This new paradigm shift in medical education moves toward competency-based education, which gives a surgeon more time to practice the real surgery rather than having to extend a residency because they’re not getting enough OR [operating room] time.”

The tools typically used to teach PCNL procedures often create their own challenges, and medical-device companies and surgical centers sometimes operate on pigs to mimic the feel and force needed to perform the surgery on a human. And that can get pretty messy.

Using VR would sidestep these issues, but the main goal is to speed up training time and improve training quality for more successful surgeries with fewer errors. The program also provides feedback to help surgeons learn from the simulation. Surgeons receive a score, as well as a real-time readout of how well they did. As surgeons improve, their scores increase.

“Urologists are competitive, so when we do tests at a trade show, they want to have a higher score,” Sainsbury says. “Urologists who grew up gaming really get it.”

An “in-game” still image of the operating room in Marion Surgical’s VR surgery-training environment. Courtesy of Marion Surgical.

An in-game still image of the operating table in Marion Surgical’s VR surgery-training environment. Courtesy of Marion Surgical.

Another view from an in-game still image of the operating table in Marion Surgical’s VR surgery-training environment. Courtesy of Marion Surgical.

Another view from an in-game still image of the operating table in Marion Surgical’s VR surgery-training environment. Courtesy of Marion Surgical.

Statistics from a training session in Marion Surgical’s VR surgery simulator. Courtesy of Marion Surgical.

Other surgeons, regardless of their gaming history, also understand the value of this type of tool. The almost-instant feedback acts as both a challenge and a teacher.

“One of the things you’re trying to learn to do is be really precise when you puncture so you only puncture once,” Sainsbury says. “Getting lots of holes in your kidneys is bad. If you puncture the kidneys so many times, you risk all of the dye that’s used to fill your kidney [to see the stones on an X-ray] all of a sudden leaking out. Then it’s like having a snowstorm in a flight simulation. You just have a messy blob.”

Other elements that determine a surgeon’s score include the number of sticks you need to get to the kidney—“1 being good and anything more lowering your score,” Sainsbury says—and how close you are to the ideal angle, the forces you use, and how many times you need the X-ray imaging. Damaging force or simulated bleeding lowers the score.

Sainsbury says one of the benefits of a platform like the VR Surgical Simulator is that educators can use it to train surgeons on difficult cases or scenarios they may not encounter frequently but should still know how to handle. Sainsbury and his team regularly update their platform to improve handling and make the experience more realistic.

surgical simulation Dr. Jason Y. Lee (right), program director of the University of Toronto’s Urology Residency Training Program
Dr. Jason Y. Lee (right), program director of the University of Toronto’s Urology Residency Training Program, leads a workshop on the VR surgical simulation at Marion Surgical’s location in the Autodesk Technology Centre. Courtesy of Marion Surgical.

“We’ve got a real-patient-data pipeline, so we’re able to get complex cases from surgeons and add them to our system ahead of time,” he says. “You can do a teaching moment on some challenging case that you had.”

In time, Sainsbury says the data they’ve collected could be useful for hospitals and surgeons to recognize more efficient ways to train doctors. It might even reduce mistakes and improve recovery time.

“We’ve taken all that data and compared expert versus nonexpert users, like cohorts of different surgeons, to see how residents stack up to experts,” he says. “The system is able to tell expert versus nonexpert based on a tool patch. Downstream, we’ll be able to recognize that the surgeons at one institution have higher scores compared to another.” That could be a way for doctors to learn from one another and more broadly improve the practice.

With help from the shop staff at the Technology Centre in Toronto, Marion Surgical uses a suite of Autodesk products and technology to 3D print different iterations of its hardware. Being in the Residency Program lets Marion Surgical quickly and efficiently generate new parts, meaning that Singal, who travels internationally to train doctors, will soon be able to leave VR devices with surgeons and remotely train them around the world.

surgical simulation marion cofounder dr. rajiv singal
Marion Surgical co-founder and urologist Dr. Rajiv Singal shown within the VR simulation. Courtesy of Marion Surgical.

“Rajiv does a lot of teaching of surgeons in developing countries,” Sainsbury says. “Part of the solution is taking one of our units over to Africa and leaving it behind so that he can continue mentoring from Canada. You can put on the headset, and Rajiv can step in and supervise inside the virtual OR and make comments.”

Sainsbury says now that they’ve fine-tuned and completed many iterations of this kidney-stone-surgery training platform, they’re looking to expand to other minimally invasive procedures for which traditional hands-on training is difficult and time consuming. That’s where VR surgical simulation could make the most difference.

“For the next operation, we’re removing scar tissue in the arteries between the heart and lungs,” he says. “That’s a very complex procedure that’s hard to train, but it actually improves mortality rates. With a combination of pills and training, we’re reducing mortality from about 20%–30% to about 2%.”

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