School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP, UK.
Young Adult Hip Service, Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
Int Orthop. 2023 Mar;47(3):611-621. doi: 10.1007/s00264-022-05663-z. Epub 2023 Jan 16.
Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments to enhanced real-world environments. In the past two decades, XR-assisted surgery has seen an increase in its use and also in research and development. This scoping review aims to map out the historical trends in these technologies and their future prospects, with an emphasis on the reported outcomes and ethical considerations on the use of these technologies.
A systematic search of PubMed, Scopus, and Embase for literature related to XR-assisted surgery and telesurgery was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Primary studies, peer-reviewed articles that described procedures performed by surgeons on human subjects and cadavers, as well as studies describing general surgical education, were included. Non-surgical procedures, bedside procedures, veterinary procedures, procedures performed by medical students, and review articles were excluded. Studies were classified into the following categories: impact on surgery (pre-operative planning and intra-operative navigation/guidance), impact on the patient (pain and anxiety), and impact on the surgeon (surgical training and surgeon confidence).
One hundred and sixty-eight studies were included for analysis. Thirty-one studies investigated the use of XR for pre-operative planning concluded that virtual reality (VR) enhanced the surgeon's spatial awareness of important anatomical landmarks. This leads to shorter operating sessions and decreases surgical insult. Forty-nine studies explored the use of XR for intra-operative planning. They noted that augmented reality (AR) headsets highlight key landmarks, as well as important structures to avoid, which lowers the chance of accidental surgical trauma. Eleven studies investigated patients' pain and noted that VR is able to generate a meditative state. This is beneficial for patients, as it reduces the need for analgesics. Ten studies commented on patient anxiety, suggesting that VR is unsuccessful at altering patients' physiological parameters such as mean arterial blood pressure or cortisol levels. Sixty studies investigated surgical training whilst seven studies suggested that the use of XR-assisted technology increased surgeon confidence.
The growth of XR-assisted surgery is driven by advances in hardware and software. Whilst augmented virtuality and mixed reality are underexplored, the use of VR is growing especially in the fields of surgical training and pre-operative planning. Real-time intra-operative guidance is key for surgical precision, which is being supplemented with AR technology. XR-assisted surgery is likely to undertake a greater role in the near future, given the effect of COVID-19 limiting physical presence and the increasing complexity of surgical procedures.
扩展现实（XR）被定义为一系列技术，范围从纯粹的虚拟环境到增强的现实环境。在过去的二十年中，XR 辅助手术的使用以及研究和开发都有所增加。本范围综述旨在绘制这些技术的历史趋势及其未来前景，重点是报告的结果和使用这些技术的伦理考虑。
根据系统评价和荟萃分析扩展的首选报告项目（PRISMA-ScR）指南，对与 XR 辅助手术和远程手术相关的文献进行了 PubMed、Scopus 和 Embase 的系统搜索。纳入了主要研究、描述外科医生对人体和尸体进行的手术程序的同行评审文章，以及描述一般外科教育的研究。非手术程序、床边程序、兽医程序、医学生进行的程序和综述文章被排除在外。研究分为以下几类：对手术的影响（术前规划和术中导航/指导）、对患者的影响（疼痛和焦虑）以及对外科医生的影响（手术培训和外科医生信心）。
纳入了 168 项研究进行分析。31 项研究调查了 XR 在术前规划中的应用，得出结论认为虚拟现实（VR）增强了外科医生对重要解剖标志的空间意识。这导致手术时间缩短，手术损伤减少。49 项研究探讨了 XR 在术中规划中的应用。他们指出，增强现实（AR）头显突出了关键地标以及要避免的重要结构，从而降低了意外手术创伤的机会。11 项研究调查了患者的疼痛，并指出 VR 能够产生冥想状态。这对患者有益，因为它减少了对镇痛药的需求。10 项研究评论了患者的焦虑，表明 VR 无法改变患者的生理参数，如平均动脉血压或皮质醇水平。60 项研究调查了手术培训，而 7 项研究表明使用 XR 辅助技术增加了外科医生的信心。
XR 辅助手术的发展是由硬件和软件的进步推动的。虽然增强虚拟现实和混合现实的应用还不够广泛，但 VR 的应用越来越广泛，特别是在手术培训和术前规划领域。实时术中指导是手术精度的关键，正在通过 AR 技术得到补充。鉴于 COVID-19 限制了身体的存在，以及手术程序的日益复杂，XR 辅助手术在不久的将来可能会发挥更大的作用。
