The Use of Virtual Reality in Surgical Training: Implications for Education, Patient Safety, and Global Health Equity

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper is quite interesting. The key points I would highlight are the followings:

- Virtual Reality in surgical training offers advantages such as increased exposure to surgical techniques, improved patient safety outcomes and better learning experiences through realistic scenarios and feedback.

- Challenges to the implementation of VR in surgical training include initial financial costs, disparities in internet access across global regions and the need to create realistic tissue models. On the other hand, VR has the potential to fill gaps in the quality of education and provide training opportunities in countries with less access to resources, where most graduates leave the country and do not return.

- Applications used for VR training can address the shortage of qualified surgeons in low- and middle-income countries, improve surgical care and eliminate the need for long-distance travel, as well as address situations such as COVID-19. Integrating VR into medical training can improve learning and provide more accessible and sustainable educational options.

- Perhaps it would be desirable to mention the difficulties of creating mathematical models.

However there are some comments I would like to add in order to improve the quality of the paper:

- Please carefully review the text , because I miss references in several places.

- The thread is a bit weird: First authors talk about what clinical education is like, what virtual reality is and how great it is (saying it's cheap and very realistic and there are studies that show significant improvements over students who only use traditional methods like textbooks).  They go on to talk about how it has helped during the pandemic and then suddenly moves on to what education is like in countries where school leavers leave and don't come back disadvantaged (there's a lot of jumping between parts). Then they talk about how integrating VR can help and then about a training programme in 1996 that has nothing to do with the previous thread. Then they go on to say that it's not really worth learning, that the models are not realistic and not worth it, and that the headsets are very expensive. In the next paragraph (about resource problems) authors say that it is cheaper to train with VR than in the traditional way and that unlike books that become obsolete, VR mitigates all the problems of sustainability of these methods. Suddenly they go on to say that headsets are now very cheap. And the conclusion doesn't sum up everything seen above.

- I don't really see where the actual ethics part is and it seems to talk about all medical training but all the examples they give are from laparoscopy. Please add more ethics part and other examples during the text.

- There is no mention of the difficulties of doing the simulations or of access to existing tools or solutions other than to talk about how expensive they were... according to past studies; and of creating realistic models.

- Authors speak only of spring mass deformations when simulators now use models based on tetrahedral meshes. The models are based on particle position and shape matching by sections, to allow not only the cutting of the meshes according to the voxels (in which the tetrahedron is subdivided) but also to be able to suture with slide constraints according to the entry points and exits of the simulated wire, with the tissue mesh. 

- They say that there are no devices with haptic feedback that are used without nuancing the robots such as davinci, Hugo, etc, where the robot itself has total feedback.

Comments on the Quality of English Language

In general the paper is well written but a final revision of the English used would be desirable.

Author Response

Dear Reviewer,

Thank you for your comments. Please find below the response to the individual remarks:

1. Please carefully review the text , because I miss references in several places.

 

Thank you for the comment, citations were added to areas where the authors believe are pertinent. New sections added to the manuscript were also properly cited.

 

1. The thread is a bit weird: First authors talk about what clinical education is like, what virtual reality is and how great it is (saying it's cheap and very realistic and there are studies that show significant improvements over students who only use traditional methods like textbooks).  They go on to talk about how it has helped during the pandemic and then suddenly moves on to what education is like in countries where school leavers leave and don't come back disadvantaged (there's a lot of jumping between parts). Then they talk about how integrating VR can help and then about a training programme in 1996 that has nothing to do with the previous thread. Then they go on to say that it's not really worth learning, that the models are not realistic and not worth it, and that the headsets are very expensive. In the next paragraph (about resource problems) authors say that it is cheaper to train with VR than in the traditional way and that unlike books that become obsolete, VR mitigates all the problems of sustainability of these methods. Suddenly they go on to say that headsets are now very cheap. And the conclusion doesn't sum up everything seen above.

 

The authors agree that the text’s flow was unideal. Topic sentences and conclusions were added to each section of the manuscript to improve with flow. We also reorganized  sections to improve clarity (for example, separating financial barriers from internet access barriers mitigating the implementation of VR). We also added to the conclusion to showcase the points highlighted in the review.

 

1. I don't really see where the actual ethics part is and it seems to talk about all medical training but all the examples they give are from laparoscopy. Please add more ethics part and other examples during the text.

 

Thank you for the remark. The authors re-phrased the manuscript as a review of implications of virtual reality in the context of surgical education, exposing how it could affect different aspects of local and global healthcare. We also included examples of different surgical specialties where VR has shown improvements in surgical technique acquisition and trainee’s confidence. We have also added how

 

1. There is no mention of the difficulties of doing the simulations or of access to existing tools or solutions other than to talk about how expensive they were... according to past studies; and of creating realistic models.

Thank you for the comment. The authors included a section devoted to the issues surrounding using virtual reality – both from a learning curve perspective as well as the symptoms that learners may experience while utilizing the technology. We have also added to our discussion of the extent to which virtual reality has been able to achieve fidelity in modeling of real surgical interventions.

 

 

1. Authors speak only of spring mass deformations when simulators now use models based on tetrahedral meshes. The models are based on particle position and shape matching by sections, to allow not only the cutting of the meshes according to the voxels (in which the tetrahedron is subdivided) but also to be able to suture with slide constraints according to the entry points and exits of the simulated wire, with the tissue mesh. They say that there are no devices with haptic feedback that are used without nuancing the robots such as davinci, Hugo, etc, where the robot itself has total feedback.

 

We appreciate the remark. We have included new developments in modeling in the appropriate section of the text alongside an applicability of said developments.

 

Reviewer 2 Report

Comments and Suggestions for Authors

1.VR is a good technology that allows people to have a real-world experience, but as a scientific paper, what the authors describe is obvious. Authors need to increase the depth and breadth of the discussion and increase the number of references.
2.The author mentions the advantages and disadvantages of VR, which are far from enough. The authors should also discuss the future direction of the field, including possible ways to overcome shortcomings, etc.
3.Each subheading of the article needs to be changed, and the title needs to clearly indicate the content of each section, such as "Does it really simulate medical care?", what it refers to？More clarity is needed in the subtitle.

Comments on the Quality of English Language

Moderate editing of English language required

Author Response

Dear review,

 

Thank you for the remarks. Please find below an answer to each comment.

 

• VR is a good technology that allows people to have a real world experience, but as a scientific paper, what the authors describe is obvious. Authors need to increase the depth and breadth of the discussion and increase the number of references.

Thank you for the comment. We have increased the depth of the discussion with new sections as well as more examples pertinent to the role of virtual reality in surgical education. We have also added references to areas of the text that were needed.

 

• The author mentions the advantages and disadvantages of VR, which are far from enough. The authors should also discuss the future direction of the field, including possible ways to overcome shortcomings, etc.

Thank you for the remark. We have included a future directions section where we point areas of virtual reality development.

 

• Each subheading of the article needs to be changed, and the title needs to clearly indicate the content of each section, such as "Does it really simulate medical care?", what it refers to？More clarity is needed in the subtitle.

The authors have edited the subtitles to better clarify the content of the sections they belong to.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thanks for the efforts done to improve the quality of the paper. Although the impact of the publication is not quite high it provides good food for thought and discussion about the implications of using VR in surgical education. Perhaps more details could be provided and extensive discussions, but as said before, it could be a good start point

Comments on the Quality of English Language  

In general the paper is well written

Author Response

Dear reviewer,

Thank you for the remarks. We have expanded the future directions section to provide an understanding of the next steps of virtual reality. 

Reviewer 2 Report

Comments and Suggestions for Authors

1.The addition of a discussion section is not only necessary, but also provides a more comprehensive and in-depth analysis and explanation. In addition, the number of references cited by the authors met the general criteria for publication, which further demonstrated the scientific and credible nature of the study.
2.The exciting vision of the future should also include solutions to the problems that may arise in the future, which should be added to the discussion section, which not only improves our foresight for the future, but also helps us to make informed decisions in the face of challenges and difficulties. This section should have been added to the discussion section, and it seems a bit short as a subsection.
3.It's good that the author has made improvements to the language expression. This makes the sentence clearer, smoother, and easier for the reader to understand the main idea being conveyed.

Comments on the Quality of English Language

It's good that the author has made improvements to the language expression. This makes the sentence clearer, smoother, and easier for the reader to understand the main idea being conveyed.

Author Response

Dear reviewer,

Thank you so much for the comments. We appreciate the suggestion and we have expanded our future directions section with avenues to improve the use of Virtual reality in surgical training, capturing its potential in practical competency evaluation, surgical planning, and intra-operative inter-member communications.