Anatomage - the virtual dissection tool and its uses: A narrative review

Abstract

Advancement in technology has given students and institutes an educational, interactive, and diagnostic aid with virtual reality functionality known as the Anatomage table. This review analyses the various spheres of the medical field where the 3D virtual tool is being used and assesses its acceptability, convenience, and practical application. A search for relevant studies in various databases namely Pubmed, Embase, Wiley Library, and Google Scholar was performed, and the data was compiled to understand the use of the Anatomage table. The search yielded a total of 24 studies that focused on the use of the Anatomage table. Eleven articles focused on using Anatomage as a learning tool and 13 described the perception of the Table. Anatomage table offers an excellent tool for learning anatomy by virtual dissection. The tool is not only used as a teaching aid, but also as a diagnostic and planning tool in residency programs. Adding the tool as an educational aid boosts the existing curriculum and helps to counter the challenges with cadaveric dissection. The equipment cost and its maintenance charges may be a deciding factor for the underutilization of the tool in developing countries.

Introduction

Recent advancement in the field of medical education is the 3-D (three-dimensional) educational and diagnostic tool developed by Anatomage, California based 3D medical technology company. Christened Anatomage Table, practically shows a digital life-sized human cadaver and helps in performing virtual dissection.[1] Furthermore, the tool has been used successfully in maxillofacial surgery and radiological courses.[2,3,4] It is known to increase the perception of students of anatomical structures and their identification.[5] The larger viewpoint helps in having a hawk-eye view of the body, useful in forensic analysis and even in archaeological settings.[6]

Residency programs in surgical specialties lay a special emphasis on cadaveric anatomy before dealing with the active cases in the operation theatre. Historically, cadavers have been the mainstay of learning the anatomy of the bones and the structures related to them. However, there is a scarcity of cadavers in many of the institutions in this pandemic scenario. Moreover, cadavers once utilized cannot be reused for dissection. Anatomage Table with its full touch screen provides access to the parts and performs virtual dissection multiple times. Digital imaging and communications in medicine (DICOM) data from magnetic resonance imaging (MRI) and computed tomography (CT) scans can be used to visualize in three planes wherein one can dissect or redo any cut or any mistake which could be detrimental while working directly on a cadaver.

Currently, in literature, there exist lacunae in knowledge in the field of virtual dissection and its uses. The purpose of the present study was to evaluate whether sufficient evidence exists to support the use of anatomage in the field of medical education and to elaborate on its uses.

Methods

Search methodology

The review was conducted over a period of 3 months (April 2021 to May 2021). The search was conducted in four databases: Pubmed, Embase, Wiley Library, and Google Scholar using the search terms “Anatomage Table”, “Virtual anatomy”, “Virtual dissection”, “Residency Program”, “Residency training”, “Undergraduate training”, “diagnostic” using boolean operators “AND” and “OR”. Bibliographies of selected articles and journals were looked for possible additional articles that were not identified. Microsoft Excel sheet was used to compile the data collected.

Eligibility criteria

All original studies were included if Anatomage was used (a) for assessing student perception or enhancing learning, (b) as a diagnostic aid, and (c) for planning surgeries. The exclusion criteria included non-English language studies, case reports, case series, reviews, letters to the editor, biomechanical studies, animal studies, and expert opinions. Only articles published after 2010 were included.

Data extraction

The roles of all included authors were well defined. Authors first and second were responsible for the initial search and the preparation of the initial list. Data extraction and tabulation were performed by the third and fourth authors. Any disparity among the investigators was thoroughly discussed and the final consensus was made by the fifth senior author. Since the study design was descriptive in nature no statistical analysis was used.

Results

The search flow diagram (PRISMA) is shown in [Figure 1]. The search yielded a total of 1642 studies and 1 article was selected through additional methods. After excluding duplicates 38 articles remained. After removing irrelevant studies, 24 articles were finalized. Of these articles, 1 assessed the use of the Anatomage table in Plastic surgery, 3 in Nursing, and 3 in Maxillofacial surgery. Eleven articles focus on learning using the Anatomage table and 13 focus on the perception of the tool. The study characteristics are listed in [Table 1].

Figure 1.

Search flow diagram (PRISMA)

Table 1.

Study characteristics of studies included

Author	Study design	Task/Test	Participants	Conclusion
Afsharpour et al.[7]	Prospective	Periods and lecture evaluation scores	cadaveric dissection- (n=352) vs anatomical model study (n-350) vs virtual dissection table (n=393)	Significant improvement by students using virtual tables in lab exam score
Anand et al.[8]	Prospective study	Pre-test and post-test questionnaire	122 students (Anatomage table vs traditional dissection)	No significant difference in the two groups 79%- believed that Anatomage tables enhanced classroom experience
Bharati et al.[9]	Cross-sectional	Questionnaire	150 students	95-95% - preferred Anatomage over test books and cadaveric dissection
Bianchi et al.[10]	Prospective cohort study	40 Questionnaire (MCQ)	130 nursing students Anatomage use vs No anatomage use	Significant improvement in exam scores with Anatomage use
Boscolo-Berto et al.[11]	Randomized controlled didactical trial	Pre-test and post-test survey	23 students Virtual (n=10) vs textbook (n=13)	Virtual dissection combined with gross cadaveric dissection showed significant improvement in the learning
Brown et al.[12]	Cross-sectional study	Questionnaire	511 students	78%- said Anatomage tables made learning more engaging. 63%- said it improved 3D anatomy understanding
Brucoli et al.[2]	Prospective observational	Questionnaire (CT images vs Anatomage Table)	10 MS residents	87% -believe Anatomage provides better clarity with respect to CT scan
Custer et al.[13]	Qualitative, single-site case study	Review of classroom activities, focus group sessions, and interviews	17 medical imaging students	96%- gave positive response to utilization of Anatomage table in their education
Darras et al.[14]	Prospective observational	Evidence-informed survey	292 students	78.7%-opined virtual dissection enhanced understanding of the cadaveric anatomy
Fyfe et al.[15]	Cross-sectional	Online surveys	326 students and 22 tutors	Students- Anatomage was a good tool for visualizing organ structure and better due to 3D effects Tutors- frustrated due to technical glitches
Fyfe et al.[16]	Cohort study	Questionnaire-based	657 students	Virtual learning offered a better 3D understanding of anatomy and allowed cross-sectional anatomy learning. Use of touch screen technology requires better curriculum design and training
Gonzalez-Sola et al.[17]	Cross-sectional	15- minute orientation class, 30-minute cadaveric dissection, 30-minute Anatomage table demonstration and other educational tools, pretest and post-test questionnaires	100 students	98% of students' anatomical knowledge increased 84% of students developed an interest in graduate degrees in STEM and allied health fields 19% - believed cadaveric dissection was the strongest educational tool
Gross et al.[18]	Prospective, observational study	Student comments	122 students	Overwhelming positive response with good acceptance of table by students
Kar et al.[19]	Prospective observational	Pre- and Post-course questionnaire	44 OTD and 48 PAS students	65-70% - believed Anatomage table helped in better understanding of structure identification due to the high-resolution screen and is a good supplementary tool
Kačoka et al.[5]	Cross-sectional	Student opinion	200 students Virtual tools vs Classroom tools	Improved visualization and memorization of different structures by using virtual tools
Martín et al.[20]	Cross-sectional	Survey	32 students	46.9%-found cadaveric dissection very useful 6.2%-found the Anatomage very useful
Paech et al.[3]	Cohort study	Questionnaire (MCQ)	238 students Radiology seminars (n=90) vs Anatomage table (n=98) vs Seminar and Table (n=50)	Radiological anatomy and virtual dissection improved gross anatomy knowledge
Rosario et al.[21]	Cohort study	Questionnaire (post-test)	100 students Cadaveric dissection vs Anatomage table	81% - considered undergraduate anatomy and physiology learning lacking without Anatomage
Silveira et al.[22]	Cross-sectional study	Questionnaire (post-test)	41 students Practical classes vs digital anatomy classes	Median scores significantly higher with the digital anatomy table which offers a better understanding
Stecco et al.[4]	Retrospective	Evaluation	10 trauma patients (Radiology workstation vs Anatomage)	Inter-observer agreement >90% Qualitative data favoring 3D reconstruction tables over radiology workstations
Tenaw et al.[23]	Cross-sectional survey	Questionnaire-based	89 students	80.89% - agreed Anatomage is a valuable additional tool for learning human anatomy
Washmuth et al.[24]	Case study	Written and practical examination	25 students Cadaveric dissection vs Anatomage table	Added advantage of Anatomage table over cadaveric dissection with similar outcomes
Whited et al.[25]	Cohort study	Pretest and post-test on anatomy	17 NP	Clinically significant improvement in all areas except in the head-neck-eye-ear-throat section
Zingaretti et al.[26]	Cross-sectional	Questionnaire	115 PS residents	Majority- claimed decrease in theatrical and surgical time was detrimental Authors propose to use virtual aids for resident training

Footnote: 3D- Three Dimensional; CT- Computed Tomography; OTD- Occupational Therapy Doctorate; PAS- Physician Assistant Studies; STEM- Science, Technology, Engineering, and Mathematics; MCQ- Multiple choice questions; OTD- Occupational Therapy Doctorate; PAD- Physician Assistant Studies; PS- plastic surgery; NP- nurse practitioners; MS- Maxillofacial surgery

Discussion

The current review tries to narrate the various uses of virtual anatomy dissection tables (Anatomage table) in the field of medical education and as a diagnostic aid. This article does not intend to promote a particular provider but the technology which can change the way medical education is imparted. To the best of our knowledge, no review article exists on the use of the Anatomage table. Moreover, the need to understand newer technologies and incorporate them into the field of medical education is ever increasing.

The Anatomage table is a virtual dissection tool combining wherein the system shows real-life size full body gross anatomy with the help of an operating table.[6,27] The tool has modules such as real color cryosections of cadavers, quiz modules, histology, and even allows importing of CT or MRI DICOM data of individual patients. It even has a case library with an extensive collection of CT and MRI scans of various regions and prosections. The newer software update includes one male and one female full-body Caucasian cadaver and one male and one female full-body Asian cadaver.[27]

From, the review of the available literature the usage of the Anatomage table can be explained in various sub-headings.

Anatomage table as a teaching aid

Anatomage table offers a virtual dissection platform supplementing or even substituting cadavers. The real-life scale cadaver along with colorful cryosections, scanned data of real-time patients, quiz mode and prosection allows instructors to preach anatomy. The table offers male and female virtual anatomy, with an excellent rendering of the muscles, bones, nerves, and internal organs. Students can use the table for self-assessment or self-review using labeled structures and annotations. The various layers can be sliced or removed to enhance the user's interest.

Brown et al.[12] noted that 78% of students agreed/strongly agreed that the Anatomage tables made learning more engaging while 63% said it improved volumetric anatomy understanding. Bharati et al.[9] in 150 undergraduate students noted an increased preference for Anatomage over textbooks. Similarly, Boscolo-Berto et al.[11] noticed a significant improvement in the learning of medical graduates when virtual dissection was combined with gross cadaveric dissection. Moreover, Anand et al.[8] revealed that the Anatomage table provided a comparable learning experience to cadaveric dissection in neuroanatomy and noted that 79% of students believed the tool enhanced classroom experience. Kar et al.[19] incorporated Anatomage into the curriculum and found it to be beneficial for students and further noted 65% of the correspondents opining for supplementing the routine cadaveric dissection with virtual dissection. However few studies noticed that students preferred traditional cadaveric dissection to virtual platforms.[20] Fyfe et al.[16] noticed that the acceptance and utility of the Anatomage table increased with time, which reflects the time required for understanding and incorporating any new technology.

Introducing a new modality into a training curriculum needs a strict focus on its functionality and to interpret the perception from the audience or students that it caters. Fyfe et al.[15] in an online survey of 326 students and 22 tutors noted the students appreciated the Anatomage table for visualizing organ structure and its 3D perception by rotating images. However, they were not satisfied with the graphics. The tutors were frustrated with technical glitches and the issue of cost but thought of it as a good idea. Tenaw et al.[23] in their cross-sectional survey found that 80.89% of students were satisfied. Overall the authors found that the students or participants had a positive perception of introducing Anatomage as a supplement to teaching or learning cadaveric anatomy.[5,14,18]

Anatomage table in residency training

The CoViD 19 pandemic has brought over unprecedented changes in the field of medical education and the residency programs world over have faced unforeseen challenges. The availability of cadavers for dissection is limited and the volume of the surgeries has decreased. The Anatomage Table provides a unique opportunity for students and residents alike to refresh their anatomical knowledge and learn anatomy from the virtual tool.

Afsharpour et al.[7] noted a significant increase in lab exam scores by students using virtual tables without any improvement in lecture exam scores. Custer et al.[13] studied the use of virtual Anatomage table in educating medical imaging science students and noted that 96% of students gave a positive response to the utilization of Anatomage table in their education. Silveira et al.[22] evaluated students' perception of temporomandibular joint anatomy by using a digital anatomy table and noticed higher median scores of teaching strategy with Anatomage table. Paech et al.[3] evaluated the improvement in gross anatomy knowledge of medical students with the incorporation of cadaveric CT scans in virtual dissection tables and noted the average score of the group with access to both was significantly better than others. Similarly, Kažoka et al.[5] noticed improved visualization and memorization of different structures in students using Anatomage table with 3D tools. The overwhelming evidence suggests that the Anatomage table or likewise any virtual dissection tool would be of great use in residency training or training paramedical staff or undergraduate students.

Anatomage as a diagnostic aid

The functionalities of Anatomage offer a different proposition for treating doctors. One can easily utilize the DICOM images of the patient's CT scan and MRI for a larger scale depiction of the anatomy and use them as a diagnostic aid in viewing the complex patterns of fractures in situations like pelvi-acetabular trauma and intra-articular fractures.[28] Brucoli et al.[2] noted that 87% of the participants believed Anatomage provides better clarity with respect to a CT scan in pre-operative planning for maxillofacial surgery residents and young surgeons.

The table offers the ability to see structures in a 3D spatial plane wherein one can view the size, position, and relation of structures to one another. Understanding anatomy is easier for those specialties not routinely used to viewing radiological images. For radiologists, the table offers research opportunities and is probably used in multi-disciplinary meetings to explain the findings more clearly. Hasni et al.[29] utilized the table for 3D reconstruction of CT scans to improve the management and monitoring of COVID-19 patients.

Anatomage in surgical planning

Patient-specific CT scans can be rendered in real-time in the table and the number of resections or corrections needed can be calculated. Stecco et al.[4] found that the inter-observer agreement was above 90% with qualitative data favoring 3D reconstruction tables over radiology workstations in a study to assess the utility of virtual dissection tables in improving the diagnostic accuracy of maxillofacial CT scans of patients with Le Fort fractures. Ahmed et al.[30] used the Anatomage table for morphometric analysis of bone resection in anterior petrosectomy. It allows layer by layer removal of tissue, thus making explanation of surgical steps easier for young surgeons. It also has potential for use in meetings promoting interactive learning and delivery of innovative surgical techniques.

The software can be used for the transfer and learning process. The DICOM images can be interpreted by radiologists and students alike and are possible to study normal and pathological conditions such as case studies.

Overall, the authors found that the use of the Anatomage table has a positive effect in the field of medical education and training. It has no ethical issues like those faced in the acquisition of cadavers, is a patient safety learning tool, filters different structures without interference, and offers freedom of action and realistic rendering on a scale of 1:1. However, it does have weaknesses such as no pediatric anatomy is provided, is costly, access is restricted to a group of people at a time, has logistical issues and there is a need to update the software regularly. To the best of our knowledge, the current review is the only one to critically evaluate this new modality on the basis of available evidence.

The study has its limitations. First, it is a narrative review. One would ideally strive for a systematic review, but the current study offers an overview of the available literature, advantages, and disadvantages of this new technology for those willing to explore it. Second, even though the search was done in multiple databases some of the studies may have been missed.

Conclusion

Virtual dissection tools such as Anatomage table can be a boon to medical education and make the curriculum in residency and undergraduate programs more interesting. Utilizing the functionalities of the Anatomage table can assist physicians and surgeons by aiding in better understanding the radiological anatomy, planning surgeries, and also providing newer research prospects.

Ethical approval

No ethical approval was required for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.