Can virtual reality technology be considered as a part of the surgical care pathway?

Abstract

Introduction

Virtual reality (VR) is emerging as a new technology in the healthcare sector. It has been shown to enhance the patient’s experience and satisfaction in various settings. This review aims to give a brief description of the use of VR and establish validity of its applications to improve the patient’s pathway through surgery.

Methods

A literature search was conducted using the PubMed and Embase™ databases to identify fields in which VR technology has been trialled in relation to surgery. The search terms ‘virtual reality’ and ‘surgery’ were employed.

Results

Although benefits relating to VR use have been identified in mental health, obesity management, and physical and cognitive rehabilitation, those in surgery have been less well documented. There are, however, some important but limited benefits reported in managing surgery related stress and improving preoperative patient education as well as VR being an adjunct to some level of postoperative analgesia.

Conclusions

The current applications of VR in relation to surgical care fall into four main categories: preoperative education, supporting mental health, postoperative pain management, and pre and postoperative patient optimisation. Future studies and validation of VR applications should be carried out so the technology can be utilised throughout the entire patient pathway as VR surgical care bundles.

Introduction

An acceleration in digital healthcare translation is underway, fuelled in part more recently by the COVID-19 pandemic, including the broader introduction of virtual reality (VR) technology. VR technology enables users to be fully immersed in a simulated world with interactive visual, auditory and motor environments. It generates superimposed three-dimensional multimedia that can be controlled and displayed through computer, mobile devices or head-mounted displays.¹

In 2018, Cipresso et al conducted a network and cluster analysis of the utilisation of VR and augmented reality.² This showed an increase in the development of VR in many industrial and educational fields with the main peak of research in media and medicine.

VR use has shown enhanced educational properties in medical education (eg anatomy studies, communication, simulation-based decision making and skills acquisition).³ Additionally, VR has played an emerging role in providing patient centred services. It was reported to be a beneficial tool for patient education, improving mental health, controlling postoperative pain, physical therapy and rehabilitation.^4-6

Depending on the modality of control and display, VR can be non-immersive or immersive, with more development and research directed towards the latter. Many reports have shown the feasibility and safety of applying immersive VR in patient care with various propositions. The focus of this review is to provide an insight into some aspects of immersive VR and its impacts on a variety of patient centred surgical applications in addition to evaluating where the benefits of VR will be prominent in the surgical space of the future.

Methods

A literature search of papers published between 2010 and June 2021 was conducted using the PubMed and Embase™ databases in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines⁷ to identify fields in which VR technology has been trialled in relation to patients undergoing surgery. The search terms ‘virtual reality’ and ‘surgery’ were employed. Figure 1 summarises the study selection process. Relevant published reports that explored the use of immersive VR with patient centred applications were included in our review, which was based on a concept of developing a VR ecosystem for surgical patients. This concept aimed to provide patients with VR applications throughout their surgical pathway with the main purpose of easing and improving patient centred surgical care.

Figure 1 .

Flowchart of study selection

Results

Thirty papers were included in our review (Figure 1). On examining the different applications for VR in surgery, four main categories were identified in which patients can utilise this technology throughout the surgical pathway: preoperative education, mitigation of surgical anxiety, impact on pain management, and prehabilitation and rehabilitation applications.

Preoperative education

Patient education has evolved from simple leaflets and text-based information to more advanced VR information.⁸ Most surgeons and physicians share procedural information and findings with patients using text-based documentations and drawings, which are more focused towards medical documentations.⁹ These standard approaches can sometimes lead to cognitive overload with mixed messages and poor communications.¹⁰

VR can provide enhanced visual and auditory feedback to patients about their conditions. This has been reported to improve health knowledge and aid in decision making through a more informative and interactive model utilising reconstructed images, prepared three-dimensional models or simulated environments, from which patients will potentially have more opportunities to gain deeper insights into the steps of their procedure and the treatment options.¹¹

Favourable results were demonstrated by Pandrangi et al with the use of VR as a preoperative educational tool for patients undergoing aortic surgery for aneurysmal disease; 17 of 19 participants (89%) agreed that VR models of their surgical anatomy were useful, informative and more effective than conventional approaches.¹² Similar results were reported for patients receiving radiotherapy for breast, prostate, lung, rectal and endometrial cancer.^13,14

Mitigation of surgical anxiety

Anxiety around surgery is related to emotional fear in the preoperative setting, the perioperative journey and recovery.^15,16 Excessive preoperative anxiety has been linked to both physical and psychological states. This can result in longer recovery, and an increase in analgesia and anaesthetic requirement, as well as unfavourable emotional and behavioural outcomes.¹⁷ Standard interventions for preoperative anxiety can be categorised as either pharmacological or non-pharmacological (eg effective communication/education strategies).¹⁸

VR can reduce anxiety in many clinical and surgical settings.¹⁹ The rationale for using VR immersive technology is its ability to provide a simulated environment tailored to match specific aspects that cause fear in patients; alternatively, VR can take patients to a relaxing augmented reality that can divert patients’ thoughts from their fear.²⁰ This has already been shown to significantly reduce anxiety, acute and chronic pain, and wound healing times, with favourable outcomes in burns and complex pain issues.^21,22

Chan et al examined the utility of a VR headset to reduce anxiety before hysteroscopy in the form of a short video of a relaxing scenario.²³ There was a significant reduction in preoperative stress and discomfort levels, and 82% of the patients rated their experience as ‘good’ or ‘excellent’. Similar results have been noted for other gynaecological interventions.^24,25 In addition, Haisley et al described using VR in a randomised controlled trial as a tool to reduce anxiety in patients undergoing minimally invasive gastrointestinal surgery.²⁶ Although their results did not reach statistical significance, they acknowledged that their study was underpowered.

Impact on pain management

Preoperatively, VR is used as an information tool for patients to understand their procedure better. This improves their experience and satisfaction, and (in some cases) reduces analgesic requirement by decreasing the level of stress.²⁷ The use of VR as a preoperative tool to reduce pain has not been described frequently in patients undergoing abdominal surgery. Some reports have evaluated the application of VR in knee and spine interventions with favourable results in reducing pain intensity and discomfort after surgery.²⁸ These applications could also be tested in abdominal surgery with enhanced recovery protocols.

In patients undergoing colonoscopy with standard sedation, Veldhuijzen et al utilised VR glasses as a distraction tool for ten patients and compared outcomes with a control group of nine patients.²⁹ Their study showed no significant difference between the two groups in terms of pain or discomfort. The VR group reported their experience as ‘pleasant and distracting’.

The utility of VR as pain control after surgery has been described for a variety of minor and major surgical procedures. In a randomised study with 182 patients undergoing haemorrhoidectomy, Ding et al compared the use of VR distraction with standard pain medications during wound dressing and found that patients in the VR distraction group had significantly lower pain scores after 5–20 minutes of wound dressing.³⁰ Another prospective non-controlled study by Mosso-Vázquez et al with 67 patients undergoing cardiac surgery noted a mean decrease in Likert pain ratings following a VR intervention in 88% of patients, with some improvement of physiological parameters in the form of reduced heart rate (37.3%) and respiratory rate (63.6%).³¹

In addition to looking at patient anxiety, Haisley et al’s study investigated the effects of a relaxing VR environment on patient reported postoperative pain and need for analgesia.²⁶ No significant difference was observed. However, the majority of the VR group stated that they would like to use VR again.

VR has also been explored in various settings to control pain in different medical conditions. A study of 120 patients by Spiegel et al compared the use of VR headsets versus relaxing videos displayed on standard monitors; patients randomised to the VR intervention had significantly lower pain scores although there was no difference between the two groups in opiate usage.³²

Prehabilitation and rehabilitation applications

Pre and postoperative physical (p)rehabilitation is regarded as an important step in enhanced recovery programmes as it improves the patient’s response to the stresses of major surgery. It aids postoperative recovery as well as return to normal functional status, nutritional status and cardiovascular function alongside reducing complications.³³ Standard preoperative exercise programmes usually involve respiratory, aerobic or resistance training. This can be either unsupervised or supervised.³⁴ With the recent progress in immersive VR-based exercise in a virtual gaming environment, VR has been recognised as a new tool to improve physical activity and health promotion.³⁵ It offers reliable and motivational exercise in an interactive augmented environment that not only encourages body movement but also stimulates the visual and auditory senses.³⁶ This helps patients to adhere to exercise routines with proven psychological benefits.³⁷

Preoperative use of VR exercises has not yet been explored. An attempt by Steffens et al to perform a systematic review in 2020 relating to technology-based preoperative exercise for patients undergoing cancer surgery did not identify any quality studies to provide reliable evidence.³⁸ While many studies have reported on VR as a postoperative rehabilitation tool, its applications in the preoperative setting require further evaluation.

Discussion

VR applications are being investigated in many surgical and medical specialties. However, there is limited research on VR applications for patients undergoing abdominal surgery. The potential of VR in general surgical fields and populations is in fact limitless, and its impact throughout the patient journey (from preoperative preparation to postoperative rehabilitation) needs to be assessed further.

Benefits in the preoperative phase include augmented education and information. This could involve education about the patient’s current problem, approaches to surgery, possible risks and benefits, and what to expect from the day of admission to discharge. Optimising the physical fitness of patients can also be aided by prehabilitation programmes prior to surgery using VR fitness games. In addition, with the help of VR environments, patients could experience the pathway from admission to the operating theatre (including anaesthesia), decreasing stress related to surgery.

In the postoperative phase, with the favourable initial results in pain management and rehabilitation, patients undergoing major abdominal surgery could benefit from a VR environment as a distraction tool to lessen pain and as an engaging means of improving physical activity. VR applications need not be limited to the hospital admission setting and could also be adapted for use at home with the same purpose.

A good example would be for patients undergoing bowel screening. This could include VR applications in performing colonoscopy, and educating the patient on the procedure and what to expect alongside educational information about bowel preparation, which is essential prior to the procedure.^39,40 With the help of the distractive properties of VR, this could also ease procedural discomfort and improve the overall experience.

Another example of VR use at home is for patients undergoing colorectal surgery. In the preoperative phase, patients could receive their preoperative planning in a virtual, patient friendly environment, with anatomy presentations showing which part of the colon or rectum is to be removed, how the connections are fashioned, education on stoma formation and post-surgery bowel function. In the perioperative phase, VR could aid short and long-term recovery in the form of physical rehabilitation, mental health support, and improving patient satisfaction and general wellbeing.

Despite its promising applications, as in any emerging technology, VR has its own initial obstacles to gaining traction in the healthcare system. These include the obvious cost of the systems and clinical validation, which can play a major role in limiting widespread adoption. Further delays in adoption would likely be seen owing to the required education of both healthcare providers and their patients, particularly with regard to the application and utilisation of VR technology. VR devices can be awkward to wear and their use will necessitate educational support. This requires the devices to have broad specifications that allow the applications to meet the wide patient and provider base while enabling customisation to the specific purpose at the same time.⁴¹

In addition, as the technology is in its infancy, many issues could still arise such as safety considerations and side effects.⁴² This will prompt the need to formally validate the applications of VR, and to standardise the use of VR for adoption in healthcare settings through collaboration between clinicians and developers.

Conclusions

VR shows great promise with regard to supporting the surgical patient through the patient pathway. Although it is currently some way from being a validated and reliable tool, further investment and research funding has huge potential returns in terms of quality of healthcare and patient satisfaction in the future.