Intended for healthcare professionals

Clinical Review Science, medicine, and the future

Virtual reality in surgery

BMJ 2001; 323 doi: (Published 20 October 2001) Cite this as: BMJ 2001;323:912

Virtual reality and surgery

Virtual reality and Surgery

Francesco Rubino, MD, Herve Maisonneuve, MD, Luc Soler, and Jacques
Marescaux, MD, FRCS

IRCAD-European Institute of Telesurgery ; 1 Place de l'Hopital BP426
67091 Strasbourg Cedex, France

we congratulate Mc Cloy and Stone for their review of virtual reality in
surgery 1. We acknowledge the difficulty of providing an updated and clear
picture of a field that undergoes impressive changes and advances just as
we talk.

We would like, however, to point out some other possibilities that
virtual reality is offering to surgery. Indeed applications of virtual
reality are likely to determine significant advances not only in surgical
training but also in operative planning, operative strategy and techniques
as well as in telesurgery.

We do see the great interest for surgical training of systems
allowing assessment of psychomotor skills based on simple part tasks.
However, we believe that these simulators are not yet preferable to the
training in live tissues, as the latter ensure a real interaction with
organs and vessels, which is the core of surgical performance. We believe
that only the future development of more perfected systems with full
anatomical simulation of organs and operations will avoid the need for
training on animals.

Current applications of virtual reality in preoperative diagnostics
include gastroscopy, bronchoscopy and colonoscopy. Some authors suggested
that virtual colonoscopy may be better than barium enema for detection of
colon polyps 2. In addition, the virtual colonoscopy has the unique
advantage to allow “navigation” in the lumen of the bowel and views of the
mucosa from any angle, as well as the possibility to pass through stenosis
and even cross the colonic wall into adjacent structures 2. These
advantages and the ease of interpretation due to the wealth of imaging
information might render virtual colonoscopy especially suitable for use
in screening programs for colorectal cancer.

The development of systems for 3-D reconstruction of liver anatomy
and hepatic lesions has been shown to improve tumor localization ability
and increase precision of operation planning3. At the European Institute
of Telesurgery we have developed a fully automated software that from CT
scan and MRI images provides, in less than 5 minutes, an accurate 3D
reconstruction of anatomical and pathological structures of the liver as
well as invisible functional information such as portal vein labelling and
anatomical segment delineation according to the Couinaud definition. After
clinical application in more than 30 patients this methods shows that
automated delineation of anatomical structures is more sensitive and more
specific than manual delineation performed by a radiologist.

Our group is also developing an augmented reality system allowing to
superimpose the 3-D reconstruction of anatomical structures on the
patient. For instance, with augmented reality 3-D reconstruction of the
vessels can appear on the visible surface of the liver through a virtual
transparency. A further step will then be to combine augmented reality and
robotic systems in order to allow for automation of surgical operations in
the future.
Despite the problem of costs may represent a limitation at present, the
advances in virtual reality and the possibility to obtain experts’
assistance from a remote site through the use of a robot 4 represent, in
our opinion, the best means to improve surgical care worldwide.


1. McCloy R, Stone R. Virtual reality in surgery. BMJ 2001; 323:912-
2. Halligan S, Fenlon HM. Virtual colonoscopy. BMJ 1999; 319: 1249-1252
3. Lamade W, Glombitza G, Fischer L, Chiu P, Cardenas CE Sr, Thorn M,
Meinzer HP, Grenacher L, Bauer H, Lehnert T, Herfarth C. The impact of 3-
Dimensional reconstructions on operation planning in liver surgery. Arch
Surg 2000; 135(11): 1256-1261
4. Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M, Butner SE,
Smith MK. Transatlantic robot-assisted telesurgery. Nature 2001;

Competing interests: No competing interests

17 November 2001
Francesco Rubino
clinical fellow advanced laparoscopic surgery
IRCAD-EITS, 1 Place de l'Hopital, 67091, Strasbourg, France