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. 2021 Jul;9(13):1074.
doi: 10.21037/atm-21-512.

Virtual reality and 3D printing improve preoperative visualization of 3D liver reconstructions-results from a preclinical comparison of presentation modalities and user's preference

Florentine Huettl  1 , Patrick Saalfeld  2 , Christian Hansen  2 , Bernhard Preim  2 , Alicia Poplawski  3 , Werner Kneist  1   4 , Hauke Lang  1 , Tobias Huber  1
Affiliations

Virtual reality and 3D printing improve preoperative visualization of 3D liver reconstructions-results from a preclinical comparison of presentation modalities and user's preference

Florentine Huettl et al. Ann Transl Med. 2021 Jul.

Abstract

Background: Preoperative three-dimensional (3D) reconstructions for liver surgery planning have been shown to be effective in reduction of blood loss and operation time. However, the role of the 'presentation modality' is not well investigated. We present the first study to compare 3D PDFs, 3D printed models (PR) and virtual reality (VR) 3D models with regard to anatomical orientation and personal preferences in a high volume liver surgery center.

Methods: Thirty participants, 10 medical students, 10 residents, 5 fellows and 5 hepatopancreatobiliary (HPB) experts, assigned the tumor-bearing segments of 20 different patient's individual liver reconstructions. Liver models were presented in a random order in all modalities. Time needed to specify the tumor location was recorded. In addition, a score was calculated factoring in correct, wrong and missing segment assignments. Furthermore, standardized test/questionnaires for spatial thinking and seeing, vegetative side effects and usability were completed.

Results: Participants named significantly more correct segments in VR (P=0.040) or PR (P=0.036) compared to PDF. Tumor assignment was significantly shorter with 3D PR models compared to 3D PDF (P<0.001) or VR application (P<0.001). Regardless of the modality, HPB experts were significantly faster (24±8 vs. 35±11 sec; P=0.014) and more often correct (0.87±0.12 vs. 0.83±0.15; P<0.001) than medical students. Test results for spatial thinking and seeing had no influence on time but on correctness of tumor assignment. Regarding usability and user experience the VR application achieved the highest scores without causing significant vegetative symptoms and was also the most preferred method (n=22, 73.3%) because of the multiple functions like scaling and change of transparency. Ninety percent (n=27) stated that this application can positively influence the operation planning.

Conclusions: 3D PR models and 3D VR models enable a better and partially faster anatomical orientation than reconstructions presented as 3D PDFs. User's preferred the VR application over the PR models and PDF. A prospective trial is needed to evaluate the different presentation modalities regarding intra- and postoperative outcomes.

Keywords: 3D liver reconstruction; 3D printing; Liver surgery; surgical planning; virtual reality (VR).

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-21-512). Dr. FH reports grants from German Federal Ministry of Education and Research, other from Medical Centre of the Johannes Gutenberg University of Mainz, during the conduct of the study. Dr. PS, Dr. CH, Dr. BP, Dr. WK, Dr. HL, and Dr. TH report grants from German Federal Ministry of Education and Research, during the conduct of the study. AP has no conflicts of interest to declare.

Figures

Figure 1
Figure 1
3D reconstruction of a patient’s individual liver with three colorectal metastases located in segment 5 and 8 as a 3D PR model (A), as 3D PDF (B) and in VR (C).
Figure 2
Figure 2
Study design. SSQ, Simulator sickness questionnaire; SUS, System Usability Scale; UEQ, User Experience Questionnaire.
Figure 3
Figure 3
Mean number of correctly named segments. The diamond indicates the mean number of correct segments for all participants and all liver models grouped by presentation modality with a statistically significant difference between VR and PR compared to PDF. The whiskers represent two standard deviations above and below the mean.
Figure 4
Figure 4
Influence of spatial thinking and seeing on the correctness ratio. (A) The diagram displays the influence of the test results of the mental rotation test on the correctness ratio for each modality. (B) The diagram displays the influence of the stereoacuity test results on the correctness ratio for each modality.
Figure 5
Figure 5
Boxplot. The diagram displays time needed for tumor assignment for each modality grouped by qualification level. The assessment time is displayed as log scale. (*P<0.05).
Figure 6
Figure 6
Boxplots of subscores and score values of the User Experience Questionnaire (UEQ) for the three different presentation modalities. Values above 0.8 are defined as positive evaluation results (red dotted line).
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