ADVANCES IN AUGMENTED REALITY (AR) FOR MEDICAL SIMULATION AND TRAINING

Digital technologies are transforming the field of medical training, simulation and modeling. Advances in the field of virtual Augmented Reality (AR) and virtual simulation are described in detail, particularly as they relate to medical education and training. An overview of key medical simulation tools is provided in order provide foundational knowledge about this rapidly growing field. A timely and valuable original Augmented Realty system is put forward. The key components of this original system for medical training and simulation include the following three dimensions: advances in open surgery, realistic visualizations and innovative haptic was used. Each component of this Augmented Reality system is described in detail. First, the open surgery module emphasized appendectomies (the most common surgical procedures used in our model). Second, three different approaches for creating realistic and accurate 3D medical models were put forth. Third, haptic feedback involved the use of an enhanced Novint Falcon system in which a custom grip provides additional degrees of freedom. Finally, advances in game simulation, modeling and role playing are discussed for the field of emergency medicine.

3C Tecnología. Glosas de innovación aplicadas a la pyme. ISSN: 2254 -4143 Edición Especial Special Issue Abril 2020 ABSTRACT Digital technologies are transforming the field of medical training, simulation and modeling. Advances in the field of virtual Augmented Reality (AR) and virtual simulation are described in detail, particularly as they relate to medical education and training. An overview of key medical simulation tools is provided in order provide foundational knowledge about this rapidly growing field. A timely and valuable original Augmented Realty system is put forward. The key components of this original system for medical training and simu-

INTRODUCTION
Medical simulations, modeling and visualizations have undergone a rapid shift the beginning of 20th century due to a number of reasons (Kron et al., 2010). First, modern approaches for less invasive surgery have redefined surgical procedures such as endoscopy and robotics surgery. Second, the dramatic rise of computing power has provided an opportunity to implement complex simulations in real-time. Finally, more accurate algorithms for rigid and soft body simulations, realistic 3d visualizations, haptic controllers, and virtual reality have allowed medical simulation to be used for digital gaming rather than simply physical modeling.
Specific approaches and technologies for medical simulations for medical simulations have grown by leaps and bounds. For example, innovative research has occurred dealing with the generation of textures of irregular objects from models and photo sequences (Chen et al., 2003). The role of medical simulations has rapidly expanded throughout the healthcare field (Kunkler, 2006). This paper involves a case study of medical simulations for lap.

MARKET OVERVIEW
According to Prescient & Strategic Intelligence data, the global surgical simulation market was valued at $254.7 million in 2017 with a growing trend. The value of this field is forecasted to increase to twice its value in 2023 ( Figure 1). Another notable trend is that augmented reality (AR) and virtual reality (VR) are being used to enhance the quality and efficiency of medical training. Thus, it is expected that this market will continue to grow, and digital technologies will continue to have a major impact on the medical simulation field.

MEDICAL SIMULATORS
VirtaMed is a company primarily focused on simulator development for orthopedics, genecology and urology. The company develops surgical simulators which are designed on a single flexible plat-form with the ability to expand and add additional procedures. All simulators are combined with an anatomical model to provide the optimal tactile feedback and real-world manipulations. In addition, for better efficiency each virtual procedure allows for guided training: specific colored hints and ghost tools show trainees how to perform different tasks ( Figure 2).

Figure 2. ArthroS Ankle by VirtaMed AG.
NeuroVR is a platform for neurological training that enables neurosurgeons to practice skills with the help of virtual reality (Figure 3). Such a system does not depend on real life models but uses haptic controllers for VR manipulations. The range of allowed exercises are derived from actual patient images, which provides more realistic and accurate images of surgical procedures. The system also captures objective metrics and measures the proficiency of procedures in order to track educational progress. SurgicalScience is a company which develops various simulation products, mostly for laparoscopy and endoscopy. The LapSim product is designed to improve psychomotor 3C Tecnología. Glosas de innovación aplicadas a la pyme. ISSN: 2254 -4143 Edición Especial Special Issue Abril 2020 skills using virtual reality with haptic feedback (Figure 4). It features different modules for laparoscopic exercises that arrange from navigation to suturing. This system also has a portable version known as "LapSim essence".

REALISTIC VISUALIZATION
Despite advanced real-time rendering solutions that are currently available, it is still difficult to produce realistic images in a surgical simulator due to a software limitations. For example it is difficult to incorporate graphics solutions onto a complex modeling engine (that captures the physics of the system). To overcome this challenge the developed system is based on a modern game engine which allows for the use of physically based shader models and enhances it with a customized physics engine to work with soft tissue (Figure 6).

CREATING MODELS BASED ON PATIENT' S DATA AND ANATOMICAL ATLASES
More accurate modeling results may be obtained by a number of approaches. One method involves taking photos from an actual surgical procedure and extracting textures from these images (Figure 7). It is also possible to build models based on a sequence of photos using photogrammetry solutions.
Another method involves building models based on MRI or CT data. For instance, a heart model with specific pathologies can be recreated with the help of MRI and contouring data. This is achieved through multiple stages (Figure 8). At first, we built model of ventricles from countering data and then projected a master heart model onto them and finally added textures based on real-life heart images.

HAPTIC FEEDBACK
In order to achieve fully realistic visualization our system is supplemented with haptic feedback. This helps to sense virtual 3D objects and allows the development of proper psychomotor skills for surgeons. The Novint Falcon Haptic device was used as the foundation to implement this haptic feedback technology. While this tool is designed primary for games, it also provides accurate haptic feed-back with three degrees of freedom (DOF). This device is also the cheapest haptic system on the market, thereby reducing the overall cost of simulator significantly.
In order to use this device as a tool for surgical simulations the system was redesigned in several ways. For example a custom designed grip was developed with extra three DOF to allow for the creation of a tilting surgical tool ( Figure 10). This tool is based on absolute hall encoders and transmits data as separate stream through a digital-to-analog converter. In addition, it has a slot for swapping different surgical instruments.

GAMES, ROLE PLAYING AND SIMULATIONS FOR EMERGENCY PHYSICIANS AND THE COVID-19 PANDEMIC
There is a need for better-trained emergency physicians in the COVID-19 era. Emergency physicians and other educational, research, and practitioners in the health field must in-creasingly have simulation experience to make crucial decisions within a highly politicized, volatile and pressurized context. The education of future generations of emergency physicians and emergency management professionals must draw across the boundaries of physical/social science, technology, engineering, and mathematics. The COVID-19 pandemic has shown that traditional approaches to responding to health disasters, reducing risk and mitigating losses are inadequate. Starting in the 1950s, the emphasis was on the disciplines of civil defense and humanitarian relief. there is a need for more such learning tools within in emergency healthcare education.
Our ongoing research seeks provide a bridge between the emergency response focus generally filled by community and technical colleges and theoretical focus of graduate level courses. Future work seeks to develop prototype simulations for undergraduate emergency medical curricula. A further outcome of the project will be a framework and workplan to leverage the lessons learned in this paper for complete development, implementation and faculty support materials of emergency medicine simulations.