case study for surgical technologist

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Case study | surgical setup reduction improves patient outcomes.

To be financially viable, a hospital’s operating rooms (ORs) must keep quality and utilization high and expenses low. It’s critical to plan ahead, be prepared, and set volumes correctly. This means an organization’s OR team should be continuously finding ways to improve turnover time in their ORs, while also sustaining improvements to patient safety, staff engagement and organizational costs.

Surgical instrument processing is critical to safe, high-quality surgical care but has receives little attention. Typical hospitals have inventories in the tens of thousands of surgical instruments organized into thousands of instrument sets. The use of these instruments for multiple procedures per day leads to millions of instrument sets being reprocessed yearly in a single hospital. Errors in the processing of sterile instruments may lead to increased operative times and costs, as well as potentially contributing to surgical infections and perioperative morbidity.

When Virginia Mason’s team examined their inventory of surgical instruments they saw, that at any one time, thousands of instruments were being used and processed during setup, surgery, breakdown or sterilization — about 5.2 million instruments per year — and still large amounts of instruments were left unused in storage. Additionally, there were roughly 3,800 unique instruments sets set to different surgeries and different physician’s preferences. Although they had worked hard to keep the inventory down, 3  they knew innovative thinking could help them make lasting improvements.

A quality monitoring approach was developed to identify and categorize errors in sterile instrument processing through use of a Daily Defect Sheet. Virginia Mason Production System ® (VMPS ® ) improvement methods were used to improve the quality of surgical instrument processing through redefining operator roles, alteration of the workspace, mistake-proofing, quality monitoring, staff training, and continuous feedback.

To study the effectiveness of the quality improvement project, a before and after comparison of prospectively collected sterile processing error rates during a 37-month time frame was performed. After implementing a transformation to their operating rooms’ build-to-order (BTO) process, they removed 58,728 unnecessary instruments, and eliminated all $500,000 worth of unused “sleeping” sets — weighing 29,480 pounds — from processing in the first year. In neurosurgery alone, instrument assembly time decreased by 42 percent, and inventory was reduced by 26 percent.

Instrument Assembly Time

Starting with inventory, progressing with data collection

To answer the question of which instruments surgeons needed most or preferred to use, the team examined and collected surgeons’ preferences based on actual usage. The vision, according to the director of sterile processing at the time, was to create a “better patient experience, with fewer defects, faster setup and better patient throughput.”

Team leaders — after evaluating their employees’ interest and aptitude — trained a nominated group of surgical technicians in VMPS ® improvement tools and methods. Following the training, the group took their clipboards, pens and timers to operating rooms, setup areas, breakdown areas, sterilization rooms and storage rooms. They observed the different work areas to understand physician priorities and track how much time was spent on tasks that made a difference to patients and staff versus time spent on wasteful processes that didn’t benefit patients and overburdened staff.

The improvement team was able to easily step into the operating rooms, introduce themselves and explain what type of data they’d be collecting. The work was transparent from the beginning, and no one felt threatened or worried. The surgeons and staff knew they were all a team and that the improvement team was there to improve work for patients and staff alike. They observed each surgeon and procedure five times, building data so that the team could truly understand the current state and begin planning for a better process to test.

Establishing a structure to guide the work

Armed with data, team members came together for a  3P  (Production Preparation Process) 4  workshop to set their vision for a dramatically more efficient process. By the end of the 3P, the participants had created a guiding team to determine next steps, oversee all the work and answer any questions that came up throughout the process. The guiding team included a sterile processing leader, operating room leader, improvement office leader, neurosurgeon, surgical technologist, sterile processing technician, project support staff member and administrative support staff member.

Using improvement methods and tools to get results

Next, the team employed the concept of  5S  (sort, simplify, sweep, standardize, self-discipline). They discovered that almost 60 percent of the items in their orthopedic case sets were rarely used. This equates to 700 tons of unnecessary instruments being processed, per year. Using data, they sorted which instruments were being used, and simplified the process by removing non-critical instruments left unused. They swept the area by designing a repeatable inspection of case sets, standardized their tray layout, and established a team agreement to continue monitoring.

The creation of the build-to-order instrument sets employed the concept of just-in-time inventory — in which just the right surgical instruments would be delivered just when they were needed — and allowed for customization to each surgeon’s needs for a procedure. The new setup technique made the process of tool assembly much easier for surgical technologists. A production board provided team members with a visual reference of the current demand for supplies.

In an additional improvement event, focusing on the setup for craniotomy procedures, participants discovered how to customize each set, reducing the setup time and the OR space needs in the suite. By the end of the event, they were able to combine sets, reducing their setup time from 34 minutes to 2 1/2 minutes, a 92 percent reduction. The team compared times before and after the improvement events and found that the more limited case sets did not increase overall procedure time but greatly increased OR turnover time.

Seeing financial gains

This work also yields significant financial benefits to a health care organization. A reduction in processing yielded an annual cost savings of $65,000 per year. The number of lost, broken and damaged instruments was also reduced.

Getting results for other surgery sets

The team spread the work by helping other specialty teams, including orthopedics, neurosurgery and thoracic surgery produce similar setup reductions. The results for improving the laminectomy surgical setup were very impressive. After implementing the build-to-order sets, the instrument assembly went from 34 minutes to 20 minutes, 15 seconds. The instrument setup in the OR went from 24 minutes, 9 seconds, to 2 minutes, 29 seconds — a 90 percent decrease. The number of instruments used decreased from 152 to 59, and the number of instrument sets decreased from 5 to 2.

Instrument Assembly

Operating Room Instrument Setup 

Number of Instruments 

Improving quality and safety

During the assessment of their instrument inventory before the improvement work, the team determined that the large number of unnecessary instruments in storage could have a big impact on safety. Not only was the probability greater for a surgical technologist to select the wrong instrument for a procedure, but the time spent searching for specific instruments and maintaining all these instruments — many of which were processed and sterilized yet never used — could potentially affect patient care.

Before the intervention, instrument processing errors occurred in 3.0 percent of surgical cases, decreasing to 1.5 percent. Improvements were observed in multiple categories of error types, particularly the assembly errors of packaging (from 0.66 to 0.24 errors per hundred cases), and foreign objects (0.17 to 0.02 errors per hundred cases).

Improving patient access and timely care delivery

The lead time for booking orthopedic surgery, for example, went from 65 days down to 21 days. This meant surgeons did not have to wait as long between procedures and could handle an increase in volume of patient cases.

Key takeaway

Surgical instrument processing errors are a barrier to the highest quality and safety in surgical care but are amenable to substantial improvement using improvement techniques.

Originally published May 24 2018, updated July 12 2021

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Surgical Technology for the Surgical Technologist: A Positive Care Approach 5th Edition

• ISBN-10 9781305956414
• ISBN-13 978-1305956414
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• Publisher Cengage Learning
• Publication date January 1, 2017
• Language English
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• Print length 1328 pages
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 18  Surgical Skills I: Planning a Case, Opening, and Start of Surgery

CHAPTER LESSON PLANS & OBJECTIVES

Lesson 18.1: Surgical Case Planning

• 1. List and define common terms used in surgical technique
• 2. Discuss the elements of a case plan
• 3. Explain surgical objectives and how they can be grouped into types
• 4. Discuss the purpose of preoperative case preparation

Lesson 18.2: Surgical Field Management

• 5. Describe the correct procedure for performing a count
• 6. Discuss the guidelines for preventing lost and retained items

Classroom Preparation

INSTRUCTOR PREPARATION

Textbook Objectives Covered

National Standards Covered

• • See the Fuller 8e/AST Core Curriculum Mapping Guide on Evolve instructor resources. 

STUDENT PREPARATION (1 hr)

50-Minute Lesson Plan

LECTURE OUTLINE (50 min)

Learning Activities (choose one or more to equal 50 min)

Critical Thinking Question

You are working on opening a case to be performed in 20 minutes when you learn that an accident victim with multiple lacerations will be brought into the operating room (OR) in 5 minutes. What do you do?

Discussion Guidelines: Students might discuss the concepts of priority setup versus secondary preparation. While establishing and maintaining the sterile field, the most important instruments should be quickly identified and made available for the case to start. With guidance and experience, the surgical technologist will learn which equipment is typically required for stabilizing a patient (e.g., controlling bleeding). Other instruments and supplies can be obtained as the case progresses.

Should the surgical technologist pass the knife to the surgeon before TIMEOUT has been performed?

Discussion Guidelines: Explain that TIMEOUT is documented and that it is the responsibility of all surgical team members to participate. This pause is to prevent serious error or injury to the patient before the surgical incision. Passing the knife to the surgeon allows the surgeon to start the skin incision without performing TIMEOUT.

Assessments

Chapter 18: Surgical Skills I: Planning a Case, Opening, and Start of Surgery

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Educational concern of surgical technology students in the operating room: A grounded theory study

Roghayeh zardosht.

Department of Operative Room and Anesthetics, Iranian Research Center on Healthy Aging, School of Paramedical, Sabzevar University of Medical Sciences, Sabzevar, Iran

Hossein Karimi Moonaghi

1 Nursing and Midwifery Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, and Department of Medical Education, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

Mohammad Etezad Razavi

2 Eye Research Center, Faculty of Medicine, Khatam-al-Anbia Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

Soleiman Ahmady

3 Department of Medical Education, Faculty of Medical Sciences Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran

INTRODUCTION:

Bachelor's program in surgical technology is a major of medical science, in Iran. Learning and adapting to different skills and roles in the operation room environment is a daunting work. The complexity of this environment needs to bring together researchers in this field to work on different aspects. The aim of this qualitative study was comprehensively understanding of clinical teaching process in surgical technology.

MATERIALS AND METHODS:

The present study was conducted based on the qualitative research design of the grounded theory approach (Corbin and Strauss, 2008). This study was conducted at schools of nursing and paramedical in five academic settings. Study participants in the present study include 14 students, seven educational instructors, six staff of operation room, one dean of faculty, three surgeon assistants, one instructor, and four head nurses of operation room. A semi-structured interview method and a memo were conducted using theoretical and purposive sampling. Constant comparative analysis was used for data analysis.

Findings showed that the nonacceptance of student by surgical team was identified as the main concern of the students. The “gaining clinical competence and approval” was found the central process (strategy) in response to main concern of clinical education, and the “interactive and dynamic nature of the operation room environment” was defined as the context for this major concern. Strategies that students used to address this concern included individual efforts to overcome distrust, learning in the shadow of surgical team members, and seeking help and support of the instructor.

CONCLUSION:

Accepting the students of surgical technology as a member of surgical team creates opportunities for students to learn, gain experience, and enhance their professional qualifications and abilities.

Introduction

The operation room staff are important members of the healthcare team who work closely with surgeons, anesthesiologists, and nurses to provide optimal care for patients.[ 1 ] The operation room, as one of the complicated educational environments, provides a context for learning and at the same time acts as a factor that impacts learning and teaching and also could play a role in supporting or prevention and restricting students' learning opportunities.[ 2 , 3 ]

The clinical environment consists of all the impressive situations and potential triggers of learning. This environment is composed of cognitive, social, cultural, emotional, motivational, and learning components. Learning and adapting to different skills and roles in clinical environments such as operation room is a tough work because students should be trained for many skills in the surgical process before, during, and after the surgery.[ 4 , 5 ] The teaching and learning process in the operation room environment is different and more complex than other clinical environments,. In addition the three elements of the patient, the instructor, and the student, other factors including surgeon, anesthesiologist, surgical team and operation room staff affect the education in operative room.[ 6 , 7 ] OR environment can be influenced by teamwork and interdisciplinary collaboration. The variety of procedures in the operation room, workload, heavy responsibilities, speed and precision of action, and rapid turn out of patients need to be managed. Unpredictability of work in many cases, rapid occurrences of high-risk incidents in the operation room, acute and severe emergency situations,[ 8 , 9 ] simultaneous management of multiple tasks and duties, and close interactions between surgical team members and multicultural environment, which could all impact the educational process.[ 3 , 10 ] The results of many researches in this field indicate the different environments of the operation room from other clinical sections, which influence corresponding education methods. These researches have mainly been conducted on surgical team interactions,[ 6 ] tensions, communication failures,[ 11 ] the effects of tensions on other members of the surgical team and students, and the development a checklist for the promotion of team communication.[ 7 ] Unfortunately, there are no effective studies in Iran on the process of clinical education of the surgical technology program. Most of the researches have been carried out quantitatively and focus only on some aspects of training in the surgical technology and have not been able to cover all corresponding aspects.[ 12 , 13 , 14 , 15 , 16 , 17 ]

Clinical education of students of surgical technology is a multifactorial process with unknown aspects and components. To understand this conceptual framework and to assess all aspects of education in this environment, in addition to quantity approaches, it is necessary to use some quality approaches with a holistic viewpoint on this issue, which merely cover a specific aspect in detail.[ 18 , 19 ] This qualitative study based on grounded theory method aimed to find out the social process of the interaction between learners and educational stakeholders, influential factors, potential challenges associated with educational issues, as well as a complete theoretical description of the clinical education of major based on the experiences of the participants in operations room.

Materials and Methods

This qualitative study was carried out in four stages, based on the grounded theory approach of Corbin and Strauss. This study was conducted at schools of nursing and paramedical in five academic settings. At the beginning, the study samples were selected through target-based sampling, with a shift to theoretical sampling with the progression of the study. Based on the entry criteria of the study, the participants (clinical educational stakeholders) were as follows: instructors of surgical technology with at least 1 year teaching experience, surgical technology students of different semesters who completed at least one internship course in operation room, surgeons, head nurses, and personnel of operation room with minimum 1 year working experience in the operation room, who were rich in information and willing to report on their experience.

Semi-structured interviews, observations, field notes, and memo were used to fully understand the clinical education process. After the participant's conviction about the objectives of the plan and obtaining informed consent, the data collection begun through semi-structured individual-based interviews with a number of open-ended questions according to the interviewer guide, and additional exploratory questions were used to gather further insights. Each interview lasted between 20 and 65 min, depending on the situation, participants' cooperation, and environmental conditions. The location of the interviews was determined by the participants. The entire interview was recorded by a digital voice recorder and converted into portable audio files. The researcher simultaneously collected the data and analyzed it using MAXQD software, immediately after each interview. Sampling continued to reach a theoretical saturation. Writing memo and attempts to fill the gaps, along with emerging codes, classes, and theories, was the main guide for the researcher in the process of data collection to reach theoretical saturation.

Saturation in grounded theory is the completion of all levels and codes until there are no new conceptual data in need of emerging new category or code or even expansion of the existing codes.[ 20 , 21 , 22 ] At the end of the data analysis for concept, main issues would arise. What did the students of the surgical technology experience relate to their field of study during their clinical education? The researcher focused on personal, environmental, organizational, familial, social, political, economic, cultural, and historical factors that influenced directly or indirectly the concept of clinical education of surgical technology students. The next step thus to identify the concepts of the field and examine the quality of clinical education of the students was data analysis for context. The third step in data analysis of the research question was to identify strategies/processes (action/interaction and emotions) by which the participants responded to in the field. Corbin and Strauss coding paradigm was used to connect the context factors to the process of clinical education of the surgical technology students.

The fourth and final step was composition or integrating categories to construct the theory.

In the present study, the theoretical story line was written using reminders and deep immersion in data and a great deal of reflection on the emerging classes derived from data analysis for the context and process. After identifying the clinical education process of surgical technology students, the researcher identified the core variable, with concentration on the main classes and their characteristics, diagrams, and classification of reminders. In fact, the central class is the main concept that connects the other concepts together and emerges with maximum clarity.[ 21 ] The researches aiming to ensure the acceptability, reliability, and consistency of the data validated the data, according to qualitative approaches, by confirmation the data via participants, adequate time allocation for analysis, open and sympathetic communication with participants, and the review of supervisors, including the supervision of three experts in the field of qualitative research at all stages of the study.[ 19 , 21 , 23 , 24 ]

Permission to conduct this study was issued by the Ethics Committee of Mashhad University of Medical Sciences based on a formal letter of introduction from the Vice Dean for Research of University of Medical Sciences, serving as the legal authority in this area (No. 940548/2015.08.15). We have placed emphasis on participants' confidentiality, their informed consent, right to exit from the study at any time, the selection of time and place of interview and anonymity. Permission, as written informed consent, was sought from the participants for the audiotaped interviews.

Thirty-six interviews were conducted. The research space was the operation rooms of several educational hospitals in five universities of medical sciences [ Table 1 ].

Research participant characteristics

OR=Operations room

Data analysis was carried out using version 10 of (Udo Kuckartz, Creator of MAXQDA. We are VERBI Software, the company behind MAXQDA). In the first step of conceptual analysis, 3424 open codes, 124 primary subgroups, 51 primary groups, and 10 main groups were identified. The researcher seeks to discover the main concerns of the participants. All data analysis, review of reminders, and observations in the field showed that the main group of “students' nonacceptance in the surgical team” represents the phenomenon with which the surgical technology students are facing in their clinical education. Hence, the main concern of the first stage was the “nonacceptance of student by the surgical team” [ Table 2 ].

Main concern and subcategories

Students were constantly worried about being refused by the surgical team that was rooted in the distrust of the surgical team members. This concern which was raised from the very 1 st day of training and lasted for the rest of education period reflected different manifestations over the different courses.

For example, Participant No. 6, an operation room staff, states in this regard, “ Because of being an amateur, students are an obstacle in a way that they tie your hands and lower the pace of performance of the surgery team. And it's very boring to teach the students how they should scrub, wear surgical gloves and prepare the sterile setup for the appropriate procedure. Unfortunately, some students don't care about such things and are very lax. ” A student (Participant No.: 3) says, “ It's our great pleasure to provide a perfect aid to surgeon and being told We are OK and well trained and also to be reliable. ”

The interview with a surgeon assistant also revealed the concern of nonacceptance of student by the team: “ We had a student who did not even know the names of the surgical tools, he was at almost zero/basic level, and our senior assistant asked us to replace him. Because after 1 h passing, we just did incision and nothing else; he really slowed the pace of performance, and we had to replace him .”

After identifying the main concern, the researcher sought to identify the context of this concern. What was the reason for nonacceptance of students by surgical team? In the data analysis for the field (second step analysis), the four main categories of the culture of the operation room, the special educational environment, the stressful atmosphere around the training program, and the bitter education were identified as the basis of the phenomenon of “nonacceptance of student by the team,” all of which were subjected to an abstract title called the interactive and dynamic nature of the operation room [ Figure 1 ].

Context of main concern and subcategories

The class of operation room culture consisted of four subclasses as follows: teamwork performance, gender discrimination, hierarchical structure, and tension in professional interactions as well as inappropriate interactions, duality of behaviors/avoiding setting rules and standards, and stress resulting from the surgeon's assistant team on the education of surgical technology students.

The class of special educational environment consisted of subclasses of lack of facilities and instructor, special physical space, the value of time, presence of students of other majors at the same time in the operation room, red lines, safety and sterility rules, using of nonspecialized instructors, and interaction between caring and technical roles.

The class of stressful atmosphere included the subclasses: the special situations (closed environment) and the paradox of expectations with the reality. The class of bitter education included subclasses of the humiliating experiences and internal tensions resulting from stressful education.

Data analysis showed that clinical education in the operation room is intertwined with the concept of teamwork and hierarchical structure. The members of the surgical team can play a positive or deterrent role in training of students in terms of technical skills. Regarding this item, a student (Participant No. 9) says, “ Most students say that instructor has an important role in teaching, but I say personnel does as well. Some staff by themselves are instructor for students, since they explain all the techniques step-by-step during the surgery. ” Another student (Participant No.: 15) says, “ Our learning depends on the surgeon's day and the staff's as well which all impact our training. ” It is the surgeon's responsibility as the surgical team's leader to protect the patient's safety and health which requires making decisions, which in some cases seems to be unfair in the student's point of view.

In this regard, a surgeon says, “ In fact, this kind of stress is natural to a surgeon, and if student density or their slowness causes some stress to a surgeon that affects his or her work and life of a patient as well, he or she may react with any behavior . Surgeons and assistants are different in their characteristics. Some surgeons can do lots of work simultaneously, without having to deal with stress; however, for some other surgeons, it is too important to concentrate on their work, and they cannot think of anything else during the surgery. Nothing is more important to them than the patient's life and safety, and the patient's life is not subject to anything (Participant No.: 32, a surgeon).”

The educational environment of the operation room is one of the most inaccessible areas in hospitals, where operations are conducted behind closed doors, and is quite different from other departments. An instructor (Participant No.: 11) says, “ Poor instructor, does not have enough time to simultaneously handle a large number of students in each groups of different grades of 4, 6, and 8 .”

An instructor regarding this special educational environment says, “ The simultaneous presence of students at different levels of education from a level zero students of third-fourth semester to assistants of year three or four and sometimes even a professor all gathered in one place, and sometimes the participation of people of inhomogeneous clinical expertise at the same time in the operation room and the fact that it's very common for a freshman student to have difficulty working with a surgeon or a 4 th -year resident .” (Participant No.: 1, an instructor).

The different educational environments of the operation room from the other sections and the coordination with the surgical team have made it more stressful to the students of surgical technology. “ The activities performed in other departments are completely different from involvement with the surgical team in the operation room. Our students are often working with the first surgeon, while they don't know so many things about surgical skills with their limited information on that and are expected to act as an expert for a surgeon. ” (Participant No.: 4; an instructor).

Data analysis showed that students of this field are experiencing technical skills under tremendous stress and pressure: “ They do not respect the students of the surgical technology at all and it is kind of lord and peasant relationship ” (Participant No.: 7; a student). One of the known stress factors for students in the operation room is the behavior of other students and staff. Disrespectful behavior of the surgical team members and occasionally, instructors, frustrates students. “ Frustration is rooted in the misconduct of the staff and surgeons and even an instructor who does not understand the students' concerns. It means that an instructor is willing a student to work and scrub in any condition. ” (Participant No.: 15; a student).

In the third phase of the analysis, the surgical technology students' strategies were identified. Their strategies include facing with the distrust phenomenon, and nonacceptance by the surgical team. Initially, these strategies seemed diverse and scattered. Over time, with more interviews and in depth analysis, researchers succeeded in discovering different strategies that ultimately fell into three categories [ Figure 2 ].

Strategies related to the main concern

The class of the efforts required to cross the wall of distrust for the student and each student's individual approach to enter the surgical team includes having the prerequisite knowledge and skills, attempts to ensure the surgical team, satisfaction of the surgeon, and constructive interpersonal communication (professional interactions, performing duties, and obtaining prerequisite skills and knowledge).

The participants' statements indicated that if the members of the surgical team had observed the effort, interest, and students' perseverance into learning and had approved their work, they would be allowed to enter the team and create learning opportunities for the student. “ Depending on the student's motivation and interest, some are more active and effective than the staff and seek work and learning opportunities. If someone is willing to work, we also have good cooperation with him or her ” (Participant No.: 12; a staff).

Learning in the shadow of the surgical team members was another strategy of the students of surgical technology to be approved by the team. This strategy involves accepting the surgeon and the operating room team as the role model, stress-free training with the supportive personnel, seeking help from the amateur staff, and effect of the surgeon's patience.

The analysis of qualitative data showed that students believed that due to the high number of surgeries and lack of enough and permanent instructor, the staff at the operation room had an important role in their training. “The one who can give the best training is the staff of the same operation room” (Participant No.: 15; a student). In line with this fact, another student says, scrub nurses of that room were very helpful, they were constantly asking us for surgical tool (Participant No. 23; a student).

The help and support that students sought from the instructor included the clinical competence of the instructor, the umbrella support and authority of the instructor, the presence and communication skill of the instructor, and the popularity and moral character of the instructor. The students addressed poor clinical experience, inadequate skills and knowledge of the instructor, and presence of instructors with other/irrelevant specialty as an obstacle to clinical education. Not all surgeries, but in the same surgery I am in charge of, the instructor should explain me about the surgery, how should I use the tools and instruments, and after all these justifications I would be ready to join the team (Participant No.: 16; a student).

Using each of these three strategies by students has some consequences, which have been gathered in a main category of identification, which consists of two subclasses; the feeling of belonging to the surgery team and/or passivity. The data showed that experiencing technical skills by the student and joining the surgical team can be effective in acquiring professional qualifications and a sense of belonging to the surgical team. Experiencing and engaging in surgical team activities played an important role in the success and achievement of professional identity of the students of surgical technology.

The fourth and final stage of the analysis is combination and integration of classes to construct the theory. The findings showed that in the training period, the students encountered stressful conditions due to the nonacceptance by the surgical team. As a result, they found other ways to acquire the competence and adequacy they need. Considering that each of the main categories derived from the data provided only a part of the story, but not the whole, the researchers defined the concept of “gaining of clinical competence and approval” as the main psycho-social process (core variable) that connects other concepts and at the same time includes all classes, and finally, data were presented in the format of a grounded theory [ Figure 3 ].

Conceptual model “gaining of clinical competence and approval”

The findings of this study led to the emergence of the theory of gaining of clinical competence and approval. The data showed that the clinical education of students in this field is obtained in the context of the interactive and dynamic nature of the operation room environment, and they face stressful conditions related to the nonacceptance by the surgical team as an educational member. Then, they turn to some approaches to be accepted by surgical team and acquire the competence and adequacy they need. Gaining competence and approval was the main social process and a central concept that the students of surgical technology used to take a role in the surgical team, would create more opportunities for learning and developing professional skills.

Lee defined empowerment as a background for increasing dialogues, critical thinking, activity in small groups and pointed out that allowing activities to move beyond the sharing and refinement of experiences, thinking, seeing, and negotiating are the main components of empowerment.[ 25 ] The findings of the present study confirmed the impact of environmental, cultural, and social factors on students' learning and further indicated that student's individual efforts were one of the main strategies for taking the role in the surgical team that has already mentioned in the theory of gaining competence and approval. Bundara's social cognitive theory concentrates on learners' individual characteristics, behavioral and environmental patterns,[ 26 ] social factors, and backgrounds in which learning and developing of behavior occur.[ 27 ]

Based on social learning theory, learning takes place in the interaction and observation of others in a social context. Learning from surgical team members and interaction with them was a concept that the current theory also referred to. In the present study, the interactive and dynamic nature of the operation room environment and its culture, special and stressful educational environment, and bitter education were identified as affecting factors in student education. The contents obtained from the grounded theory study of Memarian et al . (2006), regarding the factors affecting nurses' clinical competence acquirement and internal or individual factors, included processes and factors such as knowledge and skills, ethical issues, task conscientiousness, accountability, and responsibility. Other contents were organizational or external factors that included the clinical and educational environment, retraining programs, job permits, control and supervision, and an efficient educational system.[ 28 ]

According to the findings of this study, the most important challenges of the students of surgical technology include facing with the stressful environment and conflicting role acceptance with the reality, and humiliating experiences. It could be said that the students of surgical technology are considering the clinical education as a bitter experience. A qualitative study conducted in clinical environment of operation rooms in the United States, Finland, and the United Kingdom in 2004 showed that overall, the experience of being in the surgical team was a very different and short experience and teamwork skills were not done systematically. The students in the operation room environment were experiencing bad feeling, so they were dependent to other people. Gaining membership with the surgical team resulted from active training process and accepting the atmosphere and team environment. Working as a team member was provocative and challenging.[ 7 ] Despite the differences in the health system of these countries with Iran, students of the other countries had similar experiences with the Iranian surgical technology students regarding their engagement with the surgical team. Amanda Henderson's research on the effect of environmental situation on students' mental and psychological conditions and subsequent learning showed that students in clinical environment with favorable clinical support achieved higher skills and abilities.[ 29 ]

Newton et al . also assessed the relationship between staff and students and the factors influencing the efficiency of clinical environments.[ 30 ] In this study, students described the stressful situation confronting with the environment, organization of the operation room, using advanced technologies and equipment, operation room's crowdedness, as well as close relationship with surgical team members as inappropriate. The dominant themes in the qualitative study of Lingard et al . were of the operation room environment, including time, security, sterilization, resources, roles, and situations. Usually, each procedure had one to four stressful incidents with a pulsatile impact and these stresses were exerted to other members of the team and the environment as well. The surgical trainee was either withdrawn of the surgical team in response to these tensions, or derided by them, both of which were negative indicators for team communication.[ 6 ] The present study showed that use of staff or head nurses as an instructor due to lack of enough instructors in the surgical technology department led to incomplete training and confusing of students. Other studies also mention the lack of qualified instructors and the use of nonspecialized instructors, regardless of their ability and expertise, as clinical educational problems.[ 3 , 9 , 14 , 31 ]

Data analysis showed that urgency of situation and time limitation may lead to inappropriate behaviors of team members toward a less experienced student. Riley and Manias believe that operation room has its own special patient care settings and is one of the inaccessible places in the hospital, with the area's division as the following: unlimited, semi-limited, and limited with different defined physical activities in each division.[ 32 ]

Limitations

Qualitative research may be partially influenced by the researcher's personal biases and idiosyncrasies. With continuous engagement with data and its confirmation by the participants as well, rigor was easily maintained. Of note, detail information was mentioned in methodology section.

Study novelty

For the first time in Iran, grounded theory was used to exploring the process of education in operating room students based on the experiences all of educational stake holders in the field of operative room. The findings inform us about the structure, process and training problems in operating room.

The results of this study based on the existing facts and using grounded theory showed that the situation of operation room is different from the other sections of the hospital. Gaining surgical team membership and capacity and professional competence of operative room technology students were increased with an experienced and teaching-oriented instructor, student's individual efforts, and learning of surgical team member.

Financial support and sponsorship

The present study is financially supported by Mashhad University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The present article is extracted from a PhD dissertation approved by Mashhad University of Medical Sciences (MUMS) Vice- Chancellor for Research (approval code: 940548) and financially supported by MUMS and School of Nursing and Midwifery, Mashhad, Iran. The authors thank all the teachers, students and operation room staff who contributed to this research despite their lack of time.

• Case report
• Open access
• Published: 17 August 2024

Virtual reality: a game-changer in the diagnosis and surgical planning of astrocytoma grade III: a case report

• Mohammed Alhamood   ORCID: orcid.org/0009-0009-5366-0225 1 ,
• Amin Abbass 1 &
• Rida Hasn 2  

Journal of Medical Case Reports volume  18 , Article number:  388 ( 2024 ) Cite this article

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In the dynamic realm of modern medicine, the advent of virtual reality technology heralds a transformative era, reshaping the contours of diagnosis and surgical planning with its immersive prowess. This study delves into the groundbreaking application of virtual reality in the intricate dance of neurosurgery, particularly spotlighting its role in the management of astrocytoma grade III—a cerebral challenge of significant complexity.

Case presentation

A 30-year-old Middle Eastern man from Syria grappled with the invisible tendrils of pain, manifesting as persistent headaches and a numbing sensation that crept into his neck and extremities. For two relentless months, the morning sun brought not hope but an intensification of his agony, rendering him unable to partake in the daily dance of life. The usual sentinels of relief, analgesic drugs, stood defeated, offering no respite. The neurological examination was normal, there were no pathological findings on sensory and motor examination, and he exhibited normal reflexes and neither meningeal nor cerebellar signs. He showed a family history of breast cancer. The initial foray into the enigmatic depths of his brain via computed tomography and magnetic resonance imaging imaging unveiled a finding in the right temporal lobe, a lesion that suggested something more sinister. Previous medical interventions included analgesic medications prescribed for persistent headaches, but they offered no relief. No other therapeutic interventions were administered prior to the current diagnosis. It was here that virtual reality technology emerged not as a mere tool but as a beacon of precision, casting a three-dimensional light on the shadowy intruder. This technological marvel allowed for meticulous measurement 21.8 × 14.5 mm and localization within the temporal theater, setting the stage for what was to come. With the path laid clear, the patient embarked on a surgical odyssey, a quest to excise the unwelcome guest. The operation was a triumph, a testament to human ingenuity and the symbiotic relationship between flesh and machine. The postoperative verdict was delivered through the lens of histopathology, confirming the presence of an astrocytoma grade III, a cerebral interloper known for its rapid proliferation. The battle, however, was far from over. Complementary radiotherapy and chemotherapy were enlisted as allies in this ongoing war, their potent forces working in concert to stave off the cellular insurgence. The patient’s journey through the healing arts was charted by periodic clinical and neurological examinations, with laboratory tests and the vigilant gaze of brain magnetic resonance imaging ensuring a watchful eye was kept on any potential resurgence.

Conclusions

In this narrative of resilience and technological prowess, we witness the harmonious fusion of human touch and digital precision, a partnership that redefines the boundaries of medicine and the art of healing, by use of virtual reality technology in the diagnosis of astrocytoma and enhancing the accuracy, effectiveness, and safety of neurosurgical procedures, which can ultimately benefit patients with brain tumors.

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Introduction

Astrocytoma, the insurgent of the brain, defies the conventional boundaries of medical intervention. It is within this intricate labyrinth that virtual reality (VR) emerges as a beacon of precision, guiding the surgeon’s hand through the neural tapestry with unparalleled clarity [ 1 ]. Recent scholarly pursuits have illuminated the efficacy of VR in enhancing diagnostic accuracy, offering surgeons a three-dimensional (3D) odyssey into the very heart of the tumor [ 2 , 4 ]. This virtual voyage not only demystifies the path ahead but also carves out a safer trajectory for therapeutic conquests, ultimately elevating patient outcomes to new zeniths (Fig.  1 ).

Illustration of an intracranial astrocytoma—Mayo Clinic

Our case report is a testament to this technological marvel, weaving together a narrative of innovation, determination, and hope. It underscores the symbiotic synergy between human intellect and technological advance, charting a course through the cerebral seas with VR as our compass.

As we navigate the complexities of astrocytoma grade III, we invite readers to embark on this journey with us, exploring the potential of VR to not just illuminate the present but also to sculpt a future where the once insurmountable is now within our grasp [ 3 ].

A 30-year-old Middle Eastern man from Syria, who is a nonsmoker, has been experiencing persistent headaches accompanied by numbness in the neck and extremities for the past 2 months. The headaches are particularly severe in the morning and significantly impair his ability to perform daily activities. Despite taking analgesic medication, there has been no relief of symptoms.

He reports an unintentional weight loss of about 5 kg (11 lbs) over the month preceding his hospital visit. Neurological examination revealed no abnormalities.

Medical history

The patient has a history of bilateral varicocele diagnosed in 2016, and a surgical history of nasal septum deviation correction performed in 2014.

Family history

There is a notable family history of breast cancer and type II diabetes mellitus (DMII).

Social and occupational history

The patient works in construction and real-estate offices. He leads an active lifestyle but has been significantly impaired by his symptoms over the past 2 months.

Timeline: a 30-year-old man with grade III astrocytoma

The complete timeline of the patient is illustrated in Fig.  2 .

Complete timeline of the patient

Diagnostic assessment

The diagnostic journey of gliomas typically commences with a neurological examination, and ophthalmology consultation followed by imaging studies.

Ophthalmology consultation for the patient

Examination of visual acuity was within normal in the eyes.

Retinal examination showed no bilateral papilledema.

Diagnostic methods

Magnetic resonance imaging (MRI) and computed tomography (CT) scans were used to evaluate the patient’s condition. Additionally, virtual reality (VR) technology was employed to visualize the tumor and plan the surgery.

We faced financial challenges related to the cost of advanced imaging techniques, as well as linguistic and cultural challenges in communicating with the patient and his family.

Prognostic characteristics

The tumor’s stage and characteristics were assessed using established criteria, and it was determined to be an astrocytoma grade III.

A noncontrast computed tomography (CT) scan was performed (Fig.  3 ) that revealed a hypodense area within the brain’s parenchyma, prompting further investigation with MRI [ 4 , 5 , 6 ].

A noncontrast head computed tomography (CT) scan revealing a small hypodense area in the right temporal lobe. The hypodensity point is indicated with an arrow, indicating the location of the astrocytoma

The MRI sequences in Figs.  4 , 5 , 6 , 7 ) provide a more detailed landscape of the tumor.

Magnetic resonance imaging (MRI) scan revealing T1-weighted images without contrast, indicating a small, low-intensity area in the right temporal region

Magnetic resonance imaging (MRI) T2-weighted imaging of the brain revealing a small high-intensity lesion in the right temporal lobe

Magnetic resonance imaging (MRI) T2-weighted imaging of the brain revealing no uptake of contrast

Magnetic resonance imaging (MRI) T1-weighted image of the brain post-contrast revealing a small high-intensity lesion in the right temporal lobe

T1-weighted images without contrast (Fig.  4 ) might show a low-intensity area, while T2-weighted and Fluid-Attenuated Inversion Recovery (FLAIR) sequences (Figs.  5 , 6 ) light up the lesion with high intensity [ 7 ]. The absence of contrast uptake on post-contrast T1 images (Fig.  7 ) often signifies a nonenhancing tumor, which can be characteristic of lower-grade gliomas [ 4 ].

In our landmark case, VR technology was employed to visualize a lesion within the right temporal lobe. The 3D rendering provided by the VR environment (Fig.  8 ; recorded videos 1 and 2), which allowed for precise measurements (21.8 × 14.5 mm) and localization (right temporal lobe), were instrumental to the successful resection of the tumor [ 5 ].

Using a virtual reality (VR) environment allowed for precise localization of a 21.8 × 14.5 mm mass in the right temporal lobe. The green arrow indicates the precise location and size of the tumor as measured using VR technology

The postoperative diagnosis of a grade III astrocytoma was confirmed histopathologically.

An astrocytoma grade III is a malignant brain tumor characterized by its rapid proliferation.

Postoperative care, including radiotherapy and chemotherapy for 6 months, was guided by periodic clinical assessments and follow-up MRI scans, ensuring a comprehensive treatment strategy [ 4 ].

The patient received postoperative care that included radiotherapy and chemotherapy for approximately 6 months. Treatment was guided by periodic clinical assessments and follow-up MRI scans, ensuring a comprehensive treatment strategy [ 4 , 5 , 6 ].

Current clinical status

The patient currently maintains a stable clinical condition with complete resolution of symptoms. Neurological examination is unremarkable, and there are no focal neurological signs. Regular follow-up is maintained, and the patient undergoes frequent clinic visits to monitor for any signs or symptoms of tumor recurrence (Figs.  9 , 10 ).

We acknowledge that detecting a tumor can be a frightening and overwhelming experience. At our hospital, we have a video that can help demonstrate how virtual reality can be used to detect tumors in our case study patients. We hope that this resource can provide some peace of mind and comfort during this challenging time. View video here: https://youtu.be/mJUgLRp_Uwg?si=wb_cFG2odO-Gk_MI

The recorded video provides a detailed guide on how to navigate a virtual reality environment to detect a tumor in a patient. The tutorial is based on the findings of our comprehensive case report and offers a step-by-step demonstration of the process. View video here: https://youtu.be/ltcOgOuq57o?si=-H6VokQAMLhGGVLD

Follow-up visits

The patient’s condition was monitored over several months through periodic clinical and neurological examinations, laboratory tests, and regular MRI scans to ensure there was no tumor recurrence.

Gliomas, the insidious inhabitants of the brain’s glial cells, account for a significant portion of brain tumors. These neoplasms, often interwoven with the brain’s normal parenchyma, present a formidable challenge in neuro-oncology [ 4 ].

Among them, astrocytoma stands out as the most common primary intraaxial brain tumor, with their spectrum ranging from the benign pilocytic astrocytoma in children to the dreaded glioblastoma multiform in adults [ 5 ].

Virtual reality (VR) has transcended its origins from Morton Heilig’s Sensorama and Ivan Sutherland’s head-mounted display to become a pivotal tool in modern medicine. In neurosurgery, VR’s immersive capabilities allow for the meticulous preoperative planning and rehearsal of complex procedures. The Medicalholodeck program, for instance, enables surgeons to visualize and interact with patient-specific 3D models, derived from actual patient scans, facilitating a deeper understanding of the tumor’s spatial relationships and surgical approach [ 4 ].

In our pioneering case, VR technology was used to visualize a grade III astrocytoma in the right temporal lobe. The 3D VR rendering allowed for precise tumor measurements and localization, crucial for its successful surgical removal [ 5 ].

The potential of VR in neurosurgery is vast, yet it is not without its challenges. The cost of implementation, the need for quality enhancement, data security concerns, and the potential for adverse health effects are significant barriers to its widespread adoption [ 8 , 9 ]. Moreover, the rapid pace of technological advancement demands continuous education and adaptation among medical professionals.

In the discussion of integrating virtual reality (VR) in the medical landscape of Arab countries, we encounter a multifaceted array of challenges that must be navigated with both precision and cultural sensitivity. The scarcity of infrastructure—including the essential technological backbone of internet connectivity, electricity, and VR-specific hardware—poses a significant barrier to the adoption of VR in medical practice [ 8 ]. This is compounded by the absence of robust legislation that would delineate the rights and responsibilities of all stakeholders, from healthcare providers to patients and technology vendors.

Moreover, the paucity of research tailored to the Arab context limits our understanding of VR’s potential impact on patient care, necessitating a concerted effort to foster studies that illuminate the benefits and implications of VR in medicine. This gap in knowledge is further exacerbated by a lack of collaborative initiatives that would bridge the divide between academia, industry, and governance, essential for nurturing an ecosystem conducive to VR’s growth [ 10 ].

Resistance to change is a human trait, and in the Arab medical community, this manifests as hesitancy toward VR adoption. Overcoming this requires building trust through education, demonstrating efficacy and ensuring cultural congruence in VR applications [ 8 ].

Comparison between traditional and VR approaches

Traditional imaging techniques such as MRI and CT scans can be limited in some cases owing to the inability to accurately visualize the precise relationships between the tumor and surrounding structures. However, VR provides a precise 3D visualization, facilitating surgical planning and reducing potential complications. Studies show that the use of VR can improve the accuracy and safety of surgery by enabling surgeons to plan meticulously and better visualize complex tissue relationships.

Addressing the delay in diagnosis, particularly in pediatric brain tumor cases, is paramount. The study “Factors associated with delayed diagnosis among Filipino pediatric brain tumor patients: a retrospective review” sheds light on the myriad factors contributing to diagnostic delays [ 11 ]. Incorporating VR into diagnostic protocols could serve as a catalyst for earlier detection and intervention, potentially improving prognosis and survival rates [ 7 ].

Early diagnosis using virtual reality

The study “Factors associated with delayed diagnosis among Filipino pediatric brain tumor patients: a retrospective review” highlights various factors contributing to diagnostic delays. Integrating VR into diagnostic protocols could serve as a catalyst for earlier detection and intervention, potentially improving prognosis and survival rates. In our case, the use of VR helped precisely locate the tumor and effectively plan the surgery, leading to improved therapeutic outcomes.

In essence, the integration of VR in neuro-oncology within Arab countries is not merely a technological upgrade but a complex interplay of infrastructure, legislation, research, collaboration, and cultural adaptation. It is a journey that, if embarked upon thoughtfully, could redefine the horizons of patient care and medical education in the region.

The case of the grade III astrocytoma underscores the transformative power of VR, suggesting a future where virtual simulations and reality coalesce to elevate the standards of healthcare delivery [ 12 ].

The integration of VR in neuro-oncology represents a paradigm shift in the diagnosis, planning, and execution of neurosurgical interventions. As we navigate the complexities of this technology, it is crucial to address the challenges it presents to unlock its full potential in enhancing patient outcomes in the realm of neurosurgery.

The case of the grade III astrocytoma serves as a testament to the transformative impact of VR, heralding a new era in medical practice where virtual and reality converge for the improvement of patient care.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

• Virtual reality

Three-Dimensional

Magnetic Resonance Imaging

Computed Tomography

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Acknowledgements

Our heartfelt thanks go out to the Military Medical Services Administration, Dr. Ammar Suleiman, and the administration of Tishreen Military Hospital, Dr. Moufid Darwich. We are deeply grateful to the compassionate and dedicated medical staff at the hospital, as well as the administration of the Medicalholodeck program, Mr. Christof von Waldkircle, for their unwavering commitment to providing exceptional patient care. Without their tireless efforts, this report would not have been possible. We extend our warmest appreciation to every one of them.

This research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors.

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All authors contributed to the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the manuscript, and revising it critically for important intellectual content. All authors have read and approved the final manuscript.

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Alhamood, M., Abbass, A. & Hasn, R. Virtual reality: a game-changer in the diagnosis and surgical planning of astrocytoma grade III: a case report. J Med Case Reports 18 , 388 (2024). https://doi.org/10.1186/s13256-024-04679-w

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DOI : https://doi.org/10.1186/s13256-024-04679-w

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