Patient outcomes in augmented reality-assisted minimally invasive

surgery: A systematic review

Erika Johannessen, Katie VanTil, and Colin Goodman

Abstract
Background: Over the past few decades, advancements in computer science and engineering
have led to the development of augmented reality technologies, which superimpose 3-
dimensional virtual objects onto the real-world view, providing an enhanced experience for the
user. One application of augmented reality is in minimally invasive surgery, where patient
imaging can be overlaid on the surgeon’s field of view to provide vital information about
anatomical structures that are otherwise obstructed or hidden. Despite the applicability of
augmented reality to minimally invasive surgery and its potential contribution to the future of
medical science, its benefit to the patient is largely unknown and unproven.

Objective: This systematic review investigates the patient outcomes of augmented reality-
assisted minimally invasive surgery reported in the literature.

Methods: PRISMA standards were followed. Nine studies were selected from a search of
MEDLINE, Pubmed, EMBASE, OVID Healthstar, Web of Science, Engineering Village, and CINAHL
databases. Information was extracted about technology design, patient outcome measures,
surgical procedure, and clinical implications.

Results: Nine studies met the inclusion criteria of this review. Implementation of augmented
reality in minimally invasive surgery can be characterized by the method of image integration
onto the operative field of view. Overall, very few studies were found that reported patient
outcomes, with most focusing instead on subjective accounts and comments on technological
feasibility.

Conclusions: Although a variety of patient outcome measures were reported in the studies
included this review, there is still a considerable opportunity to improve the rigor with which

i
augmented reality-assisted surgical research is done. More studies featuring randomized
controls are needed to prove the benefit of this technology to patients.

Table of Contents
Abstract ........................................................................................................................................ i
Introduction ................................................................................................................................ 1
Methods ...................................................................................................................................... 4
Study Eligibility ........................................................................................................................ 4
Search Strategy ....................................................................................................................... 4
Study Selection........................................................................................................................ 5
Data Extraction and Synthesis ................................................................................................ 6
Results ......................................................................................................................................... 7
Study Characteristics............................................................................................................... 7
Patient Outcomes ................................................................................................................... 8
Methodological Quality .......................................................................................................... 9
Publication by Year ............................................................................................................... 10
Discussion.................................................................................................................................. 11
Emergent Themes ................................................................................................................. 11
Quality of Research ............................................................................................................... 16
Ongoing Challenges .............................................................................................................. 20
Limitations of the Review ..................................................................................................... 21
Conclusions ............................................................................................................................... 22
Appendix A: Study Characteristics by Theme ........................................................................... 23
Appendix B: Search Strategy by Database ................................................................................ 25
Appendix C: Medline Search Strategy (OVID Search Engine) ................................................... 26
Appendix D: PRISMA Checklist .................................................................................................. 27
References ................................................................................................................................ 29

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Introduction
Modern advancements in engineering and medical science have led to the development

of new technologies that make surgical procedures faster, safer, and less traumatic for the

patient [1]. Improvements in medical device engineering and imaging technology have made it

possible for surgeons to perform highly complex surgical procedures through very small incisions,

limiting the risk of infection for the patient [2]. Over the past twenty years, minimally invasive

surgery has become the preferred technique across many specialties of medicine because it

drastically decreases the length of hospital recovery time for the patient [2]. Unlike traditional

open surgery, minimally invasive procedures are performed using a combination of thin-needles

and an endoscopic camera to guide the operator through the procedure [3]. Although minimally

invasive techniques reduce postoperative pain and offer patients improved cosmetic outcomes,

there are several setbacks associated with this approach [4]. For example, with limited access to

internal organs, surgeons cannot rely on their tactile feedback for palpation of anatomical

landmarks or tumor boundaries which are visually hidden [4]. Additionally, endoscopic

navigation in minimally invasive surgery is often done on a two dimensional display, which

eliminates the operator’s depth perception and encumbers hand-eye coordination, leading to a

potential increase in operative time [4]. To help combat challenges from the restricted field of

vision, the adoption of augmented reality techniques in minimally invasive surgery have allowed

for an enhanced surgical view by incorporating additional medical images onto the operative

field. In this way, the use of augmented reality combines the advantage of direct visualization

that is achieved through the traditional open surgery with the patient benefits of minimally

invasive surgery.

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 With the use of ultrasound, CT scans, MRIs, and other imaging techniques, physicians are

now able to create highly accurate three-dimensional reconstructions of individual patient

anatomy to make informed decisions for disease treatment and surgical intervention [5]. These

reconstructions can be used during surgery where the surgeon has real-time access to the

reconstructed images fused with the real environment, creating an augmented reality. In the

broad sense, augmented reality is defined as adjusting the natural feedback to the operator using

simulated cues [6]. This augmentation can be accomplished using an optical head-mounted

display where the user can see directly through a semi-transparent display medium to the real

world fused with projected virtual images [6]. Alternatively, a monitor-based display can be used

in which the computer generated images are digitally overlaid onto live or stored video feeds [6].

As this technology has developed, it has been found to have many potential applications in

surgical practice ranging from training simulations to use in the operating room [7].

The conventional approach for augmented reality to be implemented in the operating

room requires three main steps to take place (Figure 1) [8]. Using modern imaging techniques,

pre-operative or intraoperative scans are taken of the area of interest. These images are then

digitally overlaid onto the patient in real time, enhancing the surgeon’s field of view.

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 Patient •Ultrasound, CT scans,
Imaging MRIs

Computer •Patient images are

mapped onto real
Reconstruction environment

•Augmented realty is
Enhanced presented to surgeon
Surgical View via "see-through" or
monitor based display

Figure 1: Three main steps to implement AR in the operating room

Because of the relative infancy of both augmented reality and minimally-invasive surgery,

few studies have examined the clinical implications of the combined use of these technologies.

Previous reviews have investigated the use of augmented reality in training only [9] and in

neurosurgery [10], but few have focused on the broad impact of this technology on patient

outcomes. Another review published in 2004 by Shuhaiber investigated the current state of

augmented reality and its bearing on surgical training, education, and patient treatment. The

authors concluded that due to the preliminary stage of the technology, further research was

required to fully assess its long term clinical impact on patients, surgeons and hospital

administration [11]. Since 2004, several advancements have been made in the field of

augmented reality, from improved rendering capabilities, image quality, and the popularization

of head-up displays. As such, this systematic review aims to included more recent developments

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in augmented reality-assisted minimally invasive surgery reported in the literature, specifically

those which report patient outcomes.

Methods
This review was planned, conducted, and reported in adherence to PRISMA quality standards

[12].

Study Eligibility

Inclusion criteria were established following the Cochrane Review Protocol and organized

according to the PICOS framework [12], [13]. The search included: Population: human surgical

patients; Intervention: augmented reality-assisted minimally invasive surgery; Comparison:

surgeries with and without augmented reality assistance; Outcome: patient outcomes.

Only English or translated to English peer-reviewed articles and conference proceedings

were included in this review. To ensure consistency and reliability of outcome measures, we

excluded studies featuring surgeries performed by medical students or surgical trainees. We also

excluded studies that included robotic co-intervention and those that used augmented reality for

preoperative planning purposes only. Lastly, studies that used cadavers or phantom patients

were excluded. No exclusions were made based on publishing year, age of participants, medical

diagnosis, or geographic location.

Search Strategy

A database search strategy was initially developed by the team of researchers (E.J., C.G.,

and K.V.) and further refined after consultation with a librarian from the Bracken Health Sciences

Library of Queen’s University. The following seven databases were chosen and searched in

4
February 2018: MEDLINE, Embase, Ovid Healthstar, Pubmed, Cumulative Index to Nursing and

Allied Health Literature (CINAHL), Engineering Village, and Web of Science. These databases were

selected to provide a comprehensive search through the libraries of medicine, biomedical

research literature, nursing research, engineering research and patents, and multidisciplinary

scholarly journals.

Combinations of key terms were used to generate a text string which was used to search

databases and can be seen in Appendix B. These three groupings of key terms were used to

search for studies involving augmented reality and similar technologies, minimally invasive

surgery, and reported patient outcomes. These groups were combined to give a final search

result with studies containing all three term categories. Search results were further refined to

only include studies written or translated to English, the spoken and written language of the

research team. A summary of the search protocol and number of results can be found in

Appendix B, and the MEDLINE search strategy can be viewed in Appendix C.

Study Selection

To identify all papers relevant to our topic, a multistage review process was adopted. For

each stage, two raters independently reviewed each reference and disagreements were resolved

by discussion. Every effort was made to avoid bias between reviewers by ensuring the review

process was independent and blinded.

In the first stage of the review, titles and abstracts were screened for studies that

implemented augmented reality or virtual reality technologies in minimally invasive

surgery. Sources were classified in Excel as either “yes,” “no,” or “maybe” based on their

5
adherence to the inclusion and exclusion criteria. Articles that focused on the use of augmented

reality for medical simulation or surgical training purposes were excluded. In the second stage

of the sorting process, we further refined our inclusion criteria to studies which reported patient

outcomes in the abstract or title. We searched specifically for terms including operative time,

postoperative complications, self-reported pain, and length of hospital stay. During the third and

final stage of the review, a list of full text papers that fit the criteria of the review was compiled.

For some titles, only abstracts were available and full text articles were not accessible online. In

these cases, the review team contacted authors directly for full-text access.

Data Extraction and Synthesis

Each full text article was then assessed independently by two reviewers using the

McMaster School of Rehabilitation Science Critical Review Form for Quantitative Studies [14]. As

a group, the authors compiled the critical review forms to summarize the main results that were

applicable to this review. A key objective of this review was to discover whether the use of

augmented reality assistive technology improved patient outcomes when used in the context of

minimally-invasive surgery. As such, a coding scheme was developed to extract the following

information from each study: name of authors, year of study, number of patients, study type,

surgical procedure, branch of medicine, imaging type, AR design, technology development stage,

outcome measures, clinical implications, and study bias. The stage of technological development

was determined as “prototype” if the software was developed by the researchers themselves

and “developed” if commercially available licensed software was used. The quality of each article

was also assessed according to the Sackett’s Level of Evidence guidelines [15].

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Results

The initial database searches yielded a total of 2228 titles after the removal of duplicates

(Figure 2). Three hundred and forty-four articles met the criteria of the first stage of the review

and 23 sources went to full text review. A total of eight studies remained that met the criteria

for the review and one additional relevant paper was found through reference screening. Two

of the nine total papers were only available in abstract form [16], [17]. All first authors of these

abstracts were contacted via email, but unfortunately, we were unable to gain access to any of

the full text versions due to confidentiality issues.

Figure 2: PRISMA Diagram of Study Selection

Study Characteristics

The nine final papers resulted in a total of 208 participants on which surgical interventions

were performed. One hundred and thirty-four surgeries were done with the use of augmented

reality technology and 74 were done without the use of augmented reality. Only two studies

7
reported a surgical control without the use of augmented reality [18], [17]. Seven of nine studies

featured augmented reality technologies in the design and prototype stage of development,

indicating a lack of an industry standard. These studies focused on establishing a proof-of-

concept for augmented reality technology in human surgery.

The design features of each study were also noted, including the type of image capture,

time of image capture in relation to the surgery, method of image overlay, and software used.

All studies used one or more forms of medical imaging to generate visualizations of the target

area for the surgery. The medical imaging techniques used in the studies were

immunofluorescence, CT scans, ultrasound, and MRI. CT scans were the most commonly used

technique with four studies solely using it [18]–[21] and one study using a combination of CT

scans and MRI [22]. Methods of image overlay and software varied across studies. Lastly, clinical

implications of the technology were noted and included subjective accounts on technological

feasibility and expert opinions. A summary of the extracted study characteristics can be seen in

Appendix A.

Patient Outcomes

The reported patient outcomes were not consistent across studies. Figure 3 shows a

breakdown of the patient outcomes most commonly reported in the literature. Due to the

variety of surgical procedures included in this review, outcomes pertaining to specific surgeries

(for example, intraperitoneal hemorrhage) were not included in the figure.

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 8
7
6

Number of Studies
5
4
3
2
1
0

Figure 3: Patient outcomes reported in included studies

Operative time was the most commonly reported outcome with seven of nine studies

reporting this measure. Only two studies were found that compared the surgical times between

the particular surgery performed with or without the AR technology [18], [17]. One study

investigated the use of augmented reality in single incision laparoscopic surgery (SILA) [] and the

other examined the use of ICG immunofluorescence in pure laparoscopic hepatectomy []. The

reduction in operating time was only found to be significant in the study involving SILA (p=0.05)

[18]. These two studies also compared the blood loss and hospital stay of the patients, but

neither reported statistically significant differences for the two measures.

Methodological Quality

Overall, the levels of evidence of the articles reviewed were very low. Seven of the nine

articles were case series studies, where information was only presented regarding the outcomes

of the group of patients and contained no comparison between patients with and without the

selected intervention [15]. This yielded a level of evidence of five [15]. Two articles reported

9
nonrandomized historical cohort comparisons between those patients who did and did not

receive the intervention of augmented reality-assisted surgery. For these studies, a level of

evidence of four was assigned, as the patients used for the comparison without the use of

augmented reality had undergone the surgery in an earlier time period at the same institution

[15]. Lastly, one article was determined to be a nonrandomized concurrent control trial and was

assigned a level of evidence of three [15].

Publication by Year

Figure 4 shows the resulting numbers of studies per year from the initial search results

after deduplication before screening was done. The result shows that research on the application

of augmented reality in surgery has increased greatly within the last decade. It should be noted

that many titles were excluded because they reported the use of augmented reality for surgical

training and planning purposes but did not actually implement augmented reality in the

operating room.

Figure 4: Histogram of study publication dates from initial database search

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 Discussion
Emergent Themes
From the nine total studies included in our review, three main themes were developed, based

on the method of image integration onto the operative field of view. In preoperative imaging

augmented reality, patient imaging is captured prior to surgery and three dimensional models of

internal structures are rendered prior to surgery and overlaid onto the endoscopic screen. In

contrast, intraoperative imaging augmented reality renders patient data in real time with the use

of live-imaging techniques such as open MRI and ultrasound. Lastly, inside out tracking uses

special markers and motion tracking cameras to define organ boundaries that can deform with

tissue movement. A breakdown of each theme and the relevant papers is featured in Appendix

A.

i. Preoperative Imaging
Preoperative imaging augmented reality involves the use of medical images of the patient

taken prior to surgery of the area of interest. One of the primary benefits of this form of

augmented reality is the lack of pre-processing required to create 3D visualizations from CT and

MRI scans [23]. The use of preoperative images in forming an augmented reality is most common

in the areas of neurosurgery, otolaryngology, and orthopedics, where the target organs are rigid

and have a constant spatial relationship to anatomical landmarks [24]. There were three studies

reviewed which involved the use of this augmented reality technique. One using CT scans and

another both CT scans and MRI images that were reconstructed in 3D and superimposed onto

the laparoscopic or endoscopic video screen during surgery [18], [22]. The third study was

conducted using the Android app “Sina Neurosurgical Assist” to view CT scan images

superimposed onto the patient’s head using a smartphone’s camera and screen [21].

11
 The use of preoperative CT scans to enhance the endoscopic video was able to

significantly reduce the time taken to perform single-incision laparoscopic adrenalectomies [18].

It was found that during minimally invasive cardiac surgery, the operation time, rather than the

length of skin incision, had a greater impact on the patient’s postoperative outcomes [25]. As

such, a reduced operative time through the use of augmented reality in minimally invasive

surgery is considered a positive patient outcome.

Surgery performed to remove intracerebral hematomas using the Android app to create

and segment reality resulted in good patient outcomes overall and a relatively short duration of

surgery; however, these statements did not include quantitative results or comparisons [21].

Additionally, it was noted that no patients experienced postoperative rebleeding, a complication

that is associated with poor postoperative outcomes [21],[26]. The mean preoperative Glasgow

Coma Scale (GCS) score (6.7 ± 3.2) was compared to those recorded one week after the

hematoma evacuation occurred (11.9 ± 3.1) and showed significant improvement (p<0.01) [21].

Although the increase GCS scores is promising, it is still unclear whether there is benefit to the

patient from the use of augmented reality in evacuation of spontaneous intracerebral

hematomas [27].

Another study found the addition of augmented reality very useful for tumor location

during pediatric surgery, as six tumors were successfully detected using the augmented reality

navigation system and were resected without complications [22]. However, the preoperative

image augmented reality system could not be used for tumor detection and resection in one

patient due to intraoperative organ deformation of the liver [22]. This study exemplifies the

drawback to this imaging technique; static CT or MRI images are no longer accurate when
12
 intraoperative tissue displacement has occurred [7]. Overall, the use of preoperative imaging in

augmented reality is useful for positioning and locating areas of interest, but is not useful when

there is tissue deformation during surgery.

ii. Intraoperative Imaging

Conventional navigation systems used in operating rooms rely on preoperative images

that do not reflect changes in anatomy due to organ deformation and shift during surgery [24].

The inability to reflect these changes has caused inaccurate targeting and major limitations to

navigation [7]. By providing real-time updates throughout the surgical process, the navigation is

made more accurate throughout the entire procedure [28]. The intraoperative imaging studies

in this review used immunofluorescence, CT scans, laparoscopic ultrasound, and MRI to image

during the surgeries. Although perioperative imaging is commonly performed in the operating

room, augmented reality technologies allow the fusion of these images onto the endoscopic

view, providing information about anatomical structures in real time.

No major complications or mortality were reported in any of the studies featuring

intraoperative imaging techniques. All augmented reality systems were found to be helpful in

visualization during the surgeries, allowing the additional visualization of structures or tumors

that would not normally be visible through traditional means. The stereoscopic augmented

reality reported a small five minute addition to the operating room setup time with the inclusion

of the augmented reality system [16]. As the operating room setup time for a conventional

laparoscopic cholecystectomy only takes approximately ten minutes, the additional cost of five

minutes was deemed acceptable [16]. The study featuring radiofrequency trigeminal rhizotomy

(RFTR) surgery for trigeminal neuralgia (TN) using the addition of virtual images concluded that

13
 through the more accurate guidance, there is potential to decrease complications and pain

recurrence after RFTR [19].

The ICG immunofluorescence technique was used in a laparoscopic hepatectomy to

thoroughly highlight the liver tumor throughout the surgery. Indocyanine green (ICG) is a sterile,

anionic, water-soluble, tricarbocyanine molecule which, when injected into the vascular system,

binds to plasma proteins and can highlight areas of interest. Based on the ability for ICG to

become fluorescent when excited by near-infrared light, real-time intraoperative organ

evaluation can be used in clinical applications, such as the detection of cancerous tissue [29]. The

study from The University of Hong Kong concluded that the short-term outcomes from the

technique were equally viable compared to the conventional technique [17]. This method lead

to the identification of three additional tumors which would have otherwise been missed, which

implies a positive patient outcome of the use of this technology [17]. Therefore, the use of

immunofluorescence is a promising augmented reality technique that may facilitate easier

identification of tumors during laparoscopic procedures in the future.

iii. Inside-out Tracking

One of the greatest challenges to the success of augmented reality-assisted surgery is

how to account for the movement of “unconstrained” organs in the thoracic and abdominal

cavities that occur during the surgery, as pre-operative imaging techniques only provide static

organ location, reducing the value of this data [7]. Unlike rigid anatomy, soft tissues are prone

to unpredictable organ shift and tissue deformation, often caused by patient movement, patient

breathing, and heartbeat as well as movement resulting from surgical manipulation itself [7]. In

endoscopic thoracic and abdominal surgeries, there is a lack of anatomical reference points,

14
making it difficult to create constant spatial relationships between target structures to provide

adequate orientation [7]. To overcome the organ shift and tissue deformation that occurs in soft

tissue surgery, the inside-out tracking method has been developed. First, custom navigational

aids are inserted into the organ of interest. An algorithm is run that allows for the tracking of the

navigational aids, enabling real time tracking of the target organ. Using preoperative images, a

3D reconstruction is created and a colour code is used to identify each anatomical structure of

interest. The reconstructed virtual images of the organ in real time are superimposed onto the

endoscopic video [20], [30].

The inside-out method of augmented reality was used in two studies, each requiring

precise removal of cancerous soft tissue. Both studies were conducted without complications

and no surgeries were reported to require conversion to open surgery. All surgeries performed

using inside-out tracking reported negative surgical margins, indicating that the resected tissue

did not contain any cancerous cells at the outer perimeter [20], [30]. In two surgeries, it was

noted that the use of augmented reality allowed for the visualization of hidden accessory vessels

during a laparoscopic partial nephrectomy [20]. By successfully avoiding these vessels, no

additional surgical time was required to perform repairs [20]. In a preliminary study using this

technology during a laparoscopic radical prostatectomy, it was suggested that this method of

navigation system can help in nerve sparing, leading to improved patient continence and potency

following the surgery [30]; however, these reported values were not compared to those obtained

without the use of augmented reality. Overall, it was concluded that the use of inside-out

tracking is feasible for clinical use and has the potential to simplify the surgery and increase tool

precision [20], [30].

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Quality of Research
Levels of Evidence
A general low level of evidence was common among the studies reviewed, with few

featuring a control group. Although case series studies can be useful in determining the feasibility

of augmented reality in minimally invasive surgery, the lack of a control group prohibits

conclusions regarding patient outcomes. For example, operative times were reported in most of

the case series studies, but without comparison to a control group, this measure does not provide

any insight into the patient benefit of this technology. As each of the studies included in this

review involved different types of minimally invasive surgery, it was not possible to compare the

operating times between the studies either. The operative times reported may have been

influenced by the additional time required for the implementation of augmented reality in the

operating room. To inform the benefit of augmented reality as a clinical intervention, all variables

must be controlled, which can be very challenging for in vivo interventional experiments [8].

It was noted that a large number of titles returned in the initial search were feasibility and

proof-of-concept studies that did not critically examine the benefits of the technology to the

patient and only provided qualitative parameters of a subjective nature. Although expert opinion

holds value in clinical settings, only quantitative measures of patient outcomes provide concrete

evidence of clinical feasibility of new technologies. As such, future studies featuring the use of

augmented reality in minimally invasive surgery should take care to report quantitative measures

of patients.

Studies Featuring Controls

From the two studies featuring control groups, the results suggest that there is a potential

benefit to the patient when augmented reality is used. The median operating times were shorter

16
for the patients undergoing augmented reality assisted surgery; however, only in SILA was the

time found to be significantly improved [18], [17]. The median blood loss and hospital stays in

both studies were found to be less when AR techniques were employed, but the difference was

not statistically significant from those in which conventional minimally invasive surgeries were

performed. In both studies, augmented reality-assisted minimally invasive surgery was

performed on only a small group of patients, limiting how the generalization of the results of

these studies can be applied to augmented reality assisted surgery as a whole. Another limitation

of the study performed using ICG is that the surgeries performed using conventional minimally

invasive surgical procedures were recorded over a three-year period and compared

retrospectively. By using historical data from previously conducted surgeries, is possible that

inappropriate comparisons may have been formed limiting the level of evidence of this study

[15]. Due to the limitations of these comparison studies, it can only be concluded that there is

potential benefit to patient outcomes with the use of augmented reality in minimally invasive

surgery, but further studies with a higher level of evidence are required to make definitive

conclusions.

Stage of Development
A significant number of studies were excluded from the first title and abstract screening

process because they tested augmented reality technology in surgery on animal models,

phantom patients, or cadavers. This observation suggests that augmented reality as a medical

intervention is still in the design and testing stage of research and that studies involving human

patients and controls may be on the horizon. Figure 5 shows typical life cycle of clinical trials as

reported by the Ontario Institute for Regenerative Medicine. Because there are relatively few

17
studies involving live patients reported in the current literature, it is likely that research in

augmented reality-assisted minimally invasive surgery is still in the beginning phases of animal

and laboratory testing.

Figure 5: The four phases of human clinical trials [31]

Augmented reality technology has risen in popularity over the past ten years, which has

sparked the development of several new commercially-available devices such as Google Glass

and Microsoft HoloLens [32]. Prior to the release of these devices, augmented reality

technologies were considered to be bulky and cumbersome and were unsuitable for use in

surgery [33]. When plotted by year in Figure 4, our search results show a steady increase in

publications each year, with a spike in 2012. We hypothesize that this peak in publications may

correspond to the release of Google Glass in 2012 and its subsequent decrease in popularity since

then [32]. One editorial reports that using the currently available goggles in the operating room

is impractical and that the ideal augmented reality device in surgery should have a see-through

lens, such as a head-mounted device or mobile application, so that the surgeon can see the real

world in case there is a problem [34]. With mobile device processing speeds and image rendering

capabilities constantly improving, it is likely that new trends in augmented reality technology will

inspire further research into its use in the operating room.

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Identification of Bias
There were several sources of possible bias identified in the studies included in this

review. The risk of bias was consistent across all nine full text articles reviewed. Because the

topic of this review is centered on the success of a new technology in surgery, it is likely there is

some level of reporting bias in the literature. That is, only studies which show acceptable or

favourable patient outcomes are published [14]. For each study, there is a risk of sampling bias

for patients who underwent this experimental treatment [14]. Although most studies reported

that participants gave informed consent prior to surgery, it is not stated how participants were

chosen for study inclusion. Therefore, it is possible that patients were selected based on the

surgeon’s confidence in achieving a favourable outcome, perhaps influenced by the severity of

their disease or overall health at the time of treatment. For most studies, surgeons self-reported

the perceived usefulness of augmented reality in minimally invasive surgeries after operation

completion, which may have been influenced by recall bias. For qualitative measures such as

these, it is difficult to assess the reliability of outcomes, especially when researchers may directly

benefit from the technology’s success. Similarly, several studies were performed during the

prototype stage of technology development, with the creators of the technology being its

operators in the experiment. As such, it is probable that performance bias was present

throughout, since surgeons may have been influenced to perform better to improve study

outcomes [14]. To ensure quality and reliability of evidence in future studies involving

augmented reality- assisted minimally invasive surgery, care should be taken to minimize these

biases by using randomized controls.

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Ongoing Challenges
Due to the complex nature of merging the surgical field of view with patient data,

discrepancies between images and reality can cause considerable challenges to implementing

augmented-reality in the operating room. This issue is particularly exacerbated in soft-tissue

abdominal surgery, where organs may shift with movement and respiration [7]. For this reason,

augmented reality is currently most reliable for surgeries where the target is rigid, such as

orthopedics. However, as our review has shown, new advancements in soft tissue tracking offer

a promising solution to overcoming these issues. Although inside-out tracking is a fairly new

method, this surgical intervention is likely paving the way for the future of augmented reality-

assisted surgeries.

Because the field of augmented reality-assisted surgery is still in the early stages, efforts

to implement this technology have been widely independent and duplicative. For example, most

of the studies included in this review featured augmented reality devices made in-house using a

combination of existing imaging equipment and did not utilize commercially available

technologies, likely because there is no industry standard for modeling and communication of

intraoperative imaging data, tracking, and surgical planning [35]. This lack of standard obliges

researchers to develop most of the components of their own navigation systems, which increases

expense and time. For this reason, collaboration between institutions at the forefront of

augmented reality research may lead to more substantial advancements in the field, especially

for the newer and more complex inside-out tracking methods. Of the nine papers included in

this study, none were done in collaboration with engineering teams. One potential reason for

the lack of engineer involvement is that the presence of extra people in the operating room may

20
impede surgical workflow [36]. However, as an interdisciplinary research interest, the

advancement of augmented reality in surgery hinges on the involvement of medical specialists,

computer scientists, and engineers to build a more robust and reliable technology that will

ultimately benefit patients and improve surgical science.

Limitations of the Review

There are several limitations of this review. First, although the original goal of the review

was to compare patient outcomes in studies which conducted surgeries both with and without

the use of augmented reality assistance, only two studies featured control. As such, the review

criteria were modified to include papers which reported patient outcomes, even those that did

not have a control group. The issue with this approach is that the reported patient outcomes do

not bear much significance or scientific integrity without a control to compare them to. Although

measures like operative time and blood loss may be meaningful in other contexts, the clinical

implications of augmented reality in surgery are difficult to assess unless matched with controls.

Also, it is possible that relevant papers were missed in the initial sorting procedure because they

did not report patient outcomes in the abstract but did report them in the manuscript text.

Papers may have been missed that were not catalogued in the seven databases that were

searched, which would constitute database bias [37]. Furthermore, because we only searched

databases and did not hand-search journals or search engines, it is possible that source-selection

bias was present [37]. Additionally, because only English articles were reviewed, it is likely that

some papers that were published in languages other than English may have met our inclusion

criteria but were not found in the initial search [37]. Lastly, although every effort was made to

include a broad scope of search terms to encompass relevant articles, it is possible that some

21
surgical techniques or patient outcomes were not included in the search and may have been

excluded during the initial database search process.

Conclusions
This systematic review sought to investigate whether the use of augmented reality in

minimally invasive surgery improved patient outcomes. Although the initial database search

results seemed promising, very few papers were found to actually report patient outcomes of

these procedures, and instead featured case studies with subjective accounts on technological

feasibility. Of the nine studies that did report patient outcomes, the measures themselves varied

across studies, with only two including control groups. As such, the methodological quality of

the studies included in this review was generally very low, with small sample sizes throughout.

More studies featuring randomized controls are needed to evaluate the clinical implications of

this technology, and care should be taken to avoid bias of the operator. Furthermore, as there

are several methods of integrating patient imaging onto the operative field of view, there is likely

a lack of industry standard for augmented reality and a need for further collaboration between

medical specialists and engineers. Overall, the results of this review suggest that the use of

augmented reality assistive technology during minimally invasive surgery is useful for enhancing

surgical view, but there is currently not enough quantitative evidence to prove benefit to the

patient.

22
Appendix A: Study Characteristics by Theme
Table 1: Intraoperative Imaging
Level of Technology
Number of Study Branch of
Title Author Evidence Surgical Procedure Imaging Type AR Design Development Outcome Measures Clinical Implications
Patients Type Medicine
(Sackett's) Stage
The role of augmented reality by  Operative time
Two group Promising technique that
ICG immunofluorescence in pure Total: 80 Immunofluorescence  Blood loss
Cheung cohort Laparoscopic hepatectomy might facilitate easier tumor
laparoscopic hepatectomy for HCC With AR: 20 4 General Surgery Immunofluorescence overlaid onto laparoscopic Prototype  Hospital stay
(2017) study, ad (partial liver resection) identification during
and cirrhosis: A propensity score Without AR: 60 view  Postoperative
hock laparoscopic hepatectomy.
analysis complications
Accuracy and success level
Virtual reality imaging technique in Radiofrequency trigeminal rate of RFTR can be improved.
Total: 2769
percutaneous radiofrequency Meng Case series rhizotomy for the Intraoperative CT scan  Surgical complications Accurate location guided by
With AR: 26 5 Neurosurgery CT Developed
rhizotomy for intractable (2009) studies treatment of trigeminal images  Reoperation need 3D CT VR has the potential to
Without AR: 0
trigeminal neuralgia. neuralgia decrease complications and
pain recurrence after RFTR.
Total: 7 The technology will aid in the
Real-time laparoscopic
Stereoscopic augmented reality With AR: 4 visualization and accurate
Shekhar Case series Laparoscopic ultrasound images merged
visualization for laparoscopic Without AR: 0 5 General Surgery Laparoscopic Ultrasound Prototype  Operation time resection of sub parenchymal
(2015) studies cholecystectomy with live stereoscopic
surgery-initial clinical experience *Error with first lesions by minimally invasive
laparoscopic video
3 approaches.
 Hospital stay
Tumor ablation therapy of liver Prototype -  Morbidity
Total: 34 Intraoperative open MRI Using open MRI, a navigation
cancers with an open magnetic Maeda Case series combination of  Postoperative
With AR: 34 5 Percutaneous liver ablation General Surgery MRI and Ultrasound imaging combined with image integrating MRI and US
resonance imaging-based (2008) studies developed complications
Without AR: 0 ultrasound enabled real-time tumor
navigation system technologies  Intraperitoneal
hemorrhage

Table 2: Inside-out Imaging

Level of Technology
Number of Study Surgical Branch of
Title Author Evidence Imaging Type AR Design Development Outcome Measures Clinical Implications
Patients Type Procedure Medicine
(Sackett's) Stage
The AR navigation allowed
 Mean tumor size
Augmented Reality: A New Tool for the visualization of
Laparoscopic video screen  Time to implement
To Improve Surgical Accuracy Total: 10 Retroperitoneal accessory vessels that would
Teber Case series with superimposed virtual  Time to locate tumor
during Laparoscopic Partial With AR: 10 5 laparoscopic partial Urology CT Prototype have been obscured using
(2009) studies model, "inside-out"  Mean operation time
Nephrectomy? Preliminary In Without AR: 0 nephrectomy conventional means,
Vitro and In Vivo Results
technique  Warm ischemia time therefore reducing operating
 Complications time.
They believe that the AR
 Time required to set up
Augmented reality visualization Total: 1 Laparoscopic video screen navigation system can help
Simpfendo Transrectal and insert navigation
during laparoscopic radical With AR: 1 Case study 5 Radical prostatectomy Urology with superimposed virtual Prototype nerve sparing, which leads to
rfer (2011) Ultrasonography aids
prostatectomy. Without AR: 0 model improved patient continence
 Operative time
and potence.

23
Table 3: Preoperative imaging
Level of Technology
Number of Surgical Branch of
Title Author Study Type Evidence Imaging Type AR Design Development Outcome Measures Clinical Implications
Patients Procedure Medicine
(Sackett's) Stage
 Hematoma volume
pre-op and post-op
Image-guided endoscopic  Operation time
Total: 25 Smartphone camera and Resulted in good outcomes and
surgery for spontaneous Sun Case series Laparoscopic  Endoscopic op time
With AR: 25 5 Neurosurgery CT Android smartphone app Developed relatively short duration of
supratentorial intracerebral (2017) studies hematoma removal  Blood loss
Without AR: 0 "Sina neurosurgical assist" surgery.
hematoma  Pre-op and post-op
(1 week) GCS score
 Pre-op planning
The AR navigation system is
very useful for detecting
An augmented reality Various tumor removal unrecognized tumor location
 Postoperative
navigation system for pediatric Total: 6 procedures Laparoscopic video screen during pediatric surgery,
Souzaki Case series Pediatric complications
oncologic surgery based on With AR: 6 5 2 Laparoscopic CT and MRI with superimposed CT and Prototype especially endoscopic surgery.
(2013) studies Oncology  Operative time
preoperative CT and MRI Without AR: 0 2 Thoracoscopic MRI images The system could not be used
 Prognosis
images. 2 Laparotomy for tumor detection with liver
resection because of intra-
operative organ deformations.
Augmented reality single  Perioperative
Image-overlay system
incision laparoscopic Nonrandomized complications The AR method can reduce the
Total: 19 Single incision between real-time
adrenalectomy: Comparison concurrent  Morbidity operative time without causing
Lin (2018) With AR: 8 3 laparoscopic General Surgery CT laparoscopic view and a Developed
with pure single incision cohort  Operative time any additional mortality or
Without AR: 11 adrenalectomy reconstructed 3D surgical
laparoscopic technique comparison  Blood loss morbidity.
model
 Hospital Stay

24
Appendix B: Search Strategy by Database

Database Search Strategy # of Results Notes

MEDLINE Search performed through Ovid Search Engine. See Appendix C for search. 667 Limited results
to English

Pubmed ("AR" or "VR" or "augmented reality" or "mixed reality" or "virtual reality" or 868 Limited results
"head-up display" or "head mounted display" or "virtual displays" or “augmented to English
reality surgical”) AND TOPIC: (“minimally invasive” OR “laparoscopic” OR
“endoscopic” OR "surgery" OR "surgical") AND TOPIC: (“patient outcomes” OR
“patient care” OR “hospital stay” OR “self report” OR “operation time” OR
“operating time” OR “recovery time” OR "post operative")

Ovid Search performed through Ovid Search Engine. See Appendix B for search. 372 Limited results
Healthstar to English

Embase Search performed through Ovid Search Engine. See Appendix B for search. 1255 Limited results
to English

Web of ("AR" or "VR" or "augmented reality" or "mixed reality" or "virtual reality" or 885 Limited results
Science "head-up display" or "head mounted display" or "virtual displays" or “augmented to English
reality surgical”) AND TOPIC: (“minimally invasive” OR “laparoscopic” OR
“endoscopic” OR "surgery" OR "surgical") AND TOPIC: (“patient outcomes” OR
“patient care” OR “hospital stay” OR “self report” OR “operation time” OR
“operating time” OR “recovery time” OR "post operative")

Engineering ("AR" or "VR" or "augmented reality" or "mixed reality" or "virtual reality" or 872 Limited results
Village "head-up display" or "head mounted display" or "virtual displays" or “augmented to English
reality surgical”) AND TOPIC: (“minimally invasive” OR “laparoscopic” OR
“endoscopic” OR "surgery" OR "surgical") AND TOPIC: (“patient outcomes” OR
“patient care” OR “hospital stay” OR “self report” OR “operation time” OR
“operating time” OR “recovery time” OR "post operative")

CINAHL ("AR" or "VR" or "augmented reality" or "mixed reality" or "virtual reality" or 18 Limited results
"head-up display" or "head mounted display" or "virtual displays" or “augmented to English
reality surgical”) AND TOPIC: (“minimally invasive” OR “laparoscopic” OR
“endoscopic” OR "surgery" OR "surgical") AND TOPIC: (“patient outcomes” OR
“patient care” OR “hospital stay” OR “self report” OR “operation time” OR
“operating time” OR “recovery time” OR "post operative")

25
Appendix C: Medline Search Strategy (OVID Search Engine)
Database: Ovid MEDLINE(R), Ovid MEDLINE(R) Daily and Epub Ahead of Print, In-Process & Other Non-Indexed
Citations <1946 to Present>
Search Strategy:
--------------------------------------------------------------------------------
1 augmented reality.mp. (1171)
2 AR.mp. (47012)
3 exp virtual reality/ or virtual reality.mp. (7436)
4 mixed reality.mp. (153)
5 head-up display.mp. (66)
6 head up display.mp. (66)
7 virtual display.mp. (26)
8 augmented reality assisted surgery.mp. (2)
9 augmented reality surgical.mp. (12)
10 VR.mp. (6144)
11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 (59236)
12 minimally invasive.mp. (64077)
13 laparoscop*.mp. (124446)
14 endoscop*.mp. (215220)
15 surgical.mp. (1198468)
16 surgery.mp. (1140465)
17 12 or 13 or 14 or 15 or 16 (2054207)
18 patient outcome*.mp. (43258)
19 patient care.mp. or exp patient care/ (968924)
20 hospital stay.mp. or exp hospitalization/ (246028)
21 self report.mp. (61580)
22 operation time.mp. or exp operation duration/ (10554)
23 operating time.mp. or exp operation duration/ (10321)
24 recovery time.mp. (9034)
25 postoperative.mp. (706947)
26 post operative.mp. (51612)
27 post-operative.mp. (51612)
28 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (1659097)
29 11 and 17 and 28 (1075)

26
Appendix D: PRISMA Checklist
Reported
Section/topic # Checklist item
on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. i
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility i
criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions
and implications of key findings; systematic review registration number.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 3
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, 4
comparisons, outcomes, and study design (PICOS).
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, 4
provide registration information including registration number.
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, 4
language, publication status) used as criteria for eligibility, giving rationale.
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify 4-5
additional studies) in the search and date last searched.
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be 28
repeated.
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if 5-6
applicable, included in the meta-analysis).
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any 6
processes for obtaining and confirming data from investigators.
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and 6
simplifications made.
Risk of bias in individual 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this 21-22
studies was done at the study or outcome level), and how this information is to be used in any data synthesis.

27
Summary measures
Synthesis of results
Risk of bias across studies
Additional analyses
RESULTS
Study selection
Study characteristics
Risk of bias within studies
Results of individual studies
Synthesis of results
Risk of bias across studies
Additional analysis
DISCUSSION
Summary of evidence
Limitations
Conclusions
FUNDING
Funding
13 State the principal summary measures (e.g., risk ratio, difference in means). NA
14 Describe the methods of handling data and combining results of studies, if done, including measures of NA
consistency (e.g., I2) for each meta-analysis.
15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective 21-22
reporting within studies).
16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, NA
indicating which were pre-specified.
17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for 7-8
exclusions at each stage, ideally with a flow diagram.
18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) 26-27
and provide the citations.
19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). 21-22
20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each NA
intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. NA
22 Present results of any assessment of risk of bias across studies (see Item 15). 21-22
23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item NA
16]).
24 Summarize the main findings including the strength of evidence for each main outcome; consider their 11-18
relevance to key groups (e.g., healthcare providers, users, and policy makers).
25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval 21-24
of identified research, reporting bias).
26 Provide a general interpretation of the results in the context of other evidence, and implications for future 24-25
research.
27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders 25
for the systematic review.
28
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