Augmented reality-enhanced cadaver surgical training for head and neck surgeons: a proof-of-concept study

Augmented reality-enhanced cadaver surgical training for head and neck surgeons: a proof-of-concept study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Augmented reality-enhanced cadaver surgical training for head and neck surgeons: a proof-of-concept study Sohei Mitani, Masaharu Isshiki, Kayo Sakamoto, Eriko Sato, Yuki Irifune, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6775613/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Surgical proficiency is a critical factor influencing postoperative complications and treatment outcomes. However, ensuring sufficient surgical training hours has become increasingly challenging owing to advancements in medical technology, concerns about patient safety, and work-hour restrictions for trainees. To address these challenges, we developed an augmented reality-enhanced cadaver surgical training (AR-CST) system to supplement traditional training methods, and conducted a proof-of-concept study. Methods: We created augmented reality (AR)-based educational content, including a three-dimensional model for neck dissection, divided into nine procedural steps, and developed an application that projects the material as AR content onto the real world via a transparent head-mounted display. Otolaryngology–head and neck surgeons performed neck dissections on cadavers using this AR-enhanced system, followed by a questionnaire survey. The questionnaire employed a 5-point Likert scale to evaluate various aspects of the training experience. Results: Fourteen surgeons participated in the AR-CST and responded to the survey. The overall usefulness of AR-CST had a rating of 4.79±0.43 out of 5, with all participants giving a perfect score for the added value of AR compared to conventional training. The burden of viewing content through the head-mounted displaywas relatively low (1.57±0.76), and users highlighted the 3D anatomical references and hands-free material access as key advantages. Conclusions: This proof-of-concept study suggests that integrating AR technology with cadaver surgical training enhances procedural understanding and promotes self-directed learning. Combining the tactile realism of cadaver-based training with readily accessible AR-based virtual materials could be an effective approach for a more productive surgical education. augmented reality cadaver surgical training head and neck surgery head-mounted display three-dimensional Figures Figure 1 Introduction The surgical skills of surgeons are a critical factor that directly affects patient prognosis, including postoperative complications, recurrence rates, and mortality[ 1 – 3 ]. However, in recent years, it has become difficult to secure sufficient surgical training time owing to increasingly sophisticated medical technologies, heightened emphasis on patient safety, and restrictions on resident work hours. Therefore, relying solely on on-the-job training is no longer sufficient. Consequently, off-the-job training (OFF-JT) has become increasingly important. Cadaver surgical training (CST) has gained attention as a particularly valuable form of OFF-JT[ 4 ]. Simultaneously, since 2016, rapid technological advancements and the commercialization of virtual reality (VR) have led to the practical implementation of image processing technologies that merge the virtual and real worlds, such as augmented reality (AR)[ 5 – 8 ]. In this study, we designed an AR-enhanced cadaver surgical training (AR-CST) to improve the efficiency of surgical training and conducted a proof-of-concept. By projecting virtual educational materials onto AR using a see-through head-mounted display (HMD), trainees can practice on cadavers while referring to real-time surgical guidance. This study aimed to demonstrate the potential of combining digital information with traditional cadaver-based education to improve learning efficiency and comprehension. Materials and Methods Preparation of Educational Materials We developed educational materials for lateral neck dissection, the most common procedure among neck dissections, which is a gateway surgery for head and neck surgeons. First, two board-certified head and neck surgeons divided the neck dissection procedure into nine steps and organized the essential tasks for each step (Table 1 ). Next, for each of these nine steps, we prepared written instructions detailing the required techniques and sequences, surgical videos performed by an expert surgeon, and schemas to supplement the explanations. Furthermore, to facilitate the understanding of the three-dimensional (3D) anatomy, we created a 3D model of the neck using a previously described method[ 9 ]. Table 1 Nine steps of lateral neck dissection (Level II-IV) Step Description 1 Skin incision 2 Skin flap elevation 3 Lateral extent (posterior border of the sternocleidomastoid muscle) 4 Deep extent (above the deep neck fascia) 5 Inferior extent (anterior border of the clavicle) 6 Superior extent (posterior belly of the digastric muscle) 7 Level IIB (accessory nerve area) 8 Carotid sheath (jugular vein, carotid artery, and vagus nerve) 9 Medial extent (lateral border of the sternohyoid muscle) We obtained dynamic contrast-enhanced computed tomography images of a patient with a largely normal anatomical structure prior to surgery for a hypoglossal schwannoma. A head and neck surgeon and a radiological technologist segmented the bone and cartilage, blood vessels, glandular tissues, esophagus, and muscles using the ZIOSTATION workstation (Zaiosoft, Inc., Tokyo, Japan). Polygon (STL data) files of each segmented organ were exported, and a 3D computer graphics software (Blender version 3.2; Blender Foundation, Netherlands) was used to build a 3D model. Finally, we commissioned a 3D artist to add the relevant nerves, including the vagus, accessory, hypoglossal, cervical, and phrenic nerves, to complete the final 3D model. Projection of Educational Materials using AR To project the educational materials in AR, we used HoloLens 2 (Microsoft Corporation, Washington) as a transparent HMD. HoloLens 2 uses built-in sensors to recognize the spatial relationship between virtual materials and the real-world environment and supports gaze- and gesture-based controls. Once an HMD is worn, virtual materials can be anchored to any desired location in the physical space, allowing hands-free access at any time. The transparent lenses enable users to view virtual materials and the surgical field simultaneously. Members of the Faculty of Engineering developed an application using the Unity game engine (Unity Technology, San Francisco) to project educational materials on AR via HoloLens 2 (Fig. 1 A). With this application, trainees could freely reference the materials in real time during the CST and operate them using gaze input and fingertip gestures (Fig. 1BC, Video). Implementation of AR-CST Fourteen surgeons with 2 to 16 years of experience in otolaryngology participated in the AR-CST. Thiel-embalmed cadavers[ 10 , 11 ] were used for the training. After each training session, we administered a questionnaire using a 5-point Likert scale to evaluate the usefulness of the AR-CST. Values are reported as mean ± standard deviation unless stated otherwise. The questionnaire included open questions, so that the participants could describe positive aspects and areas for improvement. This study was conducted at an academic university hospital and was approved by the Institutional Review Board of XXXX (registration number: XXXX). Consent was obtained from both the individuals and their families for clinical research use, in addition to participation in dissection training. Written informed consent was obtained from all patients for 3D model creation and video recording. Results Fourteen participants from six institutions participated in the AR-CST (Table 2 ). Five participants served as primary surgeons and nine as assistants. The participants included four board-certified head and neck surgeons with > 50 cases of neck dissection. All participants completed the entire lateral neck dissection process from steps 1 to 9. The training sessions lasted between 60 and 120 min. Table 2 Participants’ characteristics Overall Primary surgeons Assistants Male/Female 10/4 4/1 6/3 Years as otolaryngologists Range (Median) 2–16 (8) 5–14 (8) 2–16 (5) Surgical cases < 10 8 3 5 10≤, < 50 2 1 1 ≤ 50 4 1 3 The results of the questionnaire are presented in Table 3 . The overall usefulness of the AR-CST had a high rating of 4.79 ± 0.43 out of 5 points. The added benefit of the AR content over conventional CST received a 5-point rating from all participants. The ease of AR content manipulation scored 4.07 ± 0.92 points, and the burden of viewing the content through the HMD had a relatively low rating of 1.57 ± 0.76 points. No major differences were observed between the responses of the primary surgeons and assistants. Table 3 Results of the questionnaire. Overall (n = 14) Primary surgeons (n = 5) Assistants (n = 9) Mean SD Mean SD Mean SD Usefulness 4.79 0.43 4.60 0.55 4.80 0.42 Additional educational value provided by the AR content 5.00 0.00 5.00 0.00 5.00 0.00 Ease of AR content manipulation 4.07 0.92 4.20 1.10 4.00 0.82 Materials Written instructions 4.79 0.43 4.80 0.45 4.70 0.48 Surgical videos 4.79 0.58 4.80 0.45 4.70 0.67 Schemas 4.93 0.27 5.00 0.00 4.80 0.42 3D models 4.79 0.43 4.80 0.45 4.70 0.48 Burden of viewing content through the head-mounted display 1.57 0.76 1.80 0.84 1.50 0.71 AR: augmented reality. 3D: three-dimensional. Regarding the positive aspects mentioned in the free-text description, participants noted the ability to train without soiling the educational materials, the convenience of referencing the content in parallel with the procedure, and the utility of the 3D model in facilitating comprehension of the 3D anatomy required for the procedure. However, negative opinions included that the HMD was sometimes uncomfortable and that becoming familiarized with its operation was time consuming. Discussion In this proof-of-concept study, we integrated AR and CST to create the AR-CST. By using a see-through HMD to project materials into the training environment, participants could refer to them in real time while conducting the procedures. A 5-point Likert scale rating of 4.79 indicates a high level of user satisfaction. A key strength of AR-CST is its ability to combine the tactile realism of cadaver-based training with readily accessible digital information using virtual materials. Table 4 compares conventional CST, VR simulation training, and AR-CST in surgical education. Table 4 Comparison of conventional CST, VR simulation training, and AR-CST. Conventional CST VR simulation training AR-CST Learning process Under supervision of a doctor Self-learning Self-learning Educational material Type Physical (e.g., textbook) Virtual Virtual Visualization 2D 3D 3D Required devices None HMD HMD Tactile feedback Presence Absence Presence CST: cadaver surgical training. VR: virtual reality. AR-CST: augmented reality-enhanced cadaver surgical training. 2D: two-dimensional. 3D: three-dimensional. HMD: head-mounted display. CST, which is conducted under conditions closely resembling those of live surgery, is considered the gold standard for OFF-JT in surgical education. Transitioning from formalin-fixed to Thiel-embalmed cadavers has improved tissue flexibility and biological reproducibility[ 10 , 11 ], thus expanding training opportunities for soft tissue surgeries such as neck dissection. However, traditional CST requires a supervising instructor to be physically present, creating geographical and scheduling constraints that can lead to disparities in educational opportunities [ 12 – 14 ]. AR-CST allows surgeons clean access to AR materials, such as surgical videos and instructions at any time while viewing the surgical field directly. All participants rated the added value of AR to the CST as 5 out of 5 points, suggesting that the system may promote self-directed learning, even in situations where continuous in-person supervision is challenging. Moreover, unlike conventional 2D educational materials such as textbooks used for surgical instruction and learning, AR can seamlessly integrate 3D information into the CST environment. The context of 3D is critical in surgery; 3D information provides great help in understanding the anatomical structures[ 15 – 17 ] that are essential for safe and effective surgery. This is particularly critical in head and neck surgery, where blood vessels, nerves, muscles, and bones interweave into complex and confined spaces[ 9 , 15 , 18 ]. In contrast, while general VR simulation training can provide an immersive 3D experience in a complete virtual space, it cannot replicate the tactile feedback of actual tissue manipulation[ 19 ]. Our findings show that combining AR with real CST makes it possible to conduct training while maintaining the tactile sensations that are extremely important in surgery[ 20 ]. Therefore, AR-CST facilitates real-time spatial understanding without removing trainees from the physical environment, and promotes the simultaneous acquisition of cognitive knowledge and psychomotor skills, fostering embodied cognition and situated learning. In this study, the burden of viewing content through an HMD had a rating of 1.57 out of 5, suggesting that it remains tolerable for 1–2 h of continuous use. Previous studies[ 6 , 21 ] emphasized that medical students and junior doctors generally respond favorably to HMDs. Such technology can enhance “Attention” in the ARCS model of learning theory[ 22 ], and the novelty or engaging experience may help maintain and improve learning motivation. In particular, HoloLens 2 has received high praise in systematic reviews[ 23 ] of AR use in surgical education, and it can improve learning efficiency through intuitive interfaces such as gaze and gesture controls. This study had several limitations. As a proof-of-concept study, the evaluation metrics for AR-CST were based on subjective questionnaires. Future research should involve objective metrics, such as operative precision and error rates, as well as comparative studies with control groups. In addition, the score for the ease of AR content manipulation was 4.07 out of five, indicating room for improvement. Continuous improvements in AR devices and software are expected to address many of these issues, making it essential to pursue ongoing technical innovations and real-world educational validation. With the advancement of technology, we believe that the concept of combining AR-based digital content into actual surgical settings has the potential to evolve beyond surgical training to include remote tele-mentoring[ 24 ] and clinical operative support systems[ 25 ]. Conclusion This proof-of-concept study demonstrated the potential of an AR-enhanced system to effectively complement and improve traditional surgical education. Combining the tactile realism of CST with readily accessible AR-based digital resources is potentially effective for enhancing surgical education. References Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. 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1","display":"","copyAsset":false,"role":"figure","size":434418,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAugmented reality-enhanced cadaver surgical training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA: Image of augmented reality (AR) content projected onto a cadaver surgical training (CST) environment using a transparent head-mounted display (HMD).\u003c/p\u003e\n\u003cp\u003eB. First-person view through the HMD while performing CST and referring to AR content.\u003c/p\u003e\n\u003cp\u003eC. External view of AR content manipulation.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6775613/v1/16afd568983a55ed6d6d513a.jpeg"},{"id":85737585,"identity":"72f4b3b1-c8a8-4d9c-82cc-01ce5e346508","added_by":"auto","created_at":"2025-07-01 08:20:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1018951,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6775613/v1/8dc3cbf6-b6e9-479f-a04d-3a4529b748d9.pdf"},{"id":85735938,"identity":"9de20fb0-2052-4052-aef4-c98405cb796d","added_by":"auto","created_at":"2025-07-01 08:04:08","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":27568943,"visible":true,"origin":"","legend":"","description":"","filename":"Video.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6775613/v1/3021d97ce135aa2c48b85758.mp4"}],"financialInterests":"","formattedTitle":"Augmented reality-enhanced cadaver surgical training for head and neck surgeons: a proof-of-concept study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe surgical skills of surgeons are a critical factor that directly affects patient prognosis, including postoperative complications, recurrence rates, and mortality[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, in recent years, it has become difficult to secure sufficient surgical training time owing to increasingly sophisticated medical technologies, heightened emphasis on patient safety, and restrictions on resident work hours. Therefore, relying solely on on-the-job training is no longer sufficient. Consequently, off-the-job training (OFF-JT) has become increasingly important. Cadaver surgical training (CST) has gained attention as a particularly valuable form of OFF-JT[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimultaneously, since 2016, rapid technological advancements and the commercialization of virtual reality (VR) have led to the practical implementation of image processing technologies that merge the virtual and real worlds, such as augmented reality (AR)[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this study, we designed an AR-enhanced cadaver surgical training (AR-CST) to improve the efficiency of surgical training and conducted a proof-of-concept. By projecting virtual educational materials onto AR using a see-through head-mounted display (HMD), trainees can practice on cadavers while referring to real-time surgical guidance. This study aimed to demonstrate the potential of combining digital information with traditional cadaver-based education to improve learning efficiency and comprehension.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePreparation of Educational Materials\u003c/h2\u003e \u003cp\u003eWe developed educational materials for lateral neck dissection, the most common procedure among neck dissections, which is a gateway surgery for head and neck surgeons. First, two board-certified head and neck surgeons divided the neck dissection procedure into nine steps and organized the essential tasks for each step (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Next, for each of these nine steps, we prepared written instructions detailing the required techniques and sequences, surgical videos performed by an expert surgeon, and schemas to supplement the explanations. Furthermore, to facilitate the understanding of the three-dimensional (3D) anatomy, we created a 3D model of the neck using a previously described method[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNine steps of lateral neck dissection (Level II-IV)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin incision\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin flap elevation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLateral extent (posterior border of the sternocleidomastoid muscle)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeep extent (above the deep neck fascia)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInferior extent (anterior border of the clavicle)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperior extent (posterior belly of the digastric muscle)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel IIB (accessory nerve area)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarotid sheath (jugular vein, carotid artery, and vagus nerve)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedial extent (lateral border of the sternohyoid muscle)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe obtained dynamic contrast-enhanced computed tomography images of a patient with a largely normal anatomical structure prior to surgery for a hypoglossal schwannoma. A head and neck surgeon and a radiological technologist segmented the bone and cartilage, blood vessels, glandular tissues, esophagus, and muscles using the ZIOSTATION workstation (Zaiosoft, Inc., Tokyo, Japan). Polygon (STL data) files of each segmented organ were exported, and a 3D computer graphics software (Blender version 3.2; Blender Foundation, Netherlands) was used to build a 3D model. Finally, we commissioned a 3D artist to add the relevant nerves, including the vagus, accessory, hypoglossal, cervical, and phrenic nerves, to complete the final 3D model.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProjection of Educational Materials using AR\u003c/h3\u003e\n\u003cp\u003eTo project the educational materials in AR, we used HoloLens 2 (Microsoft Corporation, Washington) as a transparent HMD. HoloLens 2 uses built-in sensors to recognize the spatial relationship between virtual materials and the real-world environment and supports gaze- and gesture-based controls. Once an HMD is worn, virtual materials can be anchored to any desired location in the physical space, allowing hands-free access at any time. The transparent lenses enable users to view virtual materials and the surgical field simultaneously. Members of the Faculty of Engineering developed an application using the Unity game engine (Unity Technology, San Francisco) to project educational materials on AR via HoloLens 2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). With this application, trainees could freely reference the materials in real time during the CST and operate them using gaze input and fingertip gestures (Fig.\u0026nbsp;1BC, Video).\u003c/p\u003e \u003ch3\u003eImplementation of AR-CST\u003c/h3\u003e\n\u003cp\u003eFourteen surgeons with 2 to 16 years of experience in otolaryngology participated in the AR-CST. Thiel-embalmed cadavers[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] were used for the training. After each training session, we administered a questionnaire using a 5-point Likert scale to evaluate the usefulness of the AR-CST. Values are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation unless stated otherwise. The questionnaire included open questions, so that the participants could describe positive aspects and areas for improvement.\u003c/p\u003e \u003cp\u003eThis study was conducted at an academic university hospital and was approved by the Institutional Review Board of XXXX (registration number: XXXX). Consent was obtained from both the individuals and their families for clinical research use, in addition to participation in dissection training. Written informed consent was obtained from all patients for 3D model creation and video recording.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFourteen participants from six institutions participated in the AR-CST (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Five participants served as primary surgeons and nine as assistants. The participants included four board-certified head and neck surgeons with \u0026gt;\u0026thinsp;50 cases of neck dissection. All participants completed the entire lateral neck dissection process from steps 1 to 9. The training sessions lasted between 60 and 120 min.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary surgeons\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAssistants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale/Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6/3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears as otolaryngologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange (Median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;16 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;14 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;16 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026le;, \u0026lt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the questionnaire are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The overall usefulness of the AR-CST had a high rating of 4.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43 out of 5 points. The added benefit of the AR content over conventional CST received a 5-point rating from all participants. The ease of AR content manipulation scored 4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 points, and the burden of viewing the content through the HMD had a relatively low rating of 1.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76 points. No major differences were observed between the responses of the primary surgeons and assistants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003ePrimary surgeons\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eAssistants\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUsefulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAdditional educational value provided by the AR content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEase of AR content manipulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaterials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWritten instructions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical videos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchemas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D models\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBurden of viewing content through the head-mounted display\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eAR: augmented reality. 3D: three-dimensional.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the positive aspects mentioned in the free-text description, participants noted the ability to train without soiling the educational materials, the convenience of referencing the content in parallel with the procedure, and the utility of the 3D model in facilitating comprehension of the 3D anatomy required for the procedure. However, negative opinions included that the HMD was sometimes uncomfortable and that becoming familiarized with its operation was time consuming.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this proof-of-concept study, we integrated AR and CST to create the AR-CST. By using a see-through HMD to project materials into the training environment, participants could refer to them in real time while conducting the procedures. A 5-point Likert scale rating of 4.79 indicates a high level of user satisfaction. A key strength of AR-CST is its ability to combine the tactile realism of cadaver-based training with readily accessible digital information using virtual materials. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares conventional CST, VR simulation training, and AR-CST in surgical education.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of conventional CST, VR simulation training, and AR-CST.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConventional CST\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVR simulation training\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAR-CST\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder supervision of a doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSelf-learning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational material\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical (e.g., textbook)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVirtual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVirtual\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisualization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRequired devices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHMD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTactile feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePresence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCST: cadaver surgical training. VR: virtual reality. AR-CST: augmented reality-enhanced cadaver surgical training. 2D: two-dimensional. 3D: three-dimensional. HMD: head-mounted display.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCST, which is conducted under conditions closely resembling those of live surgery, is considered the gold standard for OFF-JT in surgical education. Transitioning from formalin-fixed to Thiel-embalmed cadavers has improved tissue flexibility and biological reproducibility[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], thus expanding training opportunities for soft tissue surgeries such as neck dissection. However, traditional CST requires a supervising instructor to be physically present, creating geographical and scheduling constraints that can lead to disparities in educational opportunities [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. AR-CST allows surgeons clean access to AR materials, such as surgical videos and instructions at any time while viewing the surgical field directly. All participants rated the added value of AR to the CST as 5 out of 5 points, suggesting that the system may promote self-directed learning, even in situations where continuous in-person supervision is challenging. Moreover, unlike conventional 2D educational materials such as textbooks used for surgical instruction and learning, AR can seamlessly integrate 3D information into the CST environment. The context of 3D is critical in surgery; 3D information provides great help in understanding the anatomical structures[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] that are essential for safe and effective surgery. This is particularly critical in head and neck surgery, where blood vessels, nerves, muscles, and bones interweave into complex and confined spaces[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, while general VR simulation training can provide an immersive 3D experience in a complete virtual space, it cannot replicate the tactile feedback of actual tissue manipulation[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our findings show that combining AR with real CST makes it possible to conduct training while maintaining the tactile sensations that are extremely important in surgery[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, AR-CST facilitates real-time spatial understanding without removing trainees from the physical environment, and promotes the simultaneous acquisition of cognitive knowledge and psychomotor skills, fostering embodied cognition and situated learning.\u003c/p\u003e \u003cp\u003eIn this study, the burden of viewing content through an HMD had a rating of 1.57 out of 5, suggesting that it remains tolerable for 1\u0026ndash;2 h of continuous use. Previous studies[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] emphasized that medical students and junior doctors generally respond favorably to HMDs. Such technology can enhance \u0026ldquo;Attention\u0026rdquo; in the ARCS model of learning theory[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and the novelty or engaging experience may help maintain and improve learning motivation. In particular, HoloLens 2 has received high praise in systematic reviews[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] of AR use in surgical education, and it can improve learning efficiency through intuitive interfaces such as gaze and gesture controls.\u003c/p\u003e \u003cp\u003eThis study had several limitations. As a proof-of-concept study, the evaluation metrics for AR-CST were based on subjective questionnaires. Future research should involve objective metrics, such as operative precision and error rates, as well as comparative studies with control groups. In addition, the score for the ease of AR content manipulation was 4.07 out of five, indicating room for improvement. Continuous improvements in AR devices and software are expected to address many of these issues, making it essential to pursue ongoing technical innovations and real-world educational validation. With the advancement of technology, we believe that the concept of combining AR-based digital content into actual surgical settings has the potential to evolve beyond surgical training to include remote tele-mentoring[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and clinical operative support systems[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis proof-of-concept study demonstrated the potential of an AR-enhanced system to effectively complement and improve traditional surgical education. Combining the tactile realism of CST with readily accessible AR-based digital resources is potentially effective for enhancing surgical education.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBirkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. 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Augmented reality telementoring (ART) platform: a randomized controlled trial to assess the efficacy of a new surgical education technology. Surg Endosc. 2014;28(12):3467\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00464-014-3625-4\u003c/span\u003e\u003cspan address=\"10.1007/s00464-014-3625-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"augmented reality, cadaver surgical training, head and neck surgery, head-mounted display, three-dimensional","lastPublishedDoi":"10.21203/rs.3.rs-6775613/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6775613/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003eSurgical proficiency is a critical factor influencing postoperative complications and treatment outcomes. However, ensuring sufficient surgical training hours has become increasingly challenging owing to advancements in medical technology, concerns about patient safety, and work-hour restrictions for trainees. To address these challenges, we developed an augmented reality-enhanced cadaver surgical training (AR-CST) system to supplement traditional training methods, and conducted a proof-of-concept study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We created augmented reality (AR)-based educational content, including a three-dimensional model for neck dissection, divided into nine procedural steps, and developed an application that projects the material as AR content onto the real world via a transparent head-mounted display. Otolaryngology–head and neck surgeons performed neck dissections on cadavers using this AR-enhanced system, followed by a questionnaire survey. The questionnaire employed a 5-point Likert scale to evaluate various aspects of the training experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFourteen surgeons participated in the AR-CST and responded to the survey. The overall usefulness of AR-CST had a rating of 4.79±0.43 out of 5, with all participants giving a perfect score for the added value of AR compared to conventional training. The burden of viewing content through the head-mounted displaywas relatively low (1.57±0.76), and users highlighted the 3D anatomical references and hands-free material access as key advantages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis proof-of-concept study suggests that integrating AR technology with cadaver surgical training enhances procedural understanding and promotes self-directed learning. Combining the tactile realism of cadaver-based training with readily accessible AR-based virtual materials could be an effective approach for a more productive surgical education.\u003c/p\u003e","manuscriptTitle":"Augmented reality-enhanced cadaver surgical training for head and neck surgeons: a proof-of-concept study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 08:04:03","doi":"10.21203/rs.3.rs-6775613/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-06-24T21:49:14+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T21:34:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-06-23T00:55:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-30T12:51:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-05-29T06:30:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"73b24698-0e7c-4e66-928d-4adbe5112187","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T19:31:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 08:04:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6775613","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6775613","identity":"rs-6775613","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}