Besta NeuroSim Center – STARS & STARS-CASCADE

Advanced planning and neuronavigation with virtual reality in neurosurgery: The STARS and STARS-CASCADE studies

The Surgical Theater for Advanced Rehearsal and Surgical performance (STARS) Study was designed to evaluate a virtual reality surgical planning device (Surgical Theater™) and assess its impact on the different phases of a surgical procedure on patients harboring brain tumors. We wanted to validate simulation and virtual reality as useful tools to improve understanding and training in neurosurgery.

The STARS study activity was held during 2018-19 at the Besta NeuroSim Center (Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan) and was organized by Dr Francesco DiMeco and Dr Alessandro Perin (Scientific Director of Besta NeuroSim Center).

Thirty patients underwent brain tumor removal; all of the surgeries were planned and rehearsed with the above device. Four residents and five attending neurosurgeons were involved in this study at C. Besta. For each patient the virtual reality platform allowed elaboration of a patient-specific 3D model; then, with specific virtual-reality tools, the surgeons devised the surgical strategy (e.g. simulating a virtual craniotomy and placing a virtual surgical corridor). They also had a virtual flyby (using a VR headset) inside the patient’s head and rehearsed the procedure before going to the operating room (OR). The system was also used in the OR and for intraoperative 3D navigation (linked to a conventional neuronavigation device).

The results showed that this device facilitated the mental surgical rehearsal for all neurosurgeons, especially those who were younger and less-experienced. Interestingly, the planning with 3D virtual reality facilitated the anatomical and surgical comprehension of residents, getting them more involved in discussion with the expert operators.

Given these encouraging results, we performed a similar study focused on vascular neurosurgery, (i.e. cerebral aneurysm surgery), called STARS – Cerebral Aneurysm Simulation Clipping and Debriefing (CASCADE) during 2019. This course involved four residents, one fellow and three expert attending neurosurgeons. All study participants performed a virtual planning of 10 aneurysm cases (in a manner similar to the STARS study). They used the virtual aneurysm clipping tool (provided by Surgical Theater™), to clip those aneurysms in a safe ‘patient-free’ environment.

After each neurosurgical procedure we set up a “postoperative debriefing” session. These sessions were similar to “grand-round” meetings, in which the expert surgeons demonstrated on the simulator how they performed that case and explained the correct approach and technique adopted for that specific patient using Surgical Theater™. All participants showed a better understanding of the neurosurgical procedure and had a better performance when asked to re-do the virtual aneurysm clipping on the simulator.

The results of both studies are going to be published soon.

May 2021