Intraoperative Use of Mixed Reality Technology in Median Neck and Branchial Cyst Excision

Round 1

Reviewer 1 Report

July 9, 2021

Review of the paper (futureinternet-1300082-peer-review-v1)

Intraoperative use of mixed reality technology in median neck and branchial cyst excision by Ivanov V.M., Krivtsov A.M., Strelkov S.V., Kalakutskiy N.V., Yaremenko A.I., Petropavlovskaya M.Yu., Portnova M.N., Lukina O.V., and Litvinov A.P.

General comments
In this paper, the Author proposed the application of Mixed Reality-based devices (HoloLens 2) for surgeries. I find the idea presented in the paper interesting but I have the following comments and concerns:  

Problems missed 
1. When reading this article, there seems to be a visible lack of comments related to the other already existed solutions. Recently, interesting analyses concerning applications of Mixed Reality in medicine were developed in the papers:

Tepper OM, Rudy HL, Lefkowitz A, Weimer KA, Marks SM, Stern CS, et al. Mixed reality with HoloLens: where virtual reality meets augmented reality in the operating room. Plast Reconstr Surg 2018;140:1066–70
De Paolis LT, An augmented reality platform for preoperative surgical planning. J Interdiscip Res App Med 2019;3:19–24
Proniewska K, Pręgowska A, Walecki P, Dołęga-Dołęgowski D, Ferrari R, Dudek D, Overview of the holographic-guided cardiovascular interventions and training - a perspective. Bio-Algorithms and Med-Systems 2020; 16(3):20200043-1-9
Ruthberg JS, Quereshy HA, Ahmadmehrabi S, Trudeau S, Chaudry E, Hair B, et al. A multimodal multi-institutional solution to remote medical student education for otolaryngology during COVID-19. Otolaryngol–Head and Neck Surgery 2020;1–3
Rokhsaritalemi S, Sadeghi-Niaraki A, Choi SM. A review on mixed reality: current trends, challenges and prospects. Appl Sci2020;10:636
Proniewska K, Dołęga-Dołęgowski D, Pręgowska A, Walecki P. Dudek D, Simulations in Medicine: Holography as a progressive revolution in medicine, De Gruyter,103-116, 2020
Bin S, Masood S, Jung Y. Chapter Twenty - virtual and augmented reality in medicine. In: Dagan Feng D, editor. Biomedical Engineering, Academic Press Elsevier; 2020: 673–86

I recommend adding (including) into the paper a Section, or at least a Paragraph, dealing with these important aspects of information concepts and their processing by neural networks among others on the above references.

2. What about the description of your methodology/application? I missed application descriptions. The proper architecture, diagrams such as use-case, activities/flowcharts, the sequence should be included.

3. The comparison with other existing literature solutions should be also added in Section: Discussion.

4. In the Abstract there should be pointed out (stressed) the general conclusion which follows from the conducted analysis. Also, the Abstract should be reformulated according to the journal requirements: “The abstract should be a total of about 200 words maximum. The abstract should be a single paragraph and should follow the style of structured abstracts, but without headings: 1) Background: Place the question addressed in a broad context and highlight the purpose of the study; 2) Methods: Describe briefly the main methods or treatments applied. Include any relevant preregistration numbers, and species and strains of any animals used. 3) Results: Summarize the article's main findings; and 4) Conclusion: Indicate the main conclusions or interpretations. The abstract should be an objective representation of the article: it must not contain results which are not presented and substantiated in the main text and should not exaggerate the main conclusions.”

5. The conclusion should be extended to stress/express the idea and analysis conducted in the manuscript.

Final comments
The idea presented and developed in the paper is promising, interesting, and important, but due to the above concerns, I could recommend this paper for publication provided that the above comments/problems will be carefully addressed. At this moment I would recommend Major Revision.

 

 

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

The paper offers very interesting insight into the application of MR in real life medical procedures such as surgeries. But some remarks can be made:

1. In the introduction section more in depth analysis of the current state of the art on the topic of MR in surgery in the last 5 years is a must for this kind of paper. A lot of progress has been made in the topic with some really good examples such as: Pepe, A., Trotta, G. F., Mohr-Ziak, P., Gsaxner, C., Wallner, J., Bevilacqua, V., & Egger, J. (2019). A marker-less registration approach for mixed reality–aided maxillofacial surgery: a pilot evaluation. Journal of digital imaging, 32(6), 1008-1018.  and Saito, Y., Sugimoto, M., Imura, S., Morine, Y., Ikemoto, T., Iwahashi, S., ... & Shimada, M. (2020). Intraoperative 3D hologram support with mixed reality techniques in liver surgery. Annals of surgery, 271(1), e4-e7.
2. A separate section should be written with a software architecture for all 3 cases with blocks such as mesh reconstruction and optimization (artefacts removal, holes filling, simplification, and filtering); generation of the 3D models of the patient anatomy necessary for the each surgical simulation (see the previously cited paper Pepe et al.  A marker-less registration approach for mixed reality–aided maxillofacial surgery: a pilot evaluation).  This section should mention if the device is previously calibrated, how the holograms are visualized etc.
3.  A question  for the authors to consider: How do you deal with the phenomenon called “focal rivalry” or the inability of the human eye to  focus on both virtual and real objects simultaneously.  This problem is studied in Condino, S., Carbone, M., Piazza, R., Ferrari, M., & Ferrari, V. (2019). Perceptual limits of optical see-through visors for augmented reality guidance of manual tasks. IEEE Transactions on Biomedical Engineering, 67(2), 411-419. and cited by Michelle Hampson from IEEE Spectrum in her paper Microsoft’s HoloLens Not Fit for AR-Assisted Surgery, from 17 May 2019.

I recommend the publishing of the paper after revisions.

Author Response

"Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

The research topic of the paper is very interesting and useful to identify anatomical models in intraoperative scenarios. However, the scientific contributions were been little explored, it is necessary to make an analysis of the state of the art, explaining the methods and procedures used. Everything is too vague and not very explicit to understand how the identification and synchronism processes were developed through landmarks. Other questions are raised regarding the precision and accuracy of the system and whether it is in line with what is desired in clinical terms. They present some results in patients, but it remains a question if the system is validated to perform these procedures.

The organization of the paper structure needs to be written in the last paragraph of the introduction.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors take into account my comments and suggestions, I recommend the article for publication.

Author Response

Response to Reviewer 1 Comments

Point 1: Moderate English changes required.

Response 1: We edited the text and in addition included a paragraph at the end of Materials and Methods section about ethic aspects. In conclusion we also discussed briefly the accuracy of the whole system and accuracy in the each case.

Reviewer 2 Report

The authors have replied to all the major previous remarks.

I would suggest a brief description of future developments such as maybe a marker-free experiment based on some facial or body key points.

 

Author Response

Response to Reviewer 2 Comments

Point 1: I would suggest a brief description of future developments such as maybe a marker-free experiment based on some facial or body key points.

Response 1: In conclusion we briefly discussed the accuracy of the whole system and accuracy in the each case and suggested future development strategy.

Reviewer 3 Report

The paper quality improved with the review performed.

It is still not clear which legal and ethical procedures were followed for the use of the solution in patients, whether or not it is validated for use in humans. The precision and accuracy of the system were not discussed.

Author Response

Response to Reviewer 2 Comments

Point 1: It is still not clear which legal and ethical procedures were followed for the use of the solution in patients, whether or not it is validated for use in humans. The precision and accuracy of the system were not discussed.

Response 1: We added a paragraph at the end of Materials and Methods section about ethic aspects. In conclusion we also discussed briefly the accuracy of the whole system and accuracy in the each case.