1. Introduction
During clinical surgery, surgeons need to monitor and view multiple visualization instruments, including endoscopes, laparoscopes, cardiac monitors, and others [
1]. The surgeons always observe the display data and images by means of rotating their head, as far as to result in torso distortion due to of maintaining a fixed position for long periods of time [
2]. Data and images are transmitted to the glasses through WIFI when using smart glasses for surgery [
3]. Their eye does not move and focus on the surgical operation. In some delicate surgeries the clarity of human eyes cannot meet the demand, and surgeons need to use a microscope to perform the surgery [
4], for instance, vestibular schwannoma of the brain [
5], dental pulp nerve endings [
6], and intracranial dural arteriovenous fistulae [
7]. Nevertheless, the microscope is too bulky and has a small operable interface which is not conducive to surgical operations. Smart Glasses have high-definition cameras with adjustable focal lengths to improve the clarity of the human eye [
8]. Meanwhile, the surgeon’s hands are freed and facilitate flexible manual operation.
Extended reality is a deep immersion experience that generates a comprehensive, three-dimensional reality-virtual continuum through computer systems. Through Virtual Reality (VR) to provide users with a virtual environment, combined with digital overlay enhanced images in Augmented Reality (AR), and use of Mixed Reality (MR) to form three-dimensional imaging, to achieve a perfect combination of physical reality environment and virtual reality environment, as shown in
Figure 1 [
9]. It promotes regional innovation and opens up new visualization avenues of application. The human body is complex and mobile, moving the internal organs of the body between exhalation and inhalation [
10]. Each part is a relatively independent and complex structure. During the operation, it can overlap with the patient entity, which is convenient for the surgeon to recognize and operate [
11,
12]. XRSG uses Expanded Reality Technology (XRT) that can create images of such sensitive images. Most important is the visual experience, which combines real and virtual human structures to create a three-dimensional, realistic medical image of the human body [
13]. Past works of literature on XRT in surgery have been insufficiently discussed.
However, from the point of view of theoretical development, the XRSG technique has met the needs of surgical procedures, such as trials in dermatology [
14], neurosurgery [
9], and urological procedures [
15], but has not yet been applied to clinical procedures [
16]. In this study, the acceptability and feasibility of the use of XRSG for surgical operations by medical specialists were tested. The XRT was studied using the Technology Acceptance Model (TAM) to explore people’s acceptance of innovation through their perception of its usefulness and ease of use [
17]. It also requires the acceptance and use of subjective consciousness leading to behavioral change suitable for the Theory of Planned Behavior (TPB) through the medical expert’s experience of the procedure [
18]. The current study proposes a new theoretical framework with a combination of TAM and TPB, the Technology Behavior Model (TBM). In this model, extended reality technology is added to make it more suitable for this study. Currently, XRSG is mainly used to improve visual effects and is not as popular as cell phones. Therefore, people’s subjective perceptions are the basis of their behaviors. In this study, the triangle mixed research method was used to collect data through an online Google questionnaire and conduct statistical analysis on the data using SmartPLS. PLS-SEM has a multiplanar structure and sophisticated model manipulation software that allows for multivariate mixed cross-tabulation analysis, which facilitates the study of the data [
19]. The structure of this paper is as follows. First, the theory and hypotheses of this study are presented by examining the previous literature. The second part presents the research methodology, data analysis, and conclusions of this study. Third, the contributions of this study are discussed, including the proposed new technical-behavioral model for medical image modeling by using Extended Reality Technology, which improves the Usage Perspicuity, standardizes the operation of medical experts while allowing the use of multiple interaction methods for viewing images and data, and avoids cross-contamination in the surgical environment. This provides a better patient-to-surgical experience, ensures a successful surgery, and reduces surgery time. This paper ends with the conclusion section, to confirm the acceptance and use of smart glasses surgery by medical experts and to provide an outlook for after research.
3. Methodology
3.1. Research Design
Research design is a research strategy that combines different elements of logic [
33], research objective questions, and data analysis processes to test the validity of objective hypotheses and obtain research results [
34]. To better answer and address the questions of this study, quantitative research, exploratory research, and cross-sectional research methods were used. First, quantitative research can use mathematical methods to analyze the collected data and perform logarithmic operations and statistical analysis [
35]. This study will collect primary data. Quantitative research can help researchers to analyze the data systematically. Secondly, exploratory studies are innovative and discovery studies [
36]. Although XRSGs have been used in medicine, they are mainly used in communication and telemedicine. The role of XRSGs in surgery is lesser-known and understood, and the reference material for this study is limited, so the study plan to use an exploratory study for this study. Third, cross-sectional studies can facilitate data collection by researchers without affecting other variables, save data collection time, and determine possible relationships. This research method was conducted over a short time, and the data collected in this study was for a period of two weeks.
3.2. Sampling Design
In this study, the researcher used non-probability sampling. As the population in this study is a cohort, it was not possible to use probability sampling because the sample size was not uniformly distributed. Based on the need of the study, the researcher chose convenience sampling as the sampling method for this study. This sampling method is simple, convenient, quick, and low cost. The target population of this study was medical specialists in five hospitals in Malaysia. This is because they need to improve the efficiency and safety of their procedures. Collecting their opinions can directly reflect their needs for XRSG. A total of 300 pieces of data were collected, which exceeded the minimum sample size of the effect size of 0.5, an alpha level of 0.05, and a power of 0.90 for the collection of 273 to meet the needs of the study data.
3.3. Measurement
To test the authenticity of the theoretical construct, a questionnaire survey was conducted among hospital medical experts in Malaysia. The questions of the questionnaire survey are based on literature and studies published in relevant peer journals and articles. This survey will investigate the impact of XRSG, whether it can help medical experts to perform better in surgery, whether it can improve the confidence of successful surgery, and other related questions. This questionnaire is completed in English.
The questionnaire is divided into two parts. The first part was demographic characteristics, including gender, age, education level, income, and occupation. The second part was the correlation between the independent and dependent variables. Each independent variable consisted of three questions to ensure that the questions were simple and easy to understand. All questions were expressed by a seven-point Likert scale with different levels and only one option for everyone.
3.4. Data Collection Method
As mentioned above, this study of the relationship between the dependent and independent variables requires the use of primary data [
37]. Due to the impact of COVID-19, the questionnaire was created using Google Forms. Respondents were sent a link and invited to fill it out. To better reach the target sample size, the questionnaire was sent through various social media platforms, such as Facebook, Whatsapp, and WeChat, and we asked the invitees to answer the questions within 10 min. Additionally, we conducted online interviews with 10 academics in the field through Zoom and Teams regarding the advantages and disadvantages of using XRSG in surgery. In addition, Google Forms was used to automatically generate results after respondents submitted their data and store the data in a database to form a data report. Researchers could view it in real-time to understand the progress, results, and distribution of the questionnaire.
5. Finding and Discussion
XRU and XREU have a significant impact on the medical experts’ use of XRSG for surgery. Ghaednia et al. [
23] reiterated that the use of SG by surgeons in the application of spinal surgery can be effective in helping the surgeon to perform the procedure better and Vasarainen et al. [
25] used SG in urological surgery. Zeng et al. [
13] confirmed in their study that XR technology can help medical experts quickly and accurately locate patients’ blood vessels and nerves and found that the usefulness and ease of use of XRSG had a significant positive impact on medical experts’ behavior in using XRSG. For example, surgeons can use the XRSG to connect internal lenses to improve the visual clarity of the human eye through the AR system of eyeglasses, expanding the surgical field and facilitating the performance of surgery [
47]. Therefore, H1 is supported and H2 support is confirmed. A wide and clear field of view can improve the efficiency of surgery, reduce the surgeon’s work pressure, and reduce the operation time and the time affected by radiation. Thus, it reflects that users can easily use XR technology for clinical operations.
On the other hand, IM is a 3D image based on the combination of XR technology and human system structure to simulate surgical practice and teaching. Due to the systematic and kinesthetic nature of the human body structure [
48], the use of stereoscopic medical image composition can clearly show the internal structure of the human body. Lee et al. [
49] found that medical experts could locate the patient’s blood vessels by image overlap and perform suturing during surgical vascular suturing. This demonstrated that the H3 hypothesis is feasible and that rapid localization simplifies the surgeon’s search in favor of H4. ID has positive interactions with both XREU and XRU. It was found that the joint use of multiple interactive technologies can better serve the communication and usage switching of medical experts during surgery [
10]. Good voice communication facilitates remote communication for surgery, and gesture recognition facilitates freeing the surgeon’s hands. Eyeglass tracking facilitates switching and viewing of monitoring visualization data and images. Enhancing the utility and ease of use of the XRSG, the operator’s behavior is subjective. Therefore, H5 and H6 are supported.
From the above discussion, it is clear that the XRSG allows the surgeon to operate surgical instruments and instruments with both hands, avoid viewing multiple visual inspection displays, standardize operational actions, and avoid unintentional human errors; therefore, H7 and H8 are supported. The built-in high-definition camera of the XRSG can replace the human eye to enhance visual clarity and make the visual images larger [
16]. In a study by Nag et al. [
50] medical experts used PicoLinker Smart Glasses to improve wire insertion under fluoroscopy. The wires were inserted exactly at the set position for ease of use. The use of the reflective SG is useful and reflects the ease of operation. Therefore, H9 and H10 are supported.
The study shows that IM, ID, ON, and UP support perceived usefulness and ease of use, change the operating habits of medical experts during surgery, and have a positive behavioral impact on surgical operations. This demonstrates the feasibility of the proposed XR technology acceptance and behavioral theory.
7. Conclusions and Future Works
The study avoids the errors and mistakes that arise from using a single research method by using a mixed-mode approach to data collection. Especially for the early stages of the development of the extended reality technology, there is no more reference material on which to base the study. This study proposes a new theoretical framework smart glasses extended reality technology behavioral model that expands the acceptance of the technology in reality and investigates the surgical behavior of medical specialists using XRSG in terms of human psychological characteristics and environmental demands. PLS-SEM was used in the data analysis, and multiple composite methods were used to compare the external and internal validity and credibility of the variables to make the results more accurate. The study showed that the total effect of XRSG in terms of image modeling, interaction design, operational specification, and clarity of use was 0.14, 0.222, 0.184, and 0.115 (
Table 11), respectively. This indicates that they can be effective in helping medical specialists to perform procedures better. Four variables were confirmed for medical specialists’ agreement with smart glasses surgery. This study has important social implications in those smart glasses surgery improves the success rate of surgery and can be effective in saving more lives, and also provides a reference for the development of future smart surgery in clinical applications. However, this study has some limitations that should be addressed in future studies. First, this study was limited to Malaysia and could not measure other countries. The influence of people’s education and culture on the acceptance of XRSG cannot objectively reflect the behavioral awareness of people in other regions. Second, the available technology places greater demands on the integration of extended reality technologies. How does XRSG ensure that the constructed human models are consistent with the movement of human organs? The technology is still immature in terms of facilitating auditory, tactile, and sixth senses. This requires further investigation by researchers. Third, although the technical features of XRSG have been improved, as the world population ages and the demand for surgery increases, more durable visualization techniques need to be developed to ensure effective demand for clinical procedures.