# A Novel Mixed Reality Solution Based on Learning Environment for Sutures in Minor Surgery
## 4 Discussion  
In this article, we provide a learning tool based on an active methodology developed for Mixed Reality technology. We used a next-generation device (Magic Leap) to take advantage of the advances that today's technology can offer in the field of education. The development of this type of solutions in this technology is notably scarce. Usability results, subjective users opinion questionnaires results, and recommendations of use Suture MR as part of learning methodology are briefly summarized as follows:  
1. Users valued the usability of the Mixed Reality solution at 72.34/100 points. Such a satisfactory level of usability included in the third quartile indicates that no adaptation of our approach would be necessary. 2. The user's subjective perception questionnaire results reveal that users find that the use of Suture MR encourages their learning process to a greater extent than reading the text alone would do. 3. The analysis of test scores suggests that the combination of a practical experience with the Mixed Reality solution after the reading of a theoretical knowledge improves the retention results of the subject. In short, Suture MR is presented as an useful, usable, ubiquitous, and motivating system that makes an interactive proposal for the teaching of academic content specialized in basic sutures of minor surgery. Considering that active learning has the capacity to emotionally link the user and strengthen the process of internalization of information, Suture MR meets these objectives, whose would be difficult to satisfy by reading texts. That is why users perceive the use of Suture MR such effective in learning terms. \begin{table}
\begin{tabular}{c c} \hline \hline
**Test/Group** & **Order of Sessions** \\ \hline Mixed Reality & \(W=0.95\) \\ \(p=0.1936\) \\ Text-Reading & \(W=134\) \\ \(p=0.82\) \\ \hline \hline \end{tabular}
\end{table} 
Table 2: Results (statistic W and \(p\)-value) of retentive score on different sessions order obtained throughout the Wilcoxon Sum Rank Test. \begin{table}
\begin{tabular}{c c c c c} \hline \hline  & **Sessions** & **Median** & **Mean** & **Variance** \\ \hline Group 1 & Mixed Reality & 2.500 & 2.313 & 1.391 \\ (Sessions Order) & Text-Reading & 3.250 & 2.969 & 1.268 \\ Group 2 & Text-Reading & 2.500 & 2.969 & 1.023 \\ (Sessions Order) & Mixed Reality & 3.250 & 2.969 & 1.152 \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Statistics (median, mean, and standard deviation) of retentive score on different methods by groups of participants. Despite the obtained positive results, several issues could be improved considered after the trials. Indeed, this study can be understood as a starting point for future works. Further future research lines to be followed could be to expand and differentiate the contents shown for each suture technique, to incorporate new fixed informative panels that reinforce the theoretical knowledge, to integrate a user guidance system in the realization of the suture stitches, or to conduct new studies aimed at medical and nursing students with greater experience in the use of extended realities. Furthermore, it would be interesting to evaluate long-term memory, to assess the potential of the learning tool as an experiential learning ecosystem. The following are available online at www.mdpi.com/xxx/s1, Video S1: Design, development and evaluation of a mixed reality solution based on learning environment for sutures in minor surgery. Conceptualization and Methodology, A.R. and L.R. ; software, formal analysis, and writing--original draft preparation A.R. ; resources and writing--review and editing, L.R. and A.S.; validation and investigation, A.R., L.R. and A.S.; funding acquisition, A.S. All authors have read and agreed to the published version of the manuscript. This research was funded by the Spanish Ministry of Science, Innovation and Universities grant number RTI2018-098694-B-I00. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. The authors declare no conflicts of interest.