# A Review of Training and Guidance Systems in Medical Surgery
## 5 Conclusions  
We have presented a survey of training and guidance systems in medical surgery and procedures. These environments are aimed to train students to acquire proper dexterity in the surgical procedures needed in the diverse medical areas, providing guidance, feedback, and assistance during task execution. Additionally, the environment should incorporate tools for assessing acquired skills and knowledge. Sixty-seven systems were retrieved through a search using the following keywords--guidance, evaluation, assessment, training, medical education, medical training, surgery, simulation training, computer-assisted instruction, and e-learning. We found that most of these systems are focused on training purposes (75%), as compared to surgery procedures (19%), and only 6% are aimed for planning (including planning/training and planning/surgery). The medical disciplines covered were, in decreasing order of numbers of systems surveyed--laparoscopy (14), endoscopy (8), open surgery (7), arthroscopy (6), orthopedics (6), dentistry (5), ophthalmology (5), ENT procedures (4), neurosurgery (3), pediatrics (2), radiology (2), endovascular procedures (2), colorectal procedures (2), and urology (1). From these figures, a first conclusion of this work is the presence of a clear potential to create novel solutions and new development branches for those areas with the lowest systems aimed for future academic research or commercial use. The works and simulators studied in this research have been reviewed and compared from their set-up, type of application, and type of use. The criteria considered for this comparison were the modeled surgical techniques, used technology, force feedback during simulation, students' learning evaluation, educational and visual aids, guidance techniques, user data and its storage, and if the solution is commercial or not. A clustering analysis was performed to associate the systems according to the following specific features--Commercial Solution, Force Feedback, Stored Metadata, Database Storage, Artificial Intelligence, Guidance, Assistance, and Evaluation. Five clusters were obtained in which the main discriminant factors were the capability of storing and managing data and metadata in databases, as well as the fact of providing tools for guiding, assisting, and evaluating medical procedures. From the clustering analysis, several opportunities for the development of environments for surgery training have been identified as future research. First, the inclusion of AI-DL in the solutions, to register and analyze the actual procedures students follow during the task, providing guidance and feedback during task execution. In this way, students can study their movements to correct them whenever it is necessary. Although the advent of new advances in these technologies is promising in the forthcoming years, only four works in our sample incorporated AI-DL in their developments. This is an up-and-coming trend for future developments of training and guidance systems for surgery and medical procedures. On the other hand, the incorporation of extensive data storage capabilities of the system, record procedures, and analyze them with detail also becomes critical. Nevertheless, it was identified that less than 40% of the works reported this capability. This issue has to be addressed by systems developers in the future. The addition of force feedback to the systems constitutes another important opportunity area in the latter's development. This technology allows providing the user tactile perception and force feedback similar to those of real surgeries. It can be coupled with other visual technologies in a system to provide a realistic training environment. For simple tasks, the use of haptic devices with 3 degrees of liberty could be appropriate. Nevertheless, for more complex procedures, the incorporation of 6 degrees of freedom is necessary. Although these systems can be relatively expensive, their cost may be reduced when haptic technology becomes more accessible.