# A Review of Training and Guidance Systems in Medical Surgery
## 3 Methods
### Synthesis of the Selected Works
#### 3.8.7 ENT Procedures  
ENT (ear, nose, and throat) procedures, also known as otolaryngology, is the surgical area that evaluates and manages a wide range of diseases of the head and neck, including the ear, nose, and throat regions. [PERSON] et al. focused their work on providing metrics and performance feedback in a mastoidectomy simulator [91]. This simulator teaches haptic, anatomic, and cognitive aspects found in this surgery. Haptic devices are used to interact and feel force feedback in the simulation. The authors decided to use the Chai3D framework, which is a C++ solution that includes haptic libraries. Aids and visualizations, such as color markers, are used to highlight pertinent parts in the session. Sessions are assessed to provide an evaluation, and they are recorded into a database. Session data is used to create a video of the procedure. By giving video support, the simulator lets users navigate it to identify where they got low scores and check it properly to improve their performance. Other solutions focus on temporal bone surgery. A commercial simulator for this surgery is Voxel-Man Tempo. It was created by the University Medical Center Hamburg-Eppendorf (UKE). [PERSON] et al. evaluated this system to evaluate its use to rehearse activities [92]. Voxel-Man Tempo provides self-study facilities, and it offers seven pre-defined training cases of the middle ear, with different anatomy and pathology. An exciting feature of the software is that it provides an upload module. It lets users load CT data to expand the surgery database. For interaction, two Geomagic Touch haptic devices are used to enhance the tactile experience. On the side of visualization, the software provides camera movement features, such as different views windows, which let users correctly orientate themselves during the virtual operation. It includes an automatic skills assessment, where the process and the trainee's knowledge can be objectively evaluated. The evaluation is based on predefined tasks, and a report is generated at the end of each session. Authors stated that since Voxel-Man offers a problem-based learning (PBL) approach, it is suitable to create new realistic scenarios. Another study centered on temporal bone surgery is the one conducted by [PERSON] et al. [93]. They evaluated another commercial simulator, Visible Ear. The Alexandra Institute created it. It provides a 3D simulation that uses one Geomagic Touch haptic device to train dissection on the temporal bone area. It gives objective evaluation, where performance scores are calculated considering the volume of bone removed, operation time, and collisions. The collision with the dura, facial nerve, inner ear, tapes, malleus, and incus are the ones considered to reduce the score obtained in the task. Visible Ear guides by using a tutor in a window. This tutor gives an explanation to users about the actions they are doing. For aid, pop-up warning messages during drilling are used to teach students the actions that have to be avoided during real operations. Even though commercial simulators provide feasible environments, they still lack the pedagogy features required in proper medical curricula. Medical institutions developed both the Voxel-Man Tempo and Visible Ear simulator. They were modeled by taking into account the educational needs that students required during simulations. Therefore, researchers should focus their attention not only on creating simulators, but also implementing pedagogical approaches to provide integral solutions in medical science. VFs are also applied in ENT studies. [PERSON] et al. used them to create an algorithm to be involved in robot-assisted surgery for cochlear implant insertion [94]. VFs are used in this work as constraints during the procedure. The system can be adapted to use the patient's anatomy by inputting pre and intraoperative optical coherence tomography (OCT). OCT is obtained using a bulk-volume scanner and a side-viewing probe. Using this hardware, imaging and registration of the cochlear lumen are obtained.