# A Novel Mixed Reality Solution Based on Learning Environment for Sutures in Minor Surgery
## 1 Introduction  
The union between theory and practice in clinical training is generally one of the main concerns for educational institutions. Medicine schools recognize dissonances between what students learned in college and what they learned in the assistance centers during their clinical practices and residencies [1]. In the educational context, the use of real practical scenarios in its educational methodology is not affordable, neither the dynamism of the clinic, nor the achievable experience on technological advances incorporated into clinical practice. Therefore, different efforts have been made to reduce the differences between both realities. Commonly alternatives are (i) mannequins, which are expensive; (ii) the use of animals, whose case has legal and ethical restrictions; and, (iii) in some cases, the collaboration of colleagues for recreation of practical cases. The biggest disadvantage of these alternatives is the inability to repeat the task in countless times, the limitation of customization of the intervention, and the discomfort of evaluating the student [2]. The emergence of immersive technologies led clinicians to the use of Virtual Reality (VR) environments, which allow a progressive training at the level of complexity and the possibility of repeating the exercise until assimilating the technique [3]. These advantages offer the ability to define a valuable personalized educational experience [4; 5]. Augmented Reality (AR) and Mixed Reality (MR) technologies allow virtual objects to be overlaid in the user's real environment [6]. The main difference between them is that MR improves the recognition of the geometrical surfaces in the real world, allowing a much more realistic integration of virtual content. Immersive technologies stimulate an emotional adherencein the subject, leading to a motivating learning process. Though these technologies allow students to be placed in highly controlled situations without consequences in real life, AR/MR makes it possible to know the results due to poor decision-making by learners [7]. In addition, the ease of access to current technologies make extended realities an increasingly everyday tool, creating urgency in the field of education to take advantage of their pedagogical benefits. Immersive technologies become potential alternatives in the generation of clinical cases or simulators in the educational training. To target this dual academic-clinical scenario, we propose an MR approach built on the combination of gesture detection and hand-tracking to implement an interactive learning. This activity sets up the motor coordination of the users favoring their involvement and motivation for learning of sutures techniques and basic suture materials. We have developed this solution as an MR application on Magic Leap HMD. We tested the user experience and retention potential of the MR learning environment approach through an experimental group with 32 subjects. Indeed, AR has facilitated medical surgical planning and guidance, due to its potential for including relevant clinical data in the sight of the clinicians [8]. The implementation of augmented platforms for the visualization of medical images on video capture has been applied both to preoperative planning of orthopedic surgery and to guidance systems [9; 10]. MR training applications have been developed for clinicians to improve their surgical skills and understand the spatial relationships and concepts. A case study is the Turini's orthopedic open surgery simulation with Hololens technology [11]. Its conclusions suggest the suitability of MR technology for this application to display relevant anatomical views. There are currently about 30 medical simulators for educational purposes intended specifically for training in laparoscopic surgery, neurosurgery procedures, and echocardiography according to [PERSON]'s review [12]. The advantage of MR and AR trainers is the ability to combine a physical simulation with a virtual reality overlay, creating more realistic situations [13].