# A Review of Training and Guidance Systems in Medical Surgery
## 4. Discussion  
Using the results obtained in Sections 3.7.1 and 3.7.2, several reflections and considerations in the area of evaluation and guidance are discussed next. Seven aspects that should be considered relevant in the development of training and surgery applications are covered and described. These are _(i) the incorporation of AI-DL_, _(ii) the addition of AR-VR_, _(iii) the inclusion of force feedback_, _(iv) the suitability of session recording_, _(v) the use of guidance systems_, _(vi) the monitoring of the learning process_, and vii) the pertinence of the use of real models and/or of virtual environments. 1. **Artificial Intelligence and Deep Learning** (AI-DL) applied in simulators was covered by References [61; 68; 69; 71; 80]. These are used to predict and categorize users' performance using inference and knowledge databases. Intelligent systems could provide very powerful reasoning systems to help experts with knowledge acquisition. Also, these systems can provide users metacognitive prompts as assistance and learning feedback according to their decisions. Systems that would use AI can help classify expertise levels and analyze patterns, which could give institutions a base that could let them choose students prepared to face real operations. Moreover, in recent years, DL, a subset of AI, is getting lots of attention [131]. In DL, models are trained using a large set of labeled data and neural network architectures that contain many layers. Therefore, DL approaches are achieving results that were not possible before [132]. 2. **Augmented Reality and Virtual Reality** (AR-VR) approaches in simulation were applied by References [47; 68; 102; 105; 110]. Alongside the advancement in data processing and artificial intelligence, solutions that allow users to dive and explore immersive computer-generated, or applications that overlay computer graphic interfaces in humans' field of view have appeared and attracted the research society's attention and different industries. AR-VR systems have become more powerful and can provide high-end visualizations. These approaches could enable researchers to create new ways of interaction and enhance the understanding of surgical tasks [133]. 3. In the area of interaction, **force feedback** is used in 55.22% of the applications covered in this paper. Haptic technologies have been gaining terrain since the last decade [8; 42]. Companies are manufacturing haptic devices to help authors develop new learning environments or just to enhance current solutions that do not provide the sufficient tactile realism needed in surgeries. An affordable haptic solution is Novint Falcon, which costs around $250-$500 (2020). However, most of the surgical procedures also require torque that is not available with Falcon. Out of the 37 simulators that implement force feedback, 45.94% uses Geomagic Touch devices. 4. **Session recording** is usually provided when applications save current session data to be analyzed later. Applications that record session data are only covered by 34.32% of the papers, where only 65.21% of it provides full storage of all sessions that occur in the system. Moreover, this feature is usually offered only by commercial solutions (33.33% are not commercial solutions). Even though this percentage is relatively low, this also indicates that authors have started to consider implementing databases to record the whole user experience. Authors have begun to notice that session databases are a great resource to track learning during training accurately. 5. On the other hand, **guidance systems** currently are not very common. A recent meta-analysis found that, over a wide array of conditions, learning from ITs was associated with higher outcome scores [134]. However, it is recognized that these systems have not lived up to their potential regarding their wider adoption, which could be due to clinicians not having experience in automated processes. It is likely to change with the introduction of AI-DL-oriented stations.