# The potential of Real-Time rendered-volume 3D Imaging in immersive virtual-reality (VR) for surgical planning in infants with congenital thoracic malformation (CTM)

## TL;DR

This study shows that VR-based 3D imaging improves surgical planning for infants with chest malformations by providing a detailed, interactive digital twin of their anatomy.

## Contribution

The study introduces VR as a digital twin for precision surgical planning in infants with congenital thoracic malformations.

## Key findings

- VR-based 3D imaging achieved 100% sensitivity in pathology detection, matching conventional 2D CT.
- VR improved spatial understanding, identifying complex anatomical features more frequently than 2D imaging.
- VR led to more accurate surgical planning, particularly in recommending lobectomy procedures.

## Abstract

CTM are difficult to evaluate preoperatively due to the limitations of low-dose computed tomography imaging in infants. Digital twin technologies, such as immersive VR, offer interactive, patient-specific simulations that replicate anatomical and pathological features in three dimensions. This study investigates the role of VR-based 3D imaging as a digital twin for precision surgical planning in infants with CTM.

Fourteen infants who underwent surgical resection for suspected CTM between 09/2020 and 02/2023 were retrospectively analyzed. Pseudonymized CT scans were reconstructed into interactive VR models, serving as digital anatomical twins. Eight surgeons assessed each case using both conventional 2D CT and VR-based reconstructions, separated by a three-month washout period. Outcomes included diagnostic accuracy, and evaluation times.

Both VR and conventional imaging achieved 100 % sensitivity in pathology detection. VR enhanced spatial understanding, identifying multilobar involvement (29 % vs. 21 %) and mediastinal shift (36 % vs. 29 %) more frequently. Surgical planning differed significantly, with VR prompting more lobectomy recommendations (57 % vs. 50 %, p = 0.046). VR required longer evaluation times (203.2 ± 117.4 s vs. 124.1 ± 69.7 s, p < 0.001) but demonstrated higher prediction accuracy for the surgical procedure (95 % vs. 84 %).

Patient-specific VR reconstructions act as digital twins, enhancing surgical planning precision and providing a personalized anatomical roadmap for CTM management. While time demands remain a limitation, VR as a digital twin aligns with precision medicine and smart hospital paradigms. It also supports less experienced surgeons and fosters interdisciplinary collaboration. Larger multicenter studies should explore its integration into perioperative decision-making and training.

•VR-based 3D reconstructions act as anatomical health digital twins for congenital thoracic malformations.•Immersive VR improved surgeons’ spatial understanding and diagnostic accuracy despite low resolution in infants.•Surgical assessment was more accurate after VR review, especially toward lobectomy.•Less experienced surgeons benefited most from the VR-based digital twin approach.•VR integration supports precision medicine and smart hospital surgical planning.

VR-based 3D reconstructions act as anatomical health digital twins for congenital thoracic malformations.

Immersive VR improved surgeons’ spatial understanding and diagnostic accuracy despite low resolution in infants.

Surgical assessment was more accurate after VR review, especially toward lobectomy.

Less experienced surgeons benefited most from the VR-based digital twin approach.

VR integration supports precision medicine and smart hospital surgical planning.