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Research Blog


Dr. Rory Windrim and Dr. Julia Kfouri

Department of Obstetrics & Gynaecology, University of Toronto


Professor Nick Woolridge and Professor Michael Corrin

Biomedical Communications, University of Toronto


Twin-twin transfusion syndrome (TTTS) is a rare, but major complication during monochorionic twin pregnancies. The treatment of choice for TTTS is fetoscopic laser ablation, a complex procedure only performed at specialized surgical centres. Currently, a gap exists in the training of surgeons learning to treat TTTS as cases are infrequent, the surgical procedure has a steep learning curve, and patient safety must take priority. Digital tools can help fill this gap using elements of serious gaming and immersive technology to create accessible, adaptive, 3D surgical simulators that teach requisite anatomical, procedural, and skill-based knowledge. While there is significant evidence supporting the use of digital simulators in medical training, there is little evidence examining the impact of visual complexity within these simulators. Instead, there is a widespread assumption that simulators featuring high-fidelity models and immersive environments—or high-complexity simulators—lead to better learning outcomes. This one-size-fits-all approach is not ideal, and learning science suggests that both low- and high-complexity simulators can play a role in helping scaffold knowledge.

  1. Construct a library of in utero 3D models that range from low- to high- complexity, are optimized for use in a real-time 3D engine, and that can be procedurally placed (randomly but correctly generated for each simulator session) for use in a TTTS surgical training simulator in Toronto, and eventually, Maternal-Fetal Medicine (MFM) centres worldwide.

  2. Develop a prototype surgical simulator that presents a scaffolded learning approach, initially using low-complexity models and building to high-complexity models as learners gain experience with repeated use of the simulator.

  3. Draft a rigorous protocol for a summative assessment that will formally evaluate the efficacy of using visual complexity to scaffold learning in surgical simulators.

  4. Document and share the process of optimizing 3D medical data sets and sculpted models for interactive use in medical education and biocommunication.


The specific outcomes and goals of my Master’s Research Project (MRP) were, in part, informed by a comprehensive literature review regarding the creation and study of medical simulators. Specifically, the literature review sought to examine how medical procedures and surgeries were traditionally taught; how simulators are used in a modern context to better educate physicians; and if these modern simulators have been evaluated to determine how visual complexity impacts learner outcomes.

The information gathered from the literature review was used to perform a media audit of medical and surgical simulators currently in use throughout North America. Each simulator within the audit was critically examined to determine the primary goals of the simulator, how learner competency was developed and tested, and how, if at all, visual complexity was used to aid learners.


Based on the literature review and media audit, I proposed a project that created the assets and design documentation necessary to begin construction on a full-scale simulator to train physicians learning TTTS fetoscopic ablation therapy. In addition to these resources, the project would lead to the creation of an evaluation that could be used to better determine if visual complexity could be scaffolded in order to increase learning gains for physicians new to complex surgical procedures.  


My complete MRP Research Proposal can be viewed here.


In order to better understand the scope of my MRP and the final simulator, a needs evaluation was performed to determine the broad and long-term goals of the simulator. This evaluation informed the creation of user personas specific to the simulator, context scenarios surrounding how users might interact with the simulator, and the design requirements necessary to ensure the simulator would succeed.

To learn more about the design thinking that went into my MRP, check out my full Scope Document here.


As one of the main project objectives for my MRP, the design documentation of this project will be constantly evolving until final sign-off. Based of off aspects of my original project proposal and scope document, the design documentation builds off both to provide a comprehensive guide to the completion of a full TTTS simulator for future designers and developers. Its current iteration includes wireframes for the simulator (seen below), a rough walkthrough of the design functionalities to be built by developers, and a series of guides explaining asset creation and optimization.


Alongside the design documentation and testing methodology needed to assess if scaffolding visual complexity can help to make medical simulators more effective, a prototype version of the simulator must be developed so that testing can be performed. The testing simulator will utilize the assets created for the final simulator; however, many of the more advanced functions and requirements necessary for the fully realized version will be omitted to simplify design and ensure a standardized testing tool. The design of the testing simulator is itself an iterative process, relying on the successive tests and builds within Unity to optimize model generation, interaction, user controls, and the overall performance of the simulator.


My first prototype can be seen below, as well as some more recent test renders from Unity using 3D models created in Autodesk Maya and ZBrush.

Final Simulator 

Based on my prototypes and test renders, I iterated and refined my design and 3D assets. I was able to incorporate my earlier UI/UX elements from the design documentation and create a fully functional test simulator for the conclusion of my MRP in August of 2019. Below is a video overview of the final product, which was submitted to the Association of Medical Illustrators annual salon for consideration in July of 2020. The project won an Award of Excellence (Student Interactive Media) and was recognized with one of two Best in Show (Student) awards. 

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