Quantifying tactile properties of liver tissue, silicone elastomers, and a 3D printed polymer for manufacturing realistic organ models

Hardness changing tactile displays for simulating the feel of organic tissues

Physical interaction with patients, for example conducted as part of a diagnostic examination or surgical procedure, provides clinicians with a wealth of information about their condition. Simulating this interaction is of great interest to researchers in both haptics and medical education, and the development of softness changing tactile interfaces is important in recreating the feel of different soft tissues. This paper presents designs for a variety of novel electromechanical and electromagnetic mechanisms for controlling particle jamming-based, hardness changing tactile displays, intended to allow medical trainees to experience these physical interactions in a range of simulation settings such as clinical skills teaching laboratories. Each design is then subjected to a battery of mechanical tests to evaluate its effectiveness compared to the state of the art, as well as their suitability for simulating the physical hardness of different types of soft tissues, previously characterised in established literature. These results demonstrate that all of the technologies presented are able to exhibit a measurable hardness change, with Shore hardness values between 3A and 57A achieved by the most effective constriction-based device. The electromechanical devices based on constriction and compression, and the state-of-the-art pneumatic device, were able to achieve hardness changes within a range that is useful for replicating the softness of organic tissue. The electromechanical and electromagnetic devices were also found to effect their full range of hardness change in less than a second, compared to several seconds for the state-of-the-art. These results show that the performance of softness changing tactile displays can be improved with the electromechanical actuation techniques proposed in this paper, and that such displays are able to replicate the physical characteristics of soft tissues and may therefore be of benefit in medical training and simulation scenarios.

Novel 3D Custom-Made Silicone Tumor Model as a Support for Teaching Surgical Oncology Principles

Alternative laboratory teaching methods are becoming increasingly desirable and effective in medical education environments. While ethical concerns associated with the use of live animals in terminal surgery laboratories have been reduced with cadaveric models, availability, and lack of pathology can limit their ability to adequately convey surgical principles and replicate clinical training. We have developed a three-dimensional (3D) custom-made silicone soft tissue tumor model using 3D-printed molds derived from canine soft tissue sarcoma computed tomography images. This novel teaching model allows users to apply surgical oncology principles and perform basic technical tasks such as incisional biopsy, margin demarcation, marginal and wide surgical excision, and inking of surgical margins. A large cohort of students in addition to a small number of professional veterinarians at different levels of specialty training followed the laboratory guidelines and evaluated the simulated tumor model based on a qualitative survey. All participants were able to successfully complete the practical training. The model also allowed the students to identify and correct technical errors associated with biopsy sampling and margin dissection, and to understand the clinical impacts related to those errors. Face and content validity of the model were assessed using Likert-style questionnaires with overall average instructors' scores of 3.8/5 and 4.6/5, respectively. Content validity assessment of the model by the students approximated instructors' evaluation with an overall average score of 4.4/5. This model development emphasizes the efficacy of alternative non-cadaveric laboratory teaching tools and could become a valuable aid in the veterinary curricula.

Advanced Strategies for the Fabrication of Multi-Material Anatomical Models of Complex Pediatric Oncologic Cases

The printing and manufacturing of anatomical 3D models has gained popularity in complex surgical cases for surgical planning, simulation and training, the evaluation of anatomical relations, medical device testing and patient-professional communication. 3D models provide the haptic feedback that Virtual or Augmented Reality (VR/AR) cannot provide. However, there are many technologies and strategies for the production of 3D models. Therefore, the aim of the present study is to show and compare eight different strategies for the manufacture of surgical planning and training prototypes. The eight strategies for creating complex abdominal oncological anatomical models, based on eight common pediatric oncological cases, were developed using four common technologies (stereolithography (SLA), selectie laser sinterning (SLS), fused filament fabrication (FFF) and material jetting (MJ)) along with indirect and hybrid 3D printing methods. Nine materials were selected for their properties, with the final models assessed for application suitability, production time, viscoelastic mechanical properties (shore hardness and elastic modulus) and cost. The manufacturing and post-processing of each strategy is assessed, with times ranging from 12 h (FFF) to 61 h (hybridization of FFF and SLS), as labor times differ significantly. Cost per model variation is also significant, ranging from EUR 80 (FFF) to EUR 600 (MJ). The main limitation is the mimicry of physiological properties. Viscoelastic properties and the combination of materials, colors and textures are also substantially different according to the strategy and the intended use. It was concluded that MJ is the best overall option, although its use in hospitals is limited due to its cost. Consequently, indirect 3D printing could be a solid and cheaper alternative.

Approaches to Laparoscopic Training in Veterinary Medicine: A Review of Personalized Simulators

Veterinary minimally invasive surgery (MIS) has experienced notable growth in recent years, yet the availability of specialized training tools remains limited and not readily accessible to practitioners worldwide. While borrowing simulators from human medicine practices suffices for acquiring fundamental laparoscopic skills, it proves inadequate when addressing procedure-specific nuances. Veterinary professionals are now taking steps to create simulators tailored to their patients, although the validation process can be time-consuming. Consequently, the availability of advanced laparoscopic simulators for veterinary training remains scarce. The present study aims to highlight custom-made simulators. A comprehensive search across five databases was conducted to uncover the simulators documented from 2010 to 2022. A total of five simulators emerged from this search, with four grounded in a canine model and only one in an equine model. These models underwent validation and were found to be effective in training surgeons for their designated tasks. The findings underscore a limited array of simulators, predominantly catering to two species (horses and dogs). Considering these findings, it is evident that further research is imperative to create laparoscopic simulators capable of facilitating advanced veterinary training. This would enable the continued evolution of surgical techniques across diverse species, including ruminants, small mammals, and non-mammalian animals.

Release Kinetics of Metronidazole from 3D Printed Silicone Scaffolds for Sustained Application to the Female Reproductive Tract

Sustained vaginal administration of antibiotics or probiotics has been proposed to improve treatment efficacy for bacterial vaginosis. 3D printing has shown promise for development of systems for local agent delivery. In contrast to oral ingestion, agent release kinetics can be fine-tuned by the 3D printing of specialized scaffold designs tailored for particular treatments while enhancing dosage effectiveness via localized sustained release. It has been challenging to establish scaffold properties as a function of fabrication parameters to obtain sustained release. In particular, the relationships between scaffold curing conditions, compressive strength, and drug release kinetics remain poorly understood. This study evaluates 3D printed scaffold formulation and feasibility to sustain the release of metronidazole, a commonly used antibiotic for BV. Cylindrical silicone scaffolds were printed and cured using three different conditions relevant to potential future incorporation of temperature-sensitive labile biologics. Compressive strength and drug release were monitored for 14d in simulated vaginal fluid to assess long-term effects of fabrication conditions on mechanical integrity and release kinetics. Scaffolds were mechanically evaluated to determine compressive and tensile strength, and elastic modulus. Release profiles were fitted to previous kinetic models to differentiate potential release mechanisms. The Higuchi, Korsmeyer-Peppas, and Peppas-Sahlin models best described the release, indicating similarity to release from insoluble or polymeric matrices. This study shows the feasibility of 3D printed silicone scaffolds to provide sustained metronidazole release over 14d, with compressive strength and drug release kinetics tuned by the fabrication parameters.

Patient-Specific 3D Printed Soft Models for Liver Surgical Planning and Hands-On Training

Background: Pre-surgical simulation-based training with three-dimensional (3D) models has been intensively developed in complex surgeries in recent years. This is also the case in liver surgery, although with fewer reported examples. The simulation-based training with 3D models represents an alternative to current surgical simulation methods based on animal or ex vivo models or virtual reality (VR), showing reported advantages, which makes the development of realistic 3D-printed models an option. This work presents an innovative, low-cost approach for producing patient-specific 3D anatomical models for hands-on simulation and training. Methods: The article reports three paediatric cases presenting complex liver tumours that were transferred to a major paediatric referral centre for treatment: hepatoblastoma, hepatic hamartoma and biliary tract rhabdomyosarcoma. The complete process of the additively manufactured liver tumour simulators is described, and the different steps for the correct development of each case are explained: (1) medical image acquisition; (2) segmentation; (3) 3D printing; (4) quality control/validation; and (5) cost. A digital workflow for liver cancer surgical planning is proposed. Results: Three hepatic surgeries were planned, with 3D simulators built using 3D printing and silicone moulding techniques. The 3D physical models showed highly accurate replications of the actual condition. Additionally, they proved to be more cost-effective in comparison with other models. Conclusions: It is demonstrated that it is possible to manufacture accurate and cost-effective 3D-printed soft surgical planning simulators for treating liver cancer. The 3D models allowed for proper pre-surgical planning and simulation training in the three cases reported, making it a valuable aid for surgeons.

Needle Penetration Simulation: Influence of Penetration Angle and Sample Stress on the Mechanical Behaviors of Polymers Applying a Cast Silicone and a 3D-Printed Resin

For surgical catheterization training applications, realistic and effective materials are desired. In this study, the relevance of a needle puncture angle and a simulated wall stress on different elastic materials were determined in a previously developed experimental setup. Both settings were considered individually in two new setups. In addition, a control setup with neither angle nor prestress was designed. During the process of puncturing the samples of two materials (Replisil 9N and Formlabs Elastic 50A), force−displacement values were collected, and three predefined parameters evaluated. The differences between the angled/stressed groups and the control group were analyzed. The additively processed material required a significantly higher force to puncture than the conventional one (p < 0.001). Moreover, a needle angulation of 45° required more force than puncturing orthogonally. Prestressing the samples did not clearly influence the resulting force. An evaluation of relative parameters showed that the investigated materials behaved differently but not linearly differently under the influence of needle angle and prestress. Therefore, it is essential to evaluate the properties and suitability of materials for surgical training models in appropriate experimental setups considering multiple parameters.

Synthesis and characterisation of a cancerous liver for presurgical planning and training applications

OBJECTIVES

Oncology surgeons use animals and cadavers in training because of a lack of alternatives. The aim of this work was to develop a design methodology to create synthetic liver models familiar to surgeons, and to help plan, teach and rehearse patient-specific cancerous liver resection surgery.

DESIGN

Synthetic gels were selected and processed to recreate accurate anthropomorphic qualities. Organic and synthetic materials were mechanically tested with the same equipment and standards to determine physical properties like hardness, elastic modulus and viscoelasticity. Collected data were compared with published data on the human liver. Patient-specific CT data were segmented and reconstructed and additive manufactured models were made of the liver vasculature, parenchyma and lesion. Using toolmaking and dissolvable scaffolds, models were transformed into tactile duplicates that could mimic liver tissue behaviour.

RESULTS

Porcine liver tissue hardness was found to be 23 H00 (±0.1) and synthetic liver was 10 H00 (±2.3), while human parenchyma was reported as 15.06 H00 (±2.64). Average elastic Young's modulus of human liver was reported as 0.012 MPa, and synthetic liver was 0.012 MPa, but warmed porcine parenchyma was 0.28 MPa. The final liver model demonstrated a time-dependant viscoelastic response to cyclic loading.

CONCLUSION

Synthetic liver was better than porcine liver at recreating the mechanical properties of living human liver. Warmed porcine liver was more brittle, less extensible and stiffer than both human and synthetic tissues. Qualitative surgical assessment of the model by a consultant liver surgeon showed vasculature was explorable and that bimanual palpation, organ delivery, transposition and organ slumping were analogous to human liver behaviour.

A parameter reduced adaptive quasi-linear viscoelastic model for soft biological tissue in uniaxial tension

Mechanical characterisation of soft viscous materials is essential for many applications including aerospace industries, material models for surgical simulation, and tissue mimicking materials for anatomical models. Constitutive material models are, therefore, necessary to describe soft biological tissues in physiologically relevant strain ranges. Hereby, the adaptive quasi-linear viscoelastic (AQLV) model enables accurate modelling of the strain-dependent non-linear viscoelastic behaviour of soft tissues with a high flexibility. However, the higher flexibility produces a large number of model parameters. In this study, porcine muscle and liver tissue samples were modelled in the framework of the originally published AQLV (3-layers of Maxwell elements) model using four incremental ramp-hold experiments in uniaxial tension. AQLV model parameters were reduced by decreasing model layers (M) as well as the number of experimental ramp-hold steps (N). Leave One out cross validation tests show that the original AQLV model (3M4N) with 19 parameters, accurately describes porcine muscle tissue with an average R² of 0.90 and porcine liver tissue, R² of 0.86. Reducing the number of layers (N) in the model produced acceptable model fits for 1-layer (R² of 0.83) and 2-layer models (R² of 0.89) for porcine muscle tissue and 1-layer (R² of 0.84) and 2-layer model (R² of 0.85) for porcine liver tissue. Additionally, a 2 step (2N) ramp-hold experiment was performed on additional samples of porcine muscle tissue only to further reduce model parameters. Calibrated spring constant values for 2N ramp-hold tests parameters k₁ and k₂ had a 16.8% and 38.0% deviation from those calibrated for a 4 step (4N) ramp hold experiment. This enables further reduction of material parameters by means of step reduction, effectively reducing the number of parameters required to calibrate the AQLV model from 19 for a 3M4N model to 8 for a 2M2N model, with the added advantage of reducing the time per experiment by 50%. This study proposes a 'reduced-parameter' AQLV model (2M2N) for the modelling of soft biological tissues at finite strain ranges. Sequentially, the comparison of model parameters of soft tissues is easier and the experimental burden is reduced.

Soft-Tissue-Mimicking Using Hydrogels for the Development of Phantoms

With the currently available materials and technologies it is difficult to mimic the mechanical properties of soft living tissues. Additionally, another significant problem is the lack of information about the mechanical properties of these tissues. Alternatively, the use of phantoms offers a promising solution to simulate biological bodies. For this reason, to advance in the state-of-the-art a wide range of organs (e.g., liver, heart, kidney as well as brain) and hydrogels (e.g., agarose, polyvinyl alcohol –PVA–, Phytagel –PHY– and methacrylate gelatine –GelMA–) were tested regarding their mechanical properties. For that, viscoelastic behavior, hardness, as well as a non-linear elastic mechanical response were measured. It was seen that there was a significant difference among the results for the different mentioned soft tissues. Some of them appear to be more elastic than viscous as well as being softer or harder. With all this information in mind, a correlation between the mechanical properties of the organs and the different materials was performed. The next conclusions were drawn: (1) to mimic the liver, the best material is 1% wt agarose; (2) to mimic the heart, the best material is 2% wt agarose; (3) to mimic the kidney, the best material is 4% wt GelMA; and (4) to mimic the brain, the best materials are 4% wt GelMA and 1% wt agarose. Neither PVA nor PHY was selected to mimic any of the studied tissues.

Material design of soft biological tissue replicas using viscoelastic micromechanical modelling

Anatomical models for research and education are often made of artificial materials that attempt to mimic biological tissues in terms of their mechanical properties. Recent developments in additive manufacturing allow tuning mechanical properties with microstructural designs. We propose a strategy for designing material microstructures to mimic soft tissue viscoelastic behaviour, based on a micromechanical Mori-Tanaka model. The model was applied to predict homogenised viscoelastic properties of materials, exhibiting a matrix-inclusion microstructure with varying inclusion volume fractions. The input properties were thereby obtained from compression relaxation tests on silicone elastomers. Validation of the model was done with experimental results for composite samples. Finally, different combinations of silicones were compared to mechanical properties of soft tissues (hepatic, myocardial, adipose, cervical, and prostate tissue), found in literature, in order to design microstructures for replicating these tissues in terms of viscoelasticity. The viscoelastic Mori-Tanaka model showed good agreement with the corresponding experimental results for low inclusion volume fractions, while high fractions lead to underestimation of the complex modulus by the model. Predictions for the loss tangent were reasonably accurate, even for higher inclusion volume fractions. Based on the model, designs for 3D printed microstructures can be extracted in order to replicate the viscoelastic properties of soft tissues.

Applications of 3-dimensional printing in small-animal surgery: A review of current practices

Three-dimensional (3D) printing, also called rapid prototyping or additive manufacturing, transforms digital images into 3D printed objects, typically by layering consecutive thin films of material. This technology has become increasingly accessible to the public, prompting applications in veterinary surgery. Three-dimensional prints provide direct visualization of complex 3D structures and also haptic feedback relevant to surgery. The main objective of this review is to report current applications of 3D printing in small-animal surgery, including surgical education, preoperative planning, and treatment of tissue defects. The reported uses of 3D prints, their proposed advantages, and current limitations are discussed considering published evidence. Aspects of the manufacturing process specific to each application are described, along with current practices in veterinary surgery.

Hyperelastic and viscoelastic characterization of hepatic tissue under uniaxial tension in time and frequency domain

In order to create accurate anatomical models for medical training and research, mechanical properties of biological tissues need to be studied. However, non-linear and viscoelastic behaviour of most soft biological tissues complicates the evaluation of their mechanical properties. In the current study, a method for measuring hyperelasticity and viscoelasticity of bovine and porcine hepatic parenchyma in tension is presented. First, non-linear stress-stretch curves resulting from ramp loading and unloading, were interpreted based on a hyperelastic framework, using a Veronda-Westmann strain energy function. Strain-specific elastic moduli, such as initial stiffness E_I, were thereupon defined in certain parts of the stress-stretch curves. Furthermore, dissipated and stored energy density were calculated. Next, the viscoelastic nature of liver tissue was examined with two different methods: stress relaxation and dynamic cyclic testing. Both tests yielded dissipated and stored energy density, as well as loss tangent (tanδ), storage modulus (E^'), and loss modulus (E^''). In tension, stress relaxation was experimentally more convenient than dynamic cyclic testing. Thus we considered whether relaxation could be used for approximating the results of the cyclic tests. Regarding the resulting elastic moduli, initial stiffness was similar for porcine and bovine liver (E_I∼30kPa), while porcine liver was stiffer for higher strains. Comparing stress relaxation with dynamic cyclic testing, tanδ of porcine and bovine liver was the same for both methods (tanδ=0.05-0.25 at 1 Hz). Storage and loss moduli matched well for bovine, but not as well for porcine tissue. In conclusion, the utilized Veronda-Westmann model was appropriate for representing the hyperelasticity of liver tissue seen in ramp tests. Concerning viscoelasticity, both chosen testing methods - stress relaxation and dynamic cyclic testing - yielded comparable results for E^', E^'', and tanδ, as long as elasticity non-linearities were heeded. The here presented method provides novel insight into the tensile viscoelastic properties of hepatic tissue, and provides guidelines for convenient evaluation of soft tissue mechanical properties.

3D printing tissue-mimicking materials for realistic transseptal puncture models

Applications of additive manufacturing (commonly referred to as 3D printing) in direct fabrication of models for pre-surgical planning, functional testing, and medical training are on the rise. However, one current limitation to the accuracy of models for cardiovascular procedural training is a lack of printable materials that accurately mimic human tissue. Most of the available elastomeric materials lack mechanical properties representative of human tissues. To address the gap, the authors explore the multi-material capability of material jetting additive manufacturing to combine non-curing and photo-curing inks to achieve material properties that more closely replicate human tissues. The authors explore the impact of relative material concentration on tissue-relevant properties from puncture and tensile testing under submerged conditions. Further, the authors demonstrate the ability to mimic the mechanical properties of the fossa ovalis, which proves beneficial for accurately simulating transseptal punctures. A fossa ovalis mimic was printed and assembled within a full patient-specific heart model for validation, where it exhibited accuracy in both mechanical properties and geometry. The explored material combination provides the opportunity to fabricate future medical models that are more realistic and better suited for pre-surgical planning and medical student training. This will ultimately guide safer, more efficient practices.

3D printed soft surgical planning prototype for a biliary tract rhabdomyosarcoma

Biliary tract rhabdomyosarcoma is a soft tissue malignant musculoskeletal tumor which is located in the biliary tract. Although this tumor represents less than 1% of the total amount of childhood cancers, when localized, a >70% overall 5-year survival rate, the resection is clinically challenging and complications might exist during the biliary obstruction. Although surgery remains a mainstay, complete tumor resection is generally difficult to achieve without mutilation and severe long-term sequelae. Therefore, manufacturing multi-material 3D surgical planning prototypes of the case provides a great opportunity for surgeons to learn beforehand what they can expect. Additionally, practicing before the operation enhances the probability of success. That is why different compositions of materials have been characterized to match the mechanical properties of the liver. To do this, Dynamic Mechanical Analysis (DMA) tests and Shore hardness tests have been carried out. Amongst the material samples produced, 6%wt PVA (poly vinyl alcohol)/1%wt PHY (Phytagel)-1FT (Freeze-Thaw cycles) and 1%wt agarose appear as the best options for mimicking the liver tissue in terms of viscoelasticity. Regarding the Shore hardness, the best solution is 1%wt agarose. Additionally, a surgical planning prototype using this last material mentioned was manufactured and validated using a CT (Computed Tomography) scanner. In most of the structures the difference between the 3D model and the organ in terms of dimensions is less than 3.35 mm, which represents a low dimensional error, around 1%. On the other hand, the total manufacturing cost of the 3D physical model was €513 which is relatively low in comparison with other technologies.