Virtual reality training for surgical trainees in laparoscopic surgery

The impact of robotic surgery on gynecologic oncology

The objective of this article was to review the published scientific literature pertaining to robotic surgery and its applications in gynecologic malignancies and to summarize the impact of robotic surgery on the field of gynecologic oncology. Summarizing data from different gynecologic disease-sites, robotic-assisted surgery is safe, feasible, and demonstrates equivalent histopathologic and oncologic outcomes. In general, benefits to robotic surgery include decreased blood loss, fewer perioperative complications and decreased length of hospital stay. Disadvantages include accessibility to robot surgical systems, decreased haptic sensation and fixed cost as well as cost of disposable equipment. As robotic surgery becomes readily available it will be imperative to develop standardized training modalities. Further research is needed to validate the role of robotic surgery in the treatment of gynecologic malignancies.

Comprehensive training curricula for minimally invasive surgery

BACKGROUND

The unique skill set required for minimally invasive surgery has in part contributed to a certain portion of surgical residency training transitioning from the operating room to the surgical skills laboratory. Simulation lends itself well as a method to shorten the learning curve for minimally invasive surgery by allowing trainees to practice the unique motor skills required for this type of surgery in a safe, structured environment. Although a significant amount of important work has been done to validate simulators as viable systems for teaching technical skills outside the operating room, the next step is to integrate simulation training into a comprehensive curriculum.

OBJECTIVES

This narrative review aims to synthesize the evidence and educational theories underlining curricula development for technical skills both in a broad context and specifically as it pertains to minimally invasive surgery.

FINDINGS

The review highlights the critical aspects of simulation training, such as the effective provision of feedback, deliberate practice, training to proficiency, the opportunity to practice at varying levels of difficulty, and the inclusion of both cognitive teaching and hands-on training. In addition, frameworks for integrating simulation training into a comprehensive curriculum are described. Finally, existing curricula on both laparoscopic box trainers and virtual reality simulators are critically evaluated.

Prospective randomized controlled trial of simulator-based versus traditional in-surgery laparoscopic camera navigation training

BACKGROUND

Surgical residents often use a laparoscopic camera in minimally invasive surgery for the first time in the operating room (OR) with no previous education or experience. Computer-based simulator training is increasingly used in residency programs. However, no randomized controlled study has compared the effect of simulator-based versus the traditional OR-based training of camera navigation skills.

METHODS

This prospective randomized controlled study included 24 pregraduation medical students without any experience in camera navigation or simulators. After a baseline camera navigation test in the OR, participants were randomized to six structured simulator-based training sessions in the skills lab (SL group) or to the traditional training in the OR navigating the camera during six laparoscopic interventions (OR group). After training, the camera test was repeated. Videos of all tests (including of 14 experts) were rated by five blinded, independent experts according to a structured protocol.

RESULTS

The groups were well randomized and comparable. Both training groups significantly improved their camera navigational skills in regard to time to completion of the camera test (SL P = 0.049; OR P = 0.02) and correct organ visualization (P = 0.04; P = 0.03). Horizon alignment improved without reaching statistical significance (P = 0.20; P = 0.09). Although both groups spent an equal amount of actual time on camera navigation training (217 vs. 272 min, P = 0.20), the SL group spent significantly less overall time in the skill lab than the OR group spent in the operating room (302 vs. 1002 min, P < 0.01).

CONCLUSION

This is the first prospective randomized controlled study indicating that simulator-based training of camera navigation can be transferred to the OR using the traditional hands-on training as controls. In addition, simulator camera navigation training for laparoscopic surgery is as effective but more time efficient than traditional teaching.

Overview of the quality assurance movement in health care

This chapter aims to describe the origin and current status of quality assurance (QA) in health care and to provide a background of similar developments in other industries, which have provided a major impetus for QA initiatives in health care. The interest in quality and safety in the health care sector has rapidly risen over the past decade. Without important lessons learnt from other industries, the interest and obtained improvements would have been far less fast. Knowledge on basic principles and challenges faced by other industries like the airline, car, and nuclear energy industry, that drove quality improvement projects, is of major relevance to understand the evolutions taking place in health care. To fully appreciate the QA movement, and design or implement quality improvement projects, its basic principles need to be understood. This chapter aims to give insights in basic principles underlying QA, and to discuss historical lessons that have been learnt from other industries. Furthermore, it discusses how to implement and assure a sustainable QA program.

Effects of virtual reality simulator training method and observational learning on surgical performance

BACKGROUND

Virtual reality (VR) simulators and Web-based instructional videos are valuable supplemental training resources in surgical programs, but it is unclear how to optimally integrate them into minimally invasive surgical training.

METHODS

Medical students were randomized to proficiency-based training on VR laparoscopy and endoscopy simulators by two different methods: proctored training (automated simulator feedback plus human expert feedback) or independent training (simulator feedback alone). After achieving simulator proficiency, trainees performed a series of laparoscopic and endoscopic tasks in a live porcine model. Prior to their entry into the animal lab, all trainees watched an instructional video of the procedure and were randomly assigned to either observe or not observe the actual procedure before performing it themselves. The joint effects of VR training method and procedure observation on time to successful task completion were evaluated with Cox regression models.

RESULTS

Thirty-two students (16 proctored, 16 independent) completed VR training. Cox regression modeling with adjustment for relevant covariates demonstrated no significant difference in the likelihood of successful task completion for independent versus proctored training [Hazard Ratio (HR) 1.28; 95% Confidence Interval (CI) 0.96-1.72; p=0.09]. Trainees who observed the actual procedure were more likely to be successful than those who watched the instructional video alone (HR 1.47; 95% CI 1.09-1.98; p=0.01).

CONCLUSIONS

Proctored VR training is no more effective than independent training with respect to surgical performance. Therefore, time-consuming human expert feedback during VR training may be unnecessary. Instructional videos, while useful, may not be adequate substitutes for actual observation when trainees are learning minimally invasive surgical procedures.

Will the Playstation generation become better endoscopic surgeons?

Background

A frequently heard comment is that the current “Playstation generation” will have superior baseline psychomotor skills. However, research has provided inconsistent results on this matter. The purpose of this study was to investigate whether the “Playstation generation” shows superior baseline psychomotor skills for endoscopic surgery on a virtual reality simulator.

Methods

The 46 study participants were interns (mean age 24 years) of the department of surgery and schoolchildren (mean age 12.5 years) of the first year of a secondary school. Participants were divided into four groups: 10 interns with videogame experience and 10 without, 13 schoolchildren with videogame experience and 13 without. They performed four tasks twice on a virtual reality simulator for basic endoscopic skills. The one-way analysis of variance (ANOVA) with post hoc test Tukey-Bonferroni and the independent Student’s t test were used to determine differences in mean scores.

Results

Interns with videogame experience scored significantly higher on total score (93 vs. 74.5; p = 0.014) compared with interns without this experience. There was a nonsignificant difference in mean total scores between the group of schoolchildren with and those without videogame experience (61.69 vs. 55.46; p = 0.411). The same accounts for interns with regard to mean scores on efficiency (50.7 vs. 38.9; p = 0.011) and speed (18.8 vs. 14.3; p = 0.023). In the group of schoolchildren, there was no statistical difference for efficiency (32.69 vs. 27.31; p = 0.218) or speed (13.92 vs. 13.15; p = 0.54). The scores concerning precision parameters did not differ for interns (23.5 vs. 21.3; p = 0.79) or for schoolchildren (mean 15.08 vs. 15; p = 0.979).

Conclusions

Our study results did not predict an advantage of videogame experience in children with regard to superior psychomotor skills for endoscopic surgery. However, at adult age, a difference in favor of gaming is present. The next generation of surgeons might benefit from videogame experience during their childhood.

The influence of resident involvement on surgical outcomes

BACKGROUND

Although the training of surgical residents is often considered in national policy addressing complications and safety, the influence of resident intraoperative involvement on surgical outcomes has not been well studied.

STUDY DESIGN

We identified 607,683 surgical cases from 234 hospitals from the 2006 to 2009 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Outcomes were compared by resident involvement for all general and vascular cases as well as for specific general surgical procedures.

RESULTS

After typical ACS NSQIP comorbidity risk adjustment and further adjustment for hospital teaching status and operative time in modeling, resident intraoperative involvement was associated with slightly increased morbidity when assessing overall general or vascular procedures (odds ratio [OR] 1.06; 95% CI 1.04 to 1.09), pancreatectomy or esophagectomy (OR 1.26; 95% CI 1.08 to 1.45), and colorectal resections (OR 1.15; 95% CI 1.09 to 1.22). In contrast, for mortality, resident intraoperative involvement was associated with reductions for overall general and vascular procedures (OR 0.91; 95% CI 0.84 to 0.99), colorectal resections (OR 0.88; 95% CI 0.78 to 0.99), and abdominal aortic aneurysm repair (OR 0.71; 95% CI 0.53 to 0.95). Results were moderated somewhat after hierarchical modeling was performed to account for hospital-level variation, with mortality results no longer reaching significance (overall morbidity OR 1.07; 95% CI 1.03 to 1.10, overall mortality OR 0.97; 95% CI 0.90 to 1.05). Based on risk-adjusted event rates, resident intraoperative involvement is associated with approximately 6.1 additional morbidity events but 1.4 fewer deaths per 1,000 general and vascular surgery procedures.

CONCLUSIONS

Resident intraoperative participation is associated with slightly higher morbidity rates but slightly decreased mortality rates across a variety of procedures and is minimized further after taking into account hospital-level variation. These clinically small effects may serve to reassure patients and others that resident involvement in surgical care is safe and possibly protective with regard to mortality.

Completion of a novel, virtual-reality-based, advanced laparoscopic curriculum improves advanced laparoscopic skills in senior residents

INTRODUCTION

Virtual reality simulators contribute to basic laparoscopic skill acquisition. These trainers have not yet been shown to contribute to the acquisition of more advanced laparoscopic skills as measured by the Fundamentals of Laparoscopic Surgery (FLS). We have customized novel basic and advanced curricula for the LapSim trainer (Surgical Science, Göteborg, Sweden). Successful completion of these programs is required of our residents. We hypothesize that the successful completion of our advanced curriculum will result in the significant improvement of our residents' advanced laparoscopic skills as measured by the FLS skills scores.

METHODS

In all, 23 surgical residents (PGY 1-4), who had already passed our basic skills curriculum, completed our advanced LapSim curriculum. All individuals underwent FLS skills testing before and after completing the training. Laparoscopic case experience during the training period was documented for all trainees. FLS scores were analyzed by t test and controlled for case experience.

RESULTS

Posttraining FLS scores demonstrate a significant increase for all residents from a mean of 57-66 (p < 0.02), especially for seniors (PGY 3-4): 56-68 (p < 0.01). The operative laparoscopic case volume ranged from 1-90 (mean, 30) for juniors (PGY 1-2) and 12-76 (mean 50) for seniors during the training period. Junior resident FLS improvement was dependent on case volume during the period of training; residents with less than 30 cases had a mean improvement of 0, whereas those with at least 30 cases had a 15 point improvement (p < 0.01). Senior resident FLS score improvement was independent of case numbers during the training period.

CONCLUSIONS

Completion of our advanced LapSim curriculum results in improved advanced laparoscopic skills in senior residents as measured by FLS scores. This skill improvement is independent of laparoscopic case experience. Continuing to mandate the use of this skills curriculum should improve our residents' performance in advanced laparoscopic surgical procedures.

The learning effect of intraoperative video-enhanced surgical procedure training

BACKGROUND

The transition from basic skills training in a skills lab to procedure training in the operating theater using the traditional master-apprentice model (MAM) lacks uniformity and efficiency. When the supervising surgeon performs parts of a procedure, training opportunities are lost. To minimize this intervention by the supervisor and maximize the actual operating time for the trainee, we created a new training method called INtraoperative Video-Enhanced Surgical Training (INVEST).

METHODS

Ten surgical residents were trained in laparoscopic cholecystectomy either by the MAM or with INVEST. Each trainee performed six cholecystectomies that were objectively evaluated on an Objective Structured Assessment of Technical Skills (OSATS) global rating scale. Absolute and relative improvements during the training curriculum were compared between the groups. A questionnaire evaluated the trainee's opinion on this new training method.

RESULTS

Skill improvement on the OSATS global rating scale was significantly greater for the trainees in the INVEST curriculum compared to the MAM, with mean absolute improvement 32.6 versus 14.0 points and mean relative improvement 59.1 versus 34.6% (P=0.02).

CONCLUSION

INVEST significantly enhances technical and procedural skill development during the early learning curve for laparoscopic cholecystectomy. Trainees were positive about the content and the idea of the curriculum.

Development of simulated arthroscopic skills

BACKGROUND AND PURPOSE

Previous studies have shown that there is a correlation between arthroscopic experience and performance on a virtual-reality (VR) unit. We analyzed the development inexperienced surgeons went through during VR training of shoulder arthroscopy.

METHODS

14 inexperienced surgeons from Silkeborg Regional Hospital were randomized into an intervention group and a control group. 7 experienced surgeons constituted another control group. All were tested twice on insightMIST-an advanced arthroscopic VR trainer-within a period of 6-15 days. The intervention group also received a 5-hour training program on the VR unit.

RESULTS

The average time for the arthroscopy in the intervention group was reduced from 720 (SD 239) seconds to 223 (SD 114) seconds (p = 0.03 compared to the inexperienced control group). Distance travelled by the camera was reduced from 367 (SD 151) cm to 84 (SD 44) cm in the intervention group (p = 0.02 compared to the inexperienced control group). Depth of collisions was also significantly reduced, whereas distance travelled by the probe and number of collisions were improved in the intervention group, although not statistically significantly.

INTERPRETATION

VR training is a possible way for young and inexperienced surgeons to achieve basic navigation skills necessary to perform arthroscopic surgery. Further studies regarding the transferability of the skills acquired on the VR unit to the operating theater are desirable.

Virtual reality laparoscopy: which potential trainee starts with a higher proficiency level?

PURPOSE

Minimally invasive surgery requires technical skills distinct from those used in conventional surgery. The aim of this prospective study was to identify personal characteristics that may predict the attainable proficiency level of first-time virtual reality laparoscopy (VRL) trainees.

METHODS

Two hundred and seventy-nine consecutive undergraduate medical students without experience attended a standardized VRL training. Performance data of an abstract and a procedural task were correlated with possible predictive factors providing potential competence in VRL.

RESULTS

Median global score requirement status was 86.7% (interquartile range (IQR) 75-93) for the abstract task and 74.4% (IQR 67-88) for the procedural task. Unadjusted analysis showed significant increase in the global score in both tasks for trainees who had a gaming console at home and frequently used it as well as for trainees who felt self-confident to assist in a laparoscopic operation. Multiple logistic regression analysis identified frequency of video gaming (often/frequently vs. rarely/not at all, odds ratio: abstract model 2.1 (95% confidence interval 1.2; 3.6), P = 0.009; virtual reality operation procedure 2.4 (95% confidence interval 1.3; 4.2), P = 0.003) as a predictive factor for VRL performance.

CONCLUSION

Frequency of video gaming is associated with quality of first-time VRL performance. Video game experience may be used as trainee selection criteria for tailored concepts of VRL training programs.

Impact of established skills in open surgery on the proficiency gain process for laparoscopic surgery

BACKGROUND

Laparoscopic training traditionally follows open surgical training. This study aimed to investigate the impact of experience in open surgery on the laparoscopic proficiency gain process.

METHODS

A survey form investigating the importance of open experience before the start of laparoscopic training was sent to surgical experts and trainees in the United Kingdom. A separate experimental study objectively assessed the effects of open experience on laparoscopic skill acquisition using a virtual reality simulator. In the study, 11 medical students with no prior surgical experience (group A) and 14 surgical trainees with open but no laparoscopic experience in (group B) performed 250 simulated laparoscopic cholecystectomies. Psychomotor skills were evaluated by motion analysis and video-based global rating scores. Before the first and after the fifth and tenth operation, knowledge of laparoscopic techniques was assessed by a written test and by self-reported confidence levels indicated on a questionnaire.

RESULTS

The 80 experts and 282 trainees who responded to the survey believed prior open experience aids confidence levels, knowledge, and skills acquisition. In the simulation study, no intergroup difference was found for any parameter after the first procedure. Group B scored significantly higher in the laparoscopic knowledge test before training began (42.7% vs. 64.3%; p = 0.002), but no significant difference was found after five operations. The two groups did not differ significantly in terms of confidence. Group B had a significantly shorter total operation time only at the first operation (2,305.6 s vs. 1,884.6 s; p = 0.037). No significant intergroup difference in path length, number of movements, or video-based global rating scores was observed.

CONCLUSIONS

Prior open experience does not aid the laparoscopic learning process, as demonstrated in a simulated setting. Given the wealth of evidence demonstrating translation of virtual skills to the operating theater, we propose that the safe and effective introduction of well-supervised laparoscopic training may be possible at the beginning of a surgical training curriculum.

Why simulation can be efficient: on the preconditions of efficient learning in complex technology based practices

BACKGROUND

It is important to demonstrate learning outcomes of simulation in technology based practices, such as in advanced health care. Although many studies show skills improvement and self-reported change to practice, there are few studies demonstrating patient outcome and societal efficiency. The objective of the study is to investigate if and why simulation can be effective and efficient in a hi-tech health care setting. This is important in order to decide whether and how to design simulation scenarios and outcome studies.

METHODS

Core theoretical insights in Science and Technology Studies (STS) are applied to analyze the field of simulation in hi-tech health care education. In particular, a process-oriented framework where technology is characterized by its devices, methods and its organizational setting is applied.

RESULTS

The analysis shows how advanced simulation can address core characteristics of technology beyond the knowledge of technology's functions. Simulation's ability to address skilful device handling as well as purposive aspects of technology provides a potential for effective and efficient learning. However, as technology is also constituted by organizational aspects, such as technology status, disease status, and resource constraints, the success of simulation depends on whether these aspects can be integrated in the simulation setting as well. This represents a challenge for future development of simulation and for demonstrating its effectiveness and efficiency.

CONCLUSION

Assessing the outcome of simulation in education in hi-tech health care settings is worthwhile if core characteristics of medical technology are addressed. This challenges the traditional technical versus non-technical divide in simulation, as organizational aspects appear to be part of technology's core characteristics.

Proficiency-based laparoscopic and endoscopic training with virtual reality simulators: a comparison of proctored and independent approaches

BACKGROUND

Virtual reality (VR) simulators for laparoscopy and endoscopy may be valuable tools for resident education. However, the cost of such training in terms of trainee and instructor time may vary depending upon whether an independent or proctored approach is employed.

METHODS

We performed a randomized controlled trial to compare independent and proctored methods of proficiency-based VR simulator training. Medical students were randomized to independent or proctored training groups. Groups were compared with respect to the number of training hours and task repetitions required to achieve expert level proficiency on laparoscopic and endoscopic simulators. Cox regression modeling was used to compare time to proficiency between groups, with adjustment for appropriate covariates.

RESULTS

Thirty-six medical students (18 independent, 18 proctored) were enrolled. Achievement of overall simulator proficiency required a median of 11 hours of training (range, 6-21 hours). Laparoscopic and endoscopic proficiency were achieved after a median of 11 (range, 6-32) and 10 (range, 5-27) task repetitions, respectively. The number of repetitions required to achieve proficiency was similar between groups. After adjustment for covariates, trainees in the independent group achieved simulator proficiency with significantly fewer hours of training (hazard ratio, 2.62; 95% confidence interval, 1.01-6.85; p = 0.048).

CONCLUSIONS

Our study quantifies the cost, in instructor and trainee hours, of proficiency-based laparoscopic and endoscopic VR simulator training, and suggests that proctored instruction does not offer any advantages to trainees. The independent approach may be preferable for surgical residency programs desiring to implement VR simulator training.

How far will simulators be involved into training?

The expansion of laparoscopy and endoscopic surgery has promoted a change in surgical skills acquisition. This review aims to identify problems that modulate surgical skills acquisition and the role of simulation in the current training programs. Social, medical, and working time constraints, together with patient safety issues, lead to a decreased availability of operating room (OR) training opportunities. Systematic reviews show that there is a positive "model to model" transfer of skills more evident for virtual reality (VR) simulation, although transfer from video tower exists for naïve trainees, both of which supplement standard laparoscopic training. VR to OR positive transfer is proven for laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, although not for all parameters analyzed. A mixed model integrating both types of trainers into surgical curricula may strengthen their respective possibilities. To what extent simulation will be included in the surgical training programs depends on development of objective and finer assessment tools and proficiency-based criteria.