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Utility of augmented reality system in hepatobiliary surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:249-53. [PMID: 22399157 DOI: 10.1007/s00534-012-0504-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE The aim of this study was to evaluate the utility of an image display system for augmented reality in hepatobiliary surgery under laparotomy. METHODS An overlay display of organs, vessels, or tumor was obtained using a video see-through system as a display system developed at our institute. Registration between visceral organs and the surface-rendering image reconstructed by preoperative computed tomography (CT) was carried out with an optical location sensor. Using this system, we performed laparotomy for a patient with benign biliary stricture, a patient with gallbladder carcinoma, and a patient with hepatocellular carcinoma. RESULTS The operative procedures performed consisted of choledochojejunostomy, right hepatectomy, and microwave coagulation therapy. All the operations were carried out safely using images of the site of tumor, preserved organs, and resection aspect overlaid onto the operation field images observed on the monitors. The position of each organ in the overlaid image closely corresponded with that of the actual organ. Intraoperative information generated from this system provided us with useful navigation. However, several problems such as registration error and lack of depth knowledge were noted. CONCLUSION The image display system appeared to be useful in performing hepatobiliary surgery under laparotomy. Further improvement of the system with individualized function for each operation will be essential, with feedback from clinical trials in the future.
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Affiliation(s)
- P Singh
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, South Wharf Road, London W2 1NY, UK
| | - A Darzi
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, South Wharf Road, London W2 1NY, UK
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Rolls A, Riga C, Bicknell C, Stoyanov D, Shah C, Van Herzeele I, Hamady M, Cheshire N. A Pilot Study of Video-motion Analysis in Endovascular Surgery: Development of Real-time Discriminatory Skill Metrics. Eur J Vasc Endovasc Surg 2013; 45:509-15. [DOI: 10.1016/j.ejvs.2013.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 02/05/2013] [Indexed: 11/16/2022]
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Sharma M, Macafee D, Horgan AF. Basic laparoscopic skills training using fresh frozen cadaver: a randomized controlled trial. Am J Surg 2013; 206:23-31. [PMID: 23623462 DOI: 10.1016/j.amjsurg.2012.10.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 09/12/2012] [Accepted: 10/03/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this study was to determine whether training on fresh cadavers improves the laparoscopic skills performance of novices. METHODS Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, were randomized into control (group A) and practice groups (group B). Group B performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers (FFCs) improvised from fundamentals of laparoscopic skills technical curriculum. Performance on cadavers was scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. The baseline technical ability of the 2 groups and any transfer of skills from FFCs was measured using a full procedural laparoscopic cholecystectomy task on a virtual reality simulator before and after practice on FFCs, respectively. Nonparametric tests were used for analysis of the results. RESULTS Twenty candidates were randomized; 1 withdrew before the study commenced, and 19 were analyzed (group A, n = 9; group B; n = 10). Four of 5 tasks (nondominant to dominant hand transfer, simulated appendectomy, intracorporeal, and extracorporeal knot tying) on FFCs showed significant improvement on learning curve analysis. After training, significant improvement was shown for safety of cautery (P = .040) and the left arm path length (P = .047) on the virtual reality simulator by the practice group. CONCLUSIONS Training on FFCs significantly improves basic laparoscopic skills and can improve full procedural performance.
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Affiliation(s)
- Mitesh Sharma
- Newcastle Surgical Training Centre, Department of General Surgery, Freeman Hospital NHS Trust, Newcastle Upon Tyne NE7 7DN, UK.
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Bharathan R, Vali S, Setchell T, Miskry T, Darzi A, Aggarwal R. Psychomotor skills and cognitive load training on a virtual reality laparoscopic simulator for tubal surgery is effective. Eur J Obstet Gynecol Reprod Biol 2013; 169:347-52. [PMID: 23608628 DOI: 10.1016/j.ejogrb.2013.03.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/28/2013] [Accepted: 03/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Validation of a virtual reality (VR) simulator for the training and assessment of laparoscopic tubal surgery and mapping of cognitive load. STUDY DESIGN Prospective cohort study conducted at the Imperial College Virtual Reality Surgical Skills laboratory amongst 25 trainees and nine senior gynaecologists. Participants performed two sessions of salpingectomy and salpingotomy procedures on a VR simulator to assess construct validity. Nine novices performed ten such sessions to enable assessment of the learning curve. The relationship between cognitive load and the dexterity parameters was assessed. Simulator fidelity was reported by experienced and intermediate level gynaecologists. Statistical analyses utilised non-parametric tests, Kruskall-Wallis and Mann-Whitney U tests. Learning curves were assessed using the Friedman test and Wilcoxon Signed Ranks test. Relationship between dexterity metrics and cognitive load was performed using Spearman's rank order correlation. RESULTS Salpingectomy demonstrated construct validity for time taken by experienced, intermediate and novice gynaecologists (median 170 vs. 191 vs. 313s (P=0.003) respectively) and movements (median 200 vs. 267 vs. 376s, P=0.045). Salpingotomy demonstrated construct validity for time taken (median 183 vs. 191 vs. 306s, P=<0.001) and movements (median 210 vs. 233 vs. 328s, P=0.005). Learning curve analysis for salpingectomy displayed a plateau for time taken after the eighth session, and the fourth session for movements. Salpingotomy displayed a plateau after the eighth session for both time taken and movements. Cognitive load correlated significantly with dexterity parameters. The fidelity scores were not significantly different between the two procedures (P=0.619). CONCLUSION The LAP Mentor VR laparoscopic simulator is a valid and effective tool for training novice surgeons in ectopic pregnancy surgery. Reduction in cognitive load significantly correlates with the learning curves.
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Affiliation(s)
- Rasiah Bharathan
- Department of Surgery and Cancer, Imperial College, St. Mary's Hospital, South Wharf Road, Paddington, London, United Kingdom.
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Kakucs T, Lukovich P, Dobó N, Benkő P, Harsányi L. [Measuring residents' and specialists' laparoscopic technique with the MENTOR® training box]. Magy Seb 2013; 66:55-61. [PMID: 23591609 DOI: 10.1556/maseb.66.2013.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Operating room is not the ideal place to acquire laparoscopic skills since patients can be put at risk and it is also relatively expensive. Using training boxes seems to be a more appropriate way of teaching and learning the technique, but there is little data about measuring the technique of experienced specialists and comparing their results with residents. METHODS At the 1st Department of Surgery, Semmelweis University we tested 30 residents and 25 specialists in general surgery and urology on MENTOR® training box. Before training, all participants completed a questionnaire on professional experience, previous usage of training boxes, virtual simulators, and video games, and whether they played a musical instrument earlier. Subjects were asked to complete in a defined time limit 3 of the Fundamentals of Laparoscopic Surgery tasks (which is required for American surgical residents for surgical board examination), and 3 tasks decided by us. Linear regression analysis (ANOVA table) was used to evaluate the data. RESULTS 16% of the specialists and 6.66% of the residents completed all tasks within time limit. Statistically significant correlation (p < 0.05) was demonstrated between the number of previous laparoscopic surgeries and task completion time, while there were no significant correlations between other factors, which may influence laparoscopic technique and task completion time. CONCLUSIONS Training boxes are suitable for developing eye-hand coordination and bimanuality, as well as for learning instrument handling. Nonetheless, residents acquire most of their laparoscopic surgical skills on patients in Hungary, yet. For this reason there is a need for organized training opportunities.
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Affiliation(s)
- Tímea Kakucs
- Semmelweis Egyetem, Általános Orvostudományi Kar I. sz. Sebészeti Klinika 1082 Budapest
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Nehme J, Sodergren MH, Sugden C, Aggarwal R, Gillen S, Feussner H, Yang GZ, Darzi A. A randomized controlled trial evaluating endoscopic and laparoscopic training in skills transfer for novices performing a simulated NOTES task. Surg Innov 2013; 20:631-8. [PMID: 23493565 DOI: 10.1177/1553350613480854] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task. METHODS A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors. RESULTS The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001). CONCLUSION This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.
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Vine SJ, Chaytor RJ, McGrath JS, Masters RSW, Wilson MR. Gaze training improves the retention and transfer of laparoscopic technical skills in novices. Surg Endosc 2013; 27:3205-13. [PMID: 23479253 DOI: 10.1007/s00464-013-2893-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/14/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gaze training is an effective way of training basic laparoscopic skills, resulting in faster acquisition periods and more robust subsequent performance under pressure. The current study is a randomized control trial which examines whether the performance benefits of gaze training stand the test of time (delayed retention) and transfer to more complex skills. METHODS Thirty-six medical students were trained to proficiency (50 trials) on a one-handed laparoscopic task (picking and dropping balls) in either a discovery learning (DL) or gaze training (GT) group. Both groups performed the one-handed task in baseline, retention and delayed retention (1 month) tests. They also performed baseline, retention and delayed retention tests of a two-handed task (grasping and cutting). Performance (completion time) and gaze control (target locking) were assessed throughout. RESULTS For the one-handed task, the GT group displayed superior performance at retention (p < .001), underpinned by more expert-like gaze control (p < .05). The GT group also displayed superior performance in the one-handed task at delayed retention (p < .005), underpinned by more expert-like gaze control strategies (p < .001). Although the DL group's performance fell to 84% of performance at retention, the GT group maintained performance at 100% of retention. There were no differences between the groups for the two-handed task at retention (p = .140); however, at delayed retention, the GT group outperformed the DL group (p < .005) and displayed more expert-like gaze control (p < .001). CONCLUSIONS Novices trained to adopt an expert-like gaze control strategy were able to attain higher levels of performance more quickly than novices who learned by discovery alone. Furthermore, these skills were more durable over time and were transferable to more complex skills. Gaze training is a beneficial intervention to aid the acquisition of the basic motor skills required for laparoscopy.
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Affiliation(s)
- Samuel J Vine
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK.
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Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial. Ann Surg 2013; 257:224-30. [PMID: 23013806 DOI: 10.1097/sla.0b013e31827051cd] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE : To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. BACKGROUND : Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. METHODS : This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. RESULTS : Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). CONCLUSIONS : Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).
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Call-associated acute fatigue in surgical residents--subjective perception or objective fact? A cross-sectional observational study to examine the influence of fatigue on surgical performance. World J Surg 2013; 37:1176-7. [PMID: 23397167 DOI: 10.1007/s00268-013-1911-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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111
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Abstract
Learning is lifelong
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Affiliation(s)
- P Singh
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, South Wharf Road, London W2 1NY, UK
| | - A Darzi
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, South Wharf Road, London W2 1NY, UK
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112
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Sarker SJ, Telfah MM, Onuba L, Patel BP. Objective assessment of skills acquisition during laparoscopic surgery courses. Surg Innov 2012; 20:530-8. [PMID: 23242519 DOI: 10.1177/1553350612468960] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this prospective study is to objectively assess the acquisition of skills of trainees attending laparoscopic surgery courses. METHODS Thirty-four junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate runs of 3-day core skills in laparoscopic surgery course. Nine control trainees were also included who did not attend the course. Three virtual tasks (camera navigation, hand-eye coordination, and 2-handed maneuver) were used from a virtual reality simulator (Simbionix) for assessment. Camera navigation was assessed by completion time and maintenance of horizontal view, whereas the other 2 tasks were assessed by completion time, path length (both hands), and the number of movements (both hands). A composite score of overall performance was calculated by combining all the 12 parameters. RESULTS The course significantly (P < 0.001) improved 91% of the junior trainees' precourse laparoscopic skills. Around 70% to 85% of the participants had improvement in skills in all the parameters following the course. The significant improvements were seen in 10 out of 12 task-specific parameters (P ≤ .004) except path length of the left hand. No significant improvement in skills was seen in any 1 of the 12 parameters for the control participants except for a slight reduction in performance matrics. Foundation and core trainees had acquired significantly (P = .02) more skills (23% improvement) than the specialist trainees (8% improvement). Overall acquired skills did not differ significantly in terms of age, sex, or dominant hand of trainees. CONCLUSION Objective validated methods can be used to demonstrate course efficacy in addition to providing participants with an insight into their skills. Junior trainees with little or no previous experience benefit the most from such courses irrespective of their age, sex, and dominant hand.
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113
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Hessel M, Buzink SN, Schoot D, Jakimowicz JJ. Face and Construct Validity of the SimSurgery SEP VR Simulator for Salpingectomy in Case of Ectopic Pregnancy. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marloes Hessel
- Department of Gynecology and Obstetrics, Catharina Hospital, Eindhoven, The Netherlands
| | - Sonja N. Buzink
- Department of Education and Research, Catharina Hospital, Eindhoven, The Netherlands
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - Dick Schoot
- Department of Gynecology and Obstetrics, Catharina Hospital, Eindhoven, The Netherlands
| | - Jack J. Jakimowicz
- Department of Education and Research, Catharina Hospital, Eindhoven, The Netherlands
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
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Have we learned from lessons of the past? A systematic review of training for single incision laparoscopic surgery. Surg Endosc 2012; 27:1478-84. [PMID: 23073688 DOI: 10.1007/s00464-012-2632-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 09/25/2012] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Single incision laparoscopic surgery (SILS) represents the next step in laparoscopic surgery in further reducing the invasiveness of surgical procedures with cosmetic advantages. Recalling the increased rates of major complications at the advent of laparoscopic cholecystectomy 20 years ago, however, it is clear that appropriate training is required before adopting a new technique. This study aims to review the current evidence for training and skills acquisition for SILS. METHODS A comprehensive database search of PubMED, MEDLINE, EMBASE and Google Scholar was carried out. Studies considered for inclusion were those addressing SILS learning curves, skills acquisition, or training. RESULTS 21 studies were included in the final analysis. Ten clinical case series with analysis of SILS learning curve demonstrated a significant learning curve for conventional multiport laparoscopic (LAP)-trained surgeons over the course of initial SILS cases, with several studies reporting increased risk of conversion and complication rates. Five laboratory-based studies demonstrated differences in SILS skills acquisition compared with LAP. Six studies describing SILS-specific training curricula were analysed, but none included a robust validation of the curriculum. CONCLUSIONS Clinical case series and laboratory-based skills acquisition studies demonstrate the unique requirements of SILS, with skill sets and ergonomic demands which cannot be directly adapted from existing LAP experience. Some studies have already reported higher complication rates in initial SILS cases. To avoid repeating the mistakes of the past, the implementation of an evidence- and competency-based SILS curriculum is necessary to ensure appropriate training of future SILS surgeons.
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Abstract
In this paper, we review the literature to date on technical competence in surgeons; how it can be defined, taught to trainees and assessed. We also examine how we can predict which candidates for surgical training will most likely develop technical competence. While technical competency is just one aspect of what makes a good surgeon, we have recognized a need to review the literature in this area and to combine this with broader definitions of competency. Our review found that several methods are available to objectively measure, assess and predict technical competence and should be used in surgical training.
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Affiliation(s)
- Clare Faurie
- Sydney Medical School, The University of Sydney, New South Wales, Australia.
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Oropesa I, Chmarra MK, Sánchez-González P, Lamata P, Rodrigues SP, Enciso S, Sánchez-Margallo FM, Jansen FW, Dankelman J, Gómez EJ. Relevance of motion-related assessment metrics in laparoscopic surgery. Surg Innov 2012; 20:299-312. [PMID: 22983805 DOI: 10.1177/1553350612459808] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Motion metrics have become an important source of information when addressing the assessment of surgical expertise. However, their direct relationship with the different surgical skills has not been fully explored. The purpose of this study is to investigate the relevance of motion-related metrics in the evaluation processes of basic psychomotor laparoscopic skills and their correlation with the different abilities sought to measure. METHODS A framework for task definition and metric analysis is proposed. An explorative survey was first conducted with a board of experts to identify metrics to assess basic psychomotor skills. Based on the output of that survey, 3 novel tasks for surgical assessment were designed. Face and construct validation was performed, with focus on motion-related metrics. Tasks were performed by 42 participants (16 novices, 22 residents, and 4 experts). Movements of the laparoscopic instruments were registered with the TrEndo tracking system and analyzed. RESULTS Time, path length, and depth showed construct validity for all 3 tasks. Motion smoothness and idle time also showed validity for tasks involving bimanual coordination and tasks requiring a more tactical approach, respectively. Additionally, motion smoothness and average speed showed a high internal consistency, proving them to be the most task-independent of all the metrics analyzed. CONCLUSION Motion metrics are complementary and valid for assessing basic psychomotor skills, and their relevance depends on the skill being evaluated. A larger clinical implementation, combined with quality performance information, will give more insight on the relevance of the results shown in this study.
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Development and validation of a comprehensive curriculum to teach an advanced minimally invasive procedure: a randomized controlled trial. Ann Surg 2012; 256:25-32. [PMID: 22664557 DOI: 10.1097/sla.0b013e318258f5aa] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. BACKGROUND Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curricula remains a major challenge in modern surgical education. Currently, no curricula have been described or validated for advanced laparoscopic procedures. METHODS This prospective, single-blinded randomized controlled trial allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. The curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. Secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator. RESULTS Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents (global score 16.0 [14.5-18.0] versus 8.0 [6.0-14.5], P = 0.030; number of operative steps performed 16.0 [12.5-17.5] versus 8.0 [6.0-14.5], P = 0.021; procedure-specific score 71.1 [54.4-81.6] versus 51.1 [36.7-74.4], P = 0.122). Curricular-trained residents scored higher on the multiple-choice test (10 [9-11] versus 7.5 [5.3-7.5], P = 0.047), and outperformed conventionally trained residents in 7 of 8 tasks on the simulator. CONCLUSIONS Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training. Reg. ID#NCT 01371136.
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Lewis TM, Aggarwal R, Kwasnicki RM, Rajaretnam N, Moorthy K, Ahmed A, Darzi A. Can virtual reality simulation be used for advanced bariatric surgical training? Surgery 2012; 151:779-84. [PMID: 22652118 DOI: 10.1016/j.surg.2012.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 03/15/2012] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Laparoscopic bariatric surgery is a safe and effective way of treating morbid obesity. However, the operations are technically challenging and training opportunities for junior surgeons are limited. This study aims to assess whether virtual reality (VR) simulation is an effective adjunct for training and assessment of laparoscopic bariatric technical skills. METHODS Twenty bariatric surgeons of varying experience (Five experienced, five intermediate, and ten novice) were recruited to perform a jejuno-jejunostomy on both cadaveric tissue and on the bariatric module of the Lapmentor VR simulator (Simbionix Corporation, Cleveland, OH). Surgical performance was assessed using validated global rating scales (GRS) and procedure specific video rating scales (PSRS). Subjects were also questioned about the appropriateness of VR as a training tool for surgeons. RESULTS Construct validity of the VR bariatric module was demonstrated with a significant difference in performance between novice and experienced surgeons on the VR jejuno-jejunostomy module GRS (median 11-15.5; P = .017) and PSRS (median 11-13; P = .003). Content validity was demonstrated with surgeons describing the VR bariatric module as useful and appropriate for training (mean Likert score 4.45/7) and they would highly recommend VR simulation to others for bariatric training (mean Likert score 5/7). Face and concurrent validity were not established. CONCLUSION This study shows that the bariatric module on a VR simulator demonstrates construct and content validity. VR simulation appears to be an effective method for training of advanced bariatric technical skills for surgeons at the start of their bariatric training. However, assessment of technical skills should still take place on cadaveric tissue.
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Affiliation(s)
- Trystan M Lewis
- Department of Cancer and Surgery, St. Marys Hospital, Imperial College London, London, UK.
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Abstract
OBJECTIVES The development of a structured virtual reality (VR) training curriculum for colonoscopy using high-fidelity simulation. BACKGROUND Colonoscopy requires detailed knowledge and technical skill. Changes to working practices in recent times have reduced the availability of traditional training opportunities. Much might, therefore, be achieved by applying novel technologies such as VR simulation to colonoscopy. Scientifically developed device-specific curricula aim to maximize the yield of laboratory-based training by focusing on validated modules and linking progression to the attainment of benchmarked proficiency criteria. METHODS Fifty participants comprised of 30 novices (<10 colonoscopies), 10 intermediates (100 to 500 colonoscopies), and 10 experienced (>500 colonoscopies) colonoscopists were recruited to participate. Surrogates of proficiency, such as number of procedures undertaken, determined prospective allocation to 1 of 3 groups (novice, intermediate, and experienced). Construct validity and learning value (comparison between groups and within groups respectively) for each task and metric on the chosen simulator model determined suitability for inclusion in the curriculum. RESULTS Eight tasks in possession of construct validity and significant learning curves were included in the curriculum: 3 abstract tasks, 4 part-procedural tasks, and 1 procedural task. The whole-procedure task was valid for 11 metrics including the following: "time taken to complete the task" (1238, 343, and 293 s; P < 0.001) and "insertion length with embedded tip" (23.8, 3.6, and 4.9 cm; P = 0.005). Learning curves consistently plateaued at or beyond the ninth attempt. Valid metrics were used to define benchmarks, derived from the performance of the experienced cohort, for each included task. CONCLUSIONS A comprehensive, stratified, benchmarked, whole-procedure curriculum has been developed for a modern high-fidelity VR colonoscopy simulator.
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Våpenstad C, Buzink SN. Procedural virtual reality simulation in minimally invasive surgery. Surg Endosc 2012; 27:364-77. [DOI: 10.1007/s00464-012-2503-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/19/2012] [Indexed: 12/16/2022]
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Sumitani D, Egi H, Tokunaga M, Hattori M, Yoshimitsu M, Kawahara T, Okajima M, Ohdan H. Virtual reality training followed by box training improves the laparoscopic skills of novice surgeons. MINIM INVASIV THER 2012; 22:150-6. [DOI: 10.3109/13645706.2012.721377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sinitsky DM, Fernando B, Berlingieri P. Establishing a curriculum for the acquisition of laparoscopic psychomotor skills in the virtual reality environment. Am J Surg 2012; 204:367-376.e1. [DOI: 10.1016/j.amjsurg.2011.11.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 11/09/2011] [Accepted: 11/09/2011] [Indexed: 01/22/2023]
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Ikonen TS, Antikainen T, Silvennoinen M, Isojärvi J, Mäkinen E, Scheinin TM. Virtual reality simulator training of laparoscopic cholecystectomies - a systematic review. Scand J Surg 2012; 101:5-12. [PMID: 22414461 DOI: 10.1177/145749691210100102] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Simulators are widely used in occupations where practice in authentic environments would involve high human or economic risks. Surgical procedures can be simulated by increasingly complex and expensive techniques. This review gives an update on computer-based virtual reality (VR) simulators in training for laparoscopic cholecystectomies. MATERIALS AND METHODS From leading databases (Medline, Cochrane, Embase), randomised or controlled trials and the latest systematic reviews were systematically searched and reviewed. Twelve randomised trials involving simulators were identified and analysed, as well as four controlled studies. Furthermore, seven studies comparing black boxes and simulators were included. RESULTS The results indicated any kind of simulator training (black box, VR) to be beneficial at novice level. After VR training, novice surgeons seemed to be able to perform their first live cholecystectomies with fewer errors, and in one trial the positive effect remained during the first ten cholecystectomies. No clinical follow-up data were found. Optimal learning requires skills training to be conducted as part of a systematic training program. No data on the cost-benefit of simulators were found, the price of a VR simulator begins at EUR 60 000. CONCLUSIONS Theoretical background to learning and limited research data support the use of simulators in the early phases of surgical training. The cost of buying and using simulators is justified if the risk of injuries and complications to patients can be reduced. Developing surgical skills requires repeated training. In order to achieve optimal learning a validated training program is needed.
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Affiliation(s)
- T S Ikonen
- Finnish Office for Health Technology Assessment, National Institute of Health and Welfare, Helsinki, Finland.
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Nugent E, Shirilla N, Hafeez A, O’Riordain DS, Traynor O, Harrison AM, Neary P. Development and evaluation of a simulator-based laparoscopic training program for surgical novices. Surg Endosc 2012; 27:214-21. [DOI: 10.1007/s00464-012-2423-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/21/2012] [Indexed: 01/22/2023]
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Are C, Lomneth C, Stoddard H, Azarow K, Thompson JS. A preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency with initial feedback. Am J Surg 2012; 204:103-9. [DOI: 10.1016/j.amjsurg.2011.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 07/13/2011] [Accepted: 08/12/2011] [Indexed: 01/07/2023]
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von Websky MW, Vitz M, Raptis DA, Rosenthal R, Clavien PA, Hahnloser D. Basic laparoscopic training using the Simbionix LAP Mentor: setting the standards in the novice group. JOURNAL OF SURGICAL EDUCATION 2012; 69:459-467. [PMID: 22677582 DOI: 10.1016/j.jsurg.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 11/22/2011] [Accepted: 12/18/2011] [Indexed: 06/01/2023]
Abstract
BACKGROUND Virtual reality devices are becoming the backbone for laparoscopic training in surgery. However, without knowledge of the achievable metrics of basic training within the trainee group, these simulators cannot be used effectively. Currently, no validated task metrics of the performance of larger trainee groups are available. STUDY DESIGN From April 2004 to December 2009, we collated an extensive prospective database using the Simbionix LAP Mentor (Simbionix USA, Cleveland, Ohio) for basic laparoscopic training of novice surgeons. This database was used to determine benchmarks for basic skill exercises and procedural tasks that combine stimulus to improve and feasibility with acceptance of the training program and the goal to train for safe surgery. RESULTS In all, 18,996 task performances of 286 novice trainees were analyzed. For the basic skill exercises, the total time for correct execution ranged between 45 seconds for basic skill 3 (eye-hand coordination) and 269 seconds for basic skill 9 (object placement). For the procedural tasks, the total time for correct execution ranged between 68 seconds for procedural task 1 (clipping and cutting) and 256 seconds for procedural task 3 (dissection). The total time to task completion depended mainly on right instrument path length with high correlation to left instrument path length. Learning curve analyses of the 4 procedural tasks demonstrated performance plateaus after 10-15 repetitions. Most complications occurred during the initial repetitions of the respective task. The best quartile of performances was chosen as peer group benchmark because it provides sufficient stimulus for improvement without discouraging trainees, thus enhancing adherence to the training program. The benchmark for safety and accuracy parameters was set at a predefined level of 95% correct execution. CONCLUSIONS As experience with virtual reality (VR) training is growing, curricula must be based on benchmarks for efficient training derived from large trainee groups to optimize use of the still costly simulators. Safety parameters should be included in trainee assessment. We share a set of metrics that take into account both performance and feasibility for basic laparoscopic training of surgical novices using the Simbionix LAP Mentor.
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Affiliation(s)
- Martin W von Websky
- Department of Visceral Surgery, University Hospital of Zurich, Zurich, Switzerland
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Sharma M, Macafee D, Pranesh N, Horgan AF. Construct validity of fresh frozen human cadaver as a training model in minimal access surgery. JSLS 2012; 16:345-52. [PMID: 23318058 PMCID: PMC3535798 DOI: 10.4293/108680812x13462882735818] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The construct validity of fresh human cadaver as a training tool has not been established previously. The aims of this study were to investigate the construct validity of fresh frozen human cadaver as a method of training in minimal access surgery and determine if novices can be rapidly trained using this model to a safe level of performance. METHODS Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers. Expert laparoscopists (>100 laparoscopic procedures) performed 3 repetitions of identical tasks. Performances were scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. Scores for 3 consecutive repetitions were compared between experts and novices to determine construct validity. Furthermore, to determine if the novices reached a safe level, a trimmed mean of the experts score was used to define a benchmark. Mann-Whitney Utest was used for construct validity analysis and 1-sample t test to compare performances of the novice group with the benchmark safe score. RESULTS Ten novices and 2 experts were recruited. Four out of 5 tasks (nondominant to dominant hand transfer; simulated appendicectomy; intracorporeal and extracorporeal knot tying) showed construct validity. Novices' scores became comparable to benchmark scores between the eighth and tenth repetition. CONCLUSION Minimal access surgical training using fresh frozen human cadavers appears to have construct validity. The laparoscopic skills of novices can be accelerated through to a safe level within 8 to 10 repetitions.
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Affiliation(s)
- Mitesh Sharma
- Newcastle Surgical Training Centre, Department of General Surgery, Freeman Hospital NHS Trust, Newcastle Upon Tyne, NE7 7DN, UK.
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Sadideen H, Kneebone R. Practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning? Am J Surg 2012; 204:396-401. [PMID: 22688108 DOI: 10.1016/j.amjsurg.2011.12.020] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/16/2011] [Accepted: 12/16/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND Teaching practical skills is a core component of undergraduate and postgraduate surgical education. It is crucial to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. This review explores the role of educational theory in promoting effective learning in practical skills teaching. METHODS Peer-reviewed publications, books, and online resources from national bodies (eg, the UK General Medical Council) were reviewed. RESULTS This review highlights several aspects of surgical education, modeling them on current educational theory. These include the following: (1) acquisition and retention of motor skills (Miller's triangle; Fitts' and Posner's theory), (2) development of expertise after repeated practice and regular reinforcement (Ericsson's theory), (3) importance of the availability of expert assistance (Vygotsky's theory), (4) learning within communities of practice (Lave and Wenger's theory), (5) importance of feedback in learning practical skills (Boud, Schon, and Endes' theories), and (6) affective component of learning. CONCLUSIONS It is hoped that new approaches to practical skills teaching are designed in light of our understanding of educational theory.
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Affiliation(s)
- Hazim Sadideen
- Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, Praed St., Second Floor QEQM Wing, London W2 1NY, UK.
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Debes AJ, Aggarwal R, Balasundaram I, Jacobsen MB. Construction of an evidence-based, graduated training curriculum for D-box, a webcam-based laparoscopic basic skills trainer box. Am J Surg 2012; 203:768-75. [DOI: 10.1016/j.amjsurg.2011.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 01/22/2023]
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Objective assessment of learning curves for the Voxel-Man TempoSurg temporal bone surgery computer simulator. The Journal of Laryngology & Otology 2012; 126:663-9. [DOI: 10.1017/s0022215112000734] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Simulators are becoming an increasingly important part of surgical training. Temporal bone surgery is one area in which simulators, such as the Voxel-Man TempoSurg simulator, are likely to play a significant role in training. We present learning curve data from novice trainees using this simulator to learn cortical mastoidectomy, exposure of the sigmoid sinus, and exposure of the short process of the incus.Methods:We measured the time taken to perform the procedures, the volume of reference bone removed, and the structures damaged during dissection.Results:We found improvement in a number of parameters over the course of the study. The overall scores, structural damage scores and time taken improved, to differing degrees, for each task. The volume of reference bone removed remained constant.Conclusion:These results indicate that the trainees' efficiency improved as they became more proficient at removing a given volume of reference bone.
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Gray RJ, Kahol K, Islam G, Smith M, Chapital A, Ferrara J. High-fidelity, low-cost, automated method to assess laparoscopic skills objectively. JOURNAL OF SURGICAL EDUCATION 2012; 69:335-339. [PMID: 22483134 DOI: 10.1016/j.jsurg.2011.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 10/06/2011] [Accepted: 10/27/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND We sought to define the extent to which a motion analysis-based assessment system constructed with simple equipment could measure technical skill objectively and quantitatively. METHODS An "off-the-shelf" digital video system was used to capture the hand and instrument movement of surgical trainees (beginner level = PGY-1, intermediate level = PGY-3, and advanced level = PGY-5/fellows) while they performed a peg transfer exercise. The video data were passed through a custom computer vision algorithm that analyzed incoming pixels to measure movement smoothness objectively. RESULTS The beginner-level group had the poorest performance, whereas those in the advanced group generated the highest scores. Intermediate-level trainees scored significantly (p < 0.04) better than beginner trainees. Advanced-level trainees scored significantly better than intermediate-level trainees and beginner-level trainees (p < 0.04 and p < 0.03, respectively). CONCLUSIONS A computer vision-based analysis of surgical movements provides an objective basis for technical expertise-level analysis with construct validity. The technology to capture the data is simple, low cost, and readily available, and it obviates the need for expert human assessment in this setting.
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Affiliation(s)
- Richard J Gray
- Department of Surgery, Mayo Clinic, Scottsdale, Arizona 85259, USA.
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Zevin B, Aggarwal R, Grantcharov TP. Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass. Br J Surg 2012; 99:887-95. [PMID: 22511220 DOI: 10.1002/bjs.8748] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Ex vivo simulation-based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux-en-Y gastric bypass (LRYGBP) has not been reviewed. METHODS Relevant studies were identified by one author from a search of MEDLINE and Embase databases from 1 January 1994 to 30 November 2010. Studies examining the learning curves and ex vivo training methods for LRYGBP were included; all other types of bariatric operations were excluded. A manual search of the references was also performed to identify additional potentially relevant papers. RESULTS Twelve studies (5 prospective and 7 retrospective case series) were selected for review. The learning curve for LRYGBP was reported to be 50-100 procedures. Bench-top laparoscopic jejunojejunostomy, anaesthetized animals and Thiel human cadavers made up the bulk of the reported models for ex vivo training. Most studies were of relatively poor quality. An evidence-based ex vivo training curriculum for LRYGBP is currently lacking. CONCLUSION Better quality studies are needed to define the learning curve for LRYGBP. Future studies should focus on the design and validation of training models, and a comprehensive curriculum for training and assessment of cognitive, technical and non-technical components of competency for laparoscopic bariatric surgery.
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Affiliation(s)
- B Zevin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Vine SJ, Masters RSW, McGrath JS, Bright E, Wilson MR. Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills. Surgery 2012; 152:32-40. [PMID: 22464048 DOI: 10.1016/j.surg.2012.02.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous research has demonstrated that trainees can be taught (via explicit verbal instruction) to adopt the gaze strategies of expert laparoscopic surgeons. The current study examined a software template designed to guide trainees to adopt expert gaze control strategies passively, without being provided with explicit instructions. METHODS We examined 27 novices (who had no laparoscopic training) performing 50 learning trials of a laparoscopic training task in either a discovery-learning (DL) group or a gaze-training (GT) group while wearing an eye tracker to assess gaze control. The GT group performed trials using a surgery-training template (STT); software that is designed to guide expert-like gaze strategies by highlighting the key locations on the monitor screen. The DL group had a normal, unrestricted view of the scene on the monitor screen. Both groups then took part in a nondelayed retention test (to assess learning) and a stress test (under social evaluative threat) with a normal view of the scene. RESULTS The STT was successful in guiding the GT group to adopt an expert-like gaze strategy (displaying more target-locking fixations). Adopting expert gaze strategies led to an improvement in performance for the GT group, which outperformed the DL group in both retention and stress tests (faster completion time and fewer errors). CONCLUSION The STT is a practical and cost-effective training interface that automatically promotes an optimal gaze strategy. Trainees who are trained to adopt the efficient target-locking gaze strategy of experts gain a performance advantage over trainees left to discover their own strategies for task completion.
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Affiliation(s)
- Samuel J Vine
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK.
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134
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Palter VN, Graafland M, Schijven MP, Grantcharov TP. Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: A Delphi approach. Surgery 2012; 151:391-7. [PMID: 22019340 DOI: 10.1016/j.surg.2011.08.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 08/04/2011] [Indexed: 11/24/2022]
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Single versus multimodality training basic laparoscopic skills. Surg Endosc 2012; 26:2172-8. [PMID: 22350237 PMCID: PMC3392502 DOI: 10.1007/s00464-012-2184-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Accepted: 01/19/2012] [Indexed: 01/22/2023]
Abstract
Introduction Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills. Methods Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S) (n = 18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M) (n = 18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks + one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test. Results Both groups improved their performance significantly (Wilcoxon signed-rank, P < 0.05). The performances of group S and group M in the additional basic task and the salpingectomy did not differ significantly (Mann–Whitney U test, P > 0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P ≤ 0.05), which can be explained by the fact that they were much more familiar with these tasks. Conclusions Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.
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Intégration de la simulation dans la formation des internes en chirurgie. Programme pédagogique du centre de simulation médicale de la faculté de médecine de Nice. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.jchirv.2011.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bréaud J, Chevallier D, Benizri E, Fournier JP, Carles M, Delotte J, Venissac N, Myx A, Ianelli A, Levraut J, Jones D, Benchimol D. The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center. J Visc Surg 2012; 149:e52-60. [PMID: 22285517 DOI: 10.1016/j.jviscsurg.2011.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.
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Affiliation(s)
- J Bréaud
- Centre de simulation médicale, faculté de médecine de Nice, université de Nice Sophia-Antipolis, France.
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Abstract
The virtual reality (VR) laparoscopic colorectal curriculum is a unique and innovative learning opportunity for surgical trainees. Although it can enhance the skills of senior surgeons, its main aim is to introduce junior surgeons to the concept and practice of laparoscopic colorectal surgery before they might have the opportunity to perform such surgery on patients in theatres. Based at the Medical Simulation Centre at the Royal Free hospital in London (http://www.rfh-simulator-centre.co.uk/), the curriculum equips the trainee with the technical skills to perform a VR laparoscopic sigmoid colectomy independently to objectively defined benchmarks calculated from surgeons who have completed over 100 laparoscopic colorectal resections.
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Affiliation(s)
- N Reed
- Core surgical trainee, London Deanery
| | - P Berlingieri
- Medical Simulation Centre, Royal Free Hospital, London
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139
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Simulators and the simulation environment: Getting the balance right in simulation-based surgical education. Int J Surg 2012; 10:458-62. [DOI: 10.1016/j.ijsu.2012.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 08/15/2012] [Accepted: 08/19/2012] [Indexed: 01/10/2023]
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140
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National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development? Am J Surg 2011; 202:720-6; discussion 726. [DOI: 10.1016/j.amjsurg.2011.06.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 01/22/2023]
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Oropesa I, Sánchez-González P, Lamata P, Chmarra MK, Pagador JB, Sánchez-Margallo JA, Sánchez-Margallo FM, Gómez EJ. Methods and Tools for Objective Assessment of Psychomotor Skills in Laparoscopic Surgery. J Surg Res 2011; 171:e81-95. [DOI: 10.1016/j.jss.2011.06.034] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 05/11/2011] [Accepted: 06/15/2011] [Indexed: 11/25/2022]
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Burden C, Oestergaard J, Larsen CR. Integration of laparoscopic virtual-reality simulation into gynaecology training. BJOG 2011; 118 Suppl 3:5-10. [DOI: 10.1111/j.1471-0528.2011.03174.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Schreuder HW, van Hove PD, Janse JA, Verheijen RR, Stassen LP, Dankelman J. An “Intermediate Curriculum” for Advanced Laparoscopic Skills Training with Virtual Reality Simulation. J Minim Invasive Gynecol 2011; 18:597-606. [DOI: 10.1016/j.jmig.2011.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 05/23/2011] [Accepted: 05/26/2011] [Indexed: 01/22/2023]
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Zhu FF, Poolton JM, Wilson MR, Hu Y, Maxwell JP, Masters RSW. Implicit motor learning promotes neural efficiency during laparoscopy. Surg Endosc 2011; 25:2950-5. [PMID: 21455805 PMCID: PMC3160550 DOI: 10.1007/s00464-011-1647-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 02/06/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND An understanding of differences in expert and novice neural behavior can inform surgical skills training. Outside the surgical domain, electroencephalographic (EEG) coherence analyses have shown that during motor performance, experts display less coactivation between the verbal-analytic and motor planning regions than their less skilled counterparts. Reduced involvement of verbal-analytic processes suggests greater neural efficiency. The authors tested the utility of an implicit motor learning intervention specifically devised to promote neural efficiency by reducing verbal-analytic involvement in laparoscopic performance. METHODS In this study, 18 novices practiced a movement pattern on a laparoscopic trainer with either conscious awareness of the movement pattern (explicit motor learning) or suppressed awareness of the movement pattern (implicit motor learning). In a retention test, movement accuracy was compared between the conditions, and coactivation (EEG coherence) was assessed between the motor planning (Fz) region and both the verbal-analytic (T3) and the visuospatial (T4) cortical regions (T3-Fz and T4-Fz, respectively). RESULTS Movement accuracy in the conditions was not different in a retention test (P = 0.231). Findings showed that the EEG coherence scores for the T3-Fz regions were lower for the implicit learners than for the explicit learners (P = 0.027), but no differences were apparent for the T4-Fz regions (P = 0.882). CONCLUSIONS Implicit motor learning reduced EEG coactivation between verbal-analytic and motor planning regions, suggesting that verbal-analytic processes were less involved in laparoscopic performance. The findings imply that training techniques that discourage nonessential coactivation during motor performance may provide surgeons with more neural resources with which to manage other aspects of surgery.
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Affiliation(s)
- Frank F. Zhu
- Institute of Human Performance, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
| | - Jamie M. Poolton
- Institute of Human Performance, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
| | - Mark R. Wilson
- College of Life and Environmental Sciences, The University of Exeter, Exeter, UK
| | - Yong Hu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
| | - Jon P. Maxwell
- Institute of Human Performance, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
| | - Rich S. W. Masters
- Institute of Human Performance, The University of Hong Kong, Pokfulam, Hong Kong, People’s Republic of China
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Abstract
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.
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Affiliation(s)
- Vanessa N Palter
- Corresponding author: Vanessa N. Palter, MD, University of Toronto, 600 University Avenue, Room 440, Toronto, ON M5G 1X5 Canada, 416.948.8790,
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Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills. Ann Surg 2011; 253:1216-22. [PMID: 21516035 DOI: 10.1097/sla.0b013e3182197016] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Virtual reality (VR) simulation provides unique training opportunities. This study evaluates whether the deliberate practice (DP) can be successfully applied to simulated laparoscopic cholecystectomy (LC) for enhancement of the quality of surgical skills. METHODS Twenty-six inexperienced surgeons underwent a training program for LC on a VR simulator. Trainees were randomly allocated to 1 of 2 specific protocols of 10 sessions comprising a total of 20 LCs. For each session, the control group performed 2 LCs separated by 30 minutes of occupational activities; the DP group were assigned 30 minutes of DP activities in between 2 LCs. Each participant then performed 2 LCs on a cadaveric porcine model. Quantitative parameters were recorded from the simulator and a motion tracking device; qualitative assessment utilized validated rating scales. RESULTS Twenty-two subjects completed training. Learning curves on the VR simulator were significant for time taken and number of movements in both groups. The DP group was slower from the third LC (1373 vs. 872 seconds, P = 0.022) and utilized more movements from the seventh (942 vs. 701, P = 0.033). Global rating scores improved significantly in both groups over repeated LCs. The DP group revealed higher scores than control from tenth (19.5 vs. 14, P = 0.014) until the twentieth LC (22 vs. 16, P = 0.003). On the porcine model, the DP group also achieved higher global rating scores (25.5 vs. 19.5, P = 0.002). CONCLUSIONS VR training improved dexterity for both groups, and led to transfer of skill onto a porcine LC model. The DP group achieved higher quality, and demonstrated superior transfer onto real tissues.
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149
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Wilson MR, McGrath JS, Vine SJ, Brewer J, Defriend D, Masters RSW. Perceptual impairment and psychomotor control in virtual laparoscopic surgery. Surg Endosc 2011; 25:2268-74. [PMID: 21359902 PMCID: PMC3116127 DOI: 10.1007/s00464-010-1546-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 11/19/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is recognised that one of the major difficulties in performing laparoscopic surgery is the translation of two-dimensional video image information to a three-dimensional working area. However, research has tended to ignore the gaze and eye-hand coordination strategies employed by laparoscopic surgeons as they attempt to overcome these perceptual constraints. This study sought to examine if measures related to tool movements, gaze strategy, and eye-hand coordination (the quiet eye) differentiate between experienced and novice operators performing a two-handed manoeuvres task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). METHODS Twenty-five right-handed surgeons were categorised as being either experienced (having led more than 60 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The 10 experienced and 15 novice surgeons completed the "two-hand manoeuvres" task from the LAP Mentor basic skills learning environment while wearing a gaze registration system. Performance, movement, gaze, and eye-hand coordination parameters were recorded and compared between groups. RESULTS The experienced surgeons completed the task significantly more quickly than the novices, used significantly fewer movements, and displayed shorter tool paths. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools. A more detailed analysis of a difficult subcomponent of the task revealed that experienced operators used a significantly longer aiming fixation (the quiet eye period) to guide precision grasping movements and hence needed fewer grasp attempts. CONCLUSION The findings of the study provide further support for the utility of examining strategic gaze behaviour and eye-hand coordination measures to help further our understanding of how experienced surgeons attempt to overcome the perceptual difficulties inherent in the laparoscopic environment.
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Affiliation(s)
- Mark R Wilson
- School of Sport and Health Sciences, University of Exeter, St Luke's Campus, Exeter, EX1 2LU, UK.
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150
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Wilson MR, Vine SJ, Bright E, Masters RSW, Defriend D, McGrath JS. Gaze training enhances laparoscopic technical skill acquisition and multi-tasking performance: a randomized, controlled study. Surg Endosc 2011; 25:3731-9. [PMID: 21671125 PMCID: PMC3213335 DOI: 10.1007/s00464-011-1802-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 05/14/2011] [Indexed: 11/29/2022]
Abstract
Background The operating room environment is replete with stressors and distractions that increase the attention demands of what are already complex psychomotor procedures. Contemporary research in other fields (e.g., sport) has revealed that gaze training interventions may support the development of robust movement skills. This current study was designed to examine the utility of gaze training for technical laparoscopic skills and to test performance under multitasking conditions. Methods Thirty medical trainees with no laparoscopic experience were divided randomly into one of three treatment groups: gaze trained (GAZE), movement trained (MOVE), and discovery learning/control (DISCOVERY). Participants were fitted with a Mobile Eye gaze registration system, which measures eye-line of gaze at 25 Hz. Training consisted of ten repetitions of the “eye-hand coordination” task from the LAP Mentor VR laparoscopic surgical simulator while receiving instruction and video feedback (specific to each treatment condition). After training, all participants completed a control test (designed to assess learning) and a multitasking transfer test, in which they completed the procedure while performing a concurrent tone counting task. Results Not only did the GAZE group learn more quickly than the MOVE and DISCOVERY groups (faster completion times in the control test), but the performance difference was even more pronounced when multitasking. Differences in gaze control (target locking fixations), rather than tool movement measures (tool path length), underpinned this performance advantage for GAZE training. Conclusions These results suggest that although the GAZE intervention focused on training gaze behavior only, there were indirect benefits for movement behaviors and performance efficiency. Additionally, focusing on a single external target when learning, rather than on complex movement patterns, may have freed-up attentional resources that could be applied to concurrent cognitive tasks.
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Affiliation(s)
- Mark R Wilson
- College of Life and Environmental Sciences, University of Exeter, St Luke's Campus, Exeter, EX1 2LU, UK.
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