Development of a virtual reality training curriculum for laparoscopic cholecystectomy

Is gynaecological surgical training a cause for concern?: a questionnaire survey of trainees and trainers

BACKGROUND

Concerns have been raised as to whether the current postgraduate training programme for gynaecological surgery is being detrimentally affected by changes in working practices, in particular the European Working Time Directive (EWTD). The purpose of this study was to investigate the surgical activity of obstetrics and gynaecology trainees and to explore trainees' and trainers' opinions on the current barriers and potential solutions to surgical training.

METHODS

Two questionnaire surveys were conducted, one to obstetrics and gynaecology trainees working within the West Midlands Deanery and a second to consultant gynaecologists in the West Midlands region.

RESULTS

One hundred and four trainees (64.3%) and 66 consultant gynaecologists (55.0%) responded. Sixty-six trainees (66.7%) reported attending up to one operating list per week. However, 28.1% reported attending up to one list every two weeks or less and 5 trainees stated that they had not attended a list at all over the preceding 8 weeks. Trainees working in a unit with less than 3999 deliveries attended significantly more theatre sessions compared to trainees in units with over 4000 deliveries (p = 0.007), as did senior trainees (p = 0.032) and trainees attached to consultants performing major gynaecological surgery (p = 0.022). In the previous 8 weeks, only 6 trainees reported performing a total abdominal hysterectomy independently, all were senior trainees (ST6 and above). In the trainers' survey, only two respondents (3.0%) agreed that the current program produces doctors competent in general gynaecological surgery by the end of training, compared to 48 (73.8%) respondents who disagreed.

CONCLUSIONS

Trainees' concerns over a lack of surgical training appear to be justified. The main barriers to training are perceived to be a lack of team structure and a lack of theatre time.

The Contribution of Simulation Training in Enhancing Key Components of Laparoscopic Competence

This study aims to investigate how basic training contributes to the performance of complex laparoscopic tasks performed in a virtual reality (VR) environment. An assessment methodology is proposed based on quantitative error analysis of key components of laparoscopic competence. Twenty-five inexperienced surgeons were trained on four basic tasks. The effect of training was assessed on three independent scenarios (two procedural: adhesiolysis and bowel suturing, and a laparoscopic cholecystectomy [LC]). Several error parameters were post hoc analyzed to yield a quantitative performance index for two fundamental skills: proficiency and safety. Time and instrument path length were also measured and compared. Correlation analysis was performed to study how these indices correlate one another. Significant learning curves were demonstrated during training. For adhesiolysis, all four indices improved significantly ( P < 0.05). Time and path length presented plateaus for all basic tasks, whereas proficiency and safety only for two and one task(s), respectively. For bowel suturing, only time and safety errors showed a decrease ( P < 0.05). Significant performance enhancement was observed for LC in which errors and path length reduced after training ( P < 0.05). Our results revealed also an increased number of correlations after training, especially for proficiency. This study finds it possible to assess key competence skills based on the quantitative analysis of various parameters generated by a VR simulator. The improvement in basic training is transferred to more complex tasks. The proposed methodology is useful for structured evaluation of laparoscopic performance demonstrating fundamental elements of surgical competence.

Training in surgical oncology - the role of VR simulation

There have been dramatic changes in surgical training over the past two decades which have resulted in a number of concerns for the development of future surgeons. Changes in the structure of cancer services, working hour restrictions and a commitment to patient safety has led to a reduction in training opportunities that are available to the surgeon in training. Simulation and in particular virtual reality (VR) simulation has been heralded as an effective adjunct to surgical training. Advances in VR simulation has allowed trainees to practice realistic full length procedures in a safe and controlled environment, where mistakes are permitted and can be used as learning points. There is considerable evidence to demonstrate that the VR simulation can be used to enhance technical skills and improve operating room performance. Future work should focus on the cost effectiveness and predictive validity of VR simulation, which in turn would increase the uptake of simulation and enhance surgical training.

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.

A virtual reality simulation curriculum for intravenous cannulation training

OBJECTIVES

Although virtual reality (VR) simulators play an important role in modern medical training, their efficacy is not often evaluated using learning curves. In this study, the learning curves of novice and intermediate users were elicited during a VR simulation-based curriculum for intravenous (IV) cannulation.

METHODS

This was a prospective observational study of subjects undergoing training using a VR model of IV cannulation. Participants were divided into two groups: novices (third-year medical students with no prior practical experience in IV catheterization) and intermediates (recent graduates with limited experience). Performance was measured with two endpoints: time to completion and errors committed. Errors were categorized as critical or noncritical. Learning curves (error score and time completion vs. session number) were analyzed using the Friedman's test. Performance before and after training was compared using the Kruskal-Wallis test. The Spearman rank correlation coefficient (r(s)) was used to determine the correlation between time completion and error score estimates. The number of attempts required to complete the training phase was also measured and compared between the two groups.

RESULTS

Thirty subjects were enrolled: 17 in the novice group and 13 in the intermediate group. Learning curve plateaus of intermediates were reached in the sixth case scenario (session), whereas novices reached a plateau in the eighth session. Performance comparison of time to completion and errors showed significant improvement for both groups. Less time and fewer attempts were required by all trainees to complete a scenario while progressing through the curriculum. The overall number of IV cannulation attempts of novices was significantly higher than that of the intermediates throughout the course.

CONCLUSIONS

Significant learning curves for novice and intermediate students were demonstrated after following the VR simulation-based curriculum. Competencies acquired during this educational course may provide an important advantage for training prior to actual clinical practice.

Advances in cancer surgery: natural orifice surgery (NOTES) for oncological diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a new concept that attempts to reduce the impact of surgery on the patient. In surgical oncology several studies have already revealed that a minimally invasive approach provides at least the same, if not a better, long-term outcome. One could hypothesize that a less invasive approach such as NOTES could further enhance such advantages. Since its initial description, NOTES has become clinical reality and today nearly every organ is accessible by a transluminal approach, in at least the experimental setting. Subsequent to published research, first clinical studies on NOTES in oncology were reported and the accuracy of transgastric peritoneoscopy for staging of pancreas cancer was shown to be similar to laparoscopy in humans. A NOTES gastro-jejunostomy via transgastric access has also been proposed to decrease invasiveness of palliative treatment of duodenal, biliary and pancreatic cancers. Colorectal cancer resection via transanal access would offer a clear-cut patient advantage over laparoscopic and would not be subject to the frequent criticism of violating an innocent second organ, as the colon or rectum is always breached in a colectomy. Natural orifice endoluminal therapies, such as endoscopic submucosal dissection, already have been clinically applied for several years. Improved techniques or instruments evolving from NOTES technology might enhance its widespread use for the treatment of early malignancies and thereby again will provide a tremendous benefit for the patient. Although still somewhat controversial, the subject of natural orifice surgery in oncological disease indicates that current laboratory efforts to introduce NOTES into cancer surgery could be ready for cautious clinical investigations. The final determination of patient benefit will need well-constructed prospective study.

European consensus on a competency-based virtual reality training program for basic endoscopic surgical psychomotor skills

BACKGROUND

Virtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program.

METHODS

A consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the t test for equality of means.

RESULTS

Consensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference.

CONCLUSIONS

A European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.

Objective assessment of technical surgical skills

Background

Surgeons are increasingly being scrutinized for their performance and there is growing interest in objective assessment of technical skills. The purpose of this study was to review all evidence for these methods, in order to provide a guideline for use in clinical practice.

Methods

A systematic search was performed using PubMed and Web of Science for studies addressing the validity and reliability of methods for objective skills assessment within surgery and gynaecology only. The studies were assessed according to the Oxford Centre for Evidence-based Medicine levels of evidence.

Results

In total 104 studies were included, of which 20 (19·2 per cent) had a level of evidence 1b or 2b. In 28 studies (26·9 per cent), the assessment method was used in the operating room. Virtual reality simulators and Objective Structured Assessment of Technical Skills (OSATS) have been studied most. Although OSATS is seen as the standard for skills assessment, only seven studies, with a low level of evidence, addressed its use in the operating room.

Conclusion

Based on currently available evidence, most methods of skills assessment are valid for feedback or measuring progress of training, but few can be used for examination or credentialing. The purpose of the assessment determines the choice of method.

Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts

Background

Surgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision.

Methods

A total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups.

Results

The experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. 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.

Conclusion

The findings of the study provide support for the utility of assessing strategic gaze behaviour to better understand the way in which surgeons utilise visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed.