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Ryason A, Xia Z, Jackson C, Wong VT, Li H, De S, Jones SB. Validation of a Virtual Simulator With Haptic Feedback for Endotracheal Intubation Training. Simul Healthc 2024; 19:122-130. [PMID: 36598824 PMCID: PMC10314962 DOI: 10.1097/sih.0000000000000708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Endotracheal intubation (ETI) is a procedure that varies in difficulty because of patient characteristics and clinical conditions. Existing physical simulators do not encompass these variations. The Virtual Airway Skills Trainer for Endotracheal Intubation (VAST-ETI) was developed to provide different patient characteristics and high-fidelity haptic feedback to improve training. METHODS We demonstrate the effectiveness of VAST-ETI as a training and evaluation tool for ETI. Construct validation was evaluated by scoring the performance of experts ( N = 15) and novices ( N = 15) on the simulator to ensure its ability to distinguish technical proficiency. Convergent and predictive validity were evaluated by performing a learning curve study, in which a group of novices ( N = 7) were trained for 2 weeks using VAST-ETI and then compared with a control group ( N = 9). RESULTS The VAST-ETI was able to distinguish between expert and novice based on mean simulator scores ( t [88] = -6.61, P < 0.0005). When used during repeated practice, individuals demonstrated a significant increase in their score on VAST-ETI over the learning period ( F [11,220] = 7206, P < 0.001); however when compared with a control group, there was not a significant interaction effect on the simulator score. There was a significant difference between the simulator-trained and control groups ( t [12.85] = -2.258, P = 0.042) when tested in the operating room. CONCLUSIONS Our results demonstrate the effectiveness of virtual simulation with haptic feedback for assessing performance and training of ETI. The simulator was not able to differentiate performance between more experienced trainees and experts because of limits in simulator difficulty.
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Affiliation(s)
- Adam Ryason
- From the Rensselaer Polytechnic Institute (A.R., H.L., S.D.), Troy, NY; Huazhong University of Science and Technology (Z.X.), Wuhan, People's Republic of China; Beth Israel Deaconess Medical Center (C.J., V.T.W.), Boston, MA; and Albany Medical College (S.B.J.), Albany, NY
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Sarmiento-Altamirano D, Ormaza F, Arroyo MR, Cabrera-Ordoñez C, Valdivieso R, Docksey M, Di Saverio S. Optimizing laparoscopic and robotic skills through simulation in participants with limited or no prior experience: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:566-576. [PMID: 38583911 DOI: 10.1016/j.gassur.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Simulation is an innovative tool for developing complex skills required for surgical training. The objective of this study was to determine the advancement of laparoscopic and robotic skills through simulation in participants with limited or no previous experience. METHODS This is a systematic review and meta-analysis of randomized controlled trials (RCTs) in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. We conducted searches using MEDLINE (PubMed), Web of Science, Google Scholar, and Cochrane Library. Variables analyzed were study characteristics, participant demographics, and characteristics of the learning program. Our main measures were effectiveness, surgical time, and errors. These were reported using standardized mean difference (SMD) with 95% CI (P < .05). Secondary measures included skill transfer and learning curve. RESULTS A total of 17 RCTs were included and comprised 619 participants: 354 participants (57%) were in the simulation group and 265 (43%) in the control group. Results indicated that laparoscopic simulation effectively enhanced surgical skills (SMD, 0.59 [0.18-1]; P = .004) and was significantly associated with shorter surgical duration (SMD, -1.08 [-1.57 to -0.59]; P < .0001) and a fewer errors made (SMD, -1.91 [-3.13 to -0.70]; P = .002). In the robotic simulation, there was no difference in effectiveness (SMD, 0.17 [-0.19 to 0.52]; P = .36) or surgical time (SMD, 0.27 [-0.86 to 1.39]; P = .64). Furthermore, skills were found to be transferable from simulation to a real-life operating room (P < .05). CONCLUSION Simulation is an effective tool for optimizing laparoscopic skills, even in participants with limited or no previous experience. This approach not only contributes to the reduction of surgical time and errors but also facilitates the transfer of skills to the surgical environment. In contrast, robotic simulation fails to maximize skill development, requiring previous experience in laparoscopy to achieve optimal levels of effectiveness.
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Affiliation(s)
| | | | | | | | | | - Megan Docksey
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Salomone Di Saverio
- Department of General Surgery Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
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Co M, Chiu S, Billy Cheung HH. Extended reality in surgical education: A systematic review. Surgery 2023; 174:1175-1183. [PMID: 37640664 DOI: 10.1016/j.surg.2023.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/06/2023] [Accepted: 07/13/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND This review aims to evaluate the effectiveness of extended reality-based training in surgical education. METHODS This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS A total of 33 studies were included in the qualitative analysis. Nine studies evaluated the effectiveness of virtual reality-based training against no substitutional training. Seven studies looked at training for laparoscopic surgery, and the results were contradicting. Two studies focused on orthopedics training, and the outcomes were positive. Fourteen studies compared the outcomes of virtual reality-based training to conventional didactic teaching, all demonstrating superior outcomes for virtual reality-based training. Nine studies compared the outcomes of virtual reality simulation training to dry lab simulation training. The inferior outcomes of virtual reality simulation training were demonstrated by 5 studies for laparoscopic surgery, 1 study for arthroscopic procedures, 1 study for robotic surgery, and 1 study for dental procedures. One study found potential benefits of virtual reality simulation training on orthopedics surgeries. One study found virtual reality simulation training to be superior to cadaveric training, and 3 studies found augmented reality and virtual reality-based training to be comparable to supervised operative opportunities. CONCLUSION Extended reality-based training is a potentially useful modality to serve as an adjunct to the current physical surgical training.
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Affiliation(s)
- Michael Co
- Centre of Education and Training, Department of Surgery, University of Hong Kong, China.
| | - Shirley Chiu
- Centre of Education and Training, Department of Surgery, University of Hong Kong, China
| | - Ho Hung Billy Cheung
- Centre of Education and Training, Department of Surgery, University of Hong Kong, China
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Rasheed F, Bukhari F, Iqbal W, Asif M, Chaudhry HAH. A low-cost unity-based virtual training simulator for laparoscopic partial nephrectomy using HTC Vive. PeerJ Comput Sci 2023; 9:e1627. [PMID: 37869468 PMCID: PMC10588702 DOI: 10.7717/peerj-cs.1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/11/2023] [Indexed: 10/24/2023]
Abstract
Laparoscopic education and surgery assessments increase the success rates and lower the risks during actual surgeries. Hospital residents need a secure setting, and trainees require a safe and controlled environment with cost-effective resources where they may hone their laparoscopic abilities. Thus, we have modeled and developed a surgical simulator to provide the initial training in Laparoscopic Partial Nephrectomy (LPN-a procedure to treat kidney cancer or renal masses). To achieve this, we created a virtual simulator using an open-source game engine that can be used with a commercially available, reasonably priced virtual reality (VR) device providing visual and haptic feedback. In this study, the proposed simulator's design is presented, costs are contrasted, and the simulator's performance is assessed using face and content validity measures. CPU- and GPU-based computers can run the novel simulation with a soft body deformation based on simplex meshes. With a reasonable trade-off between price and performance, the HTC Vive's controlled soft body effect, physics-based deformation, and haptic rendering offer the advantages of an excellent surgical simulator. The trials show that the medical volunteers who performed the initial LPN procedures for newbie surgeons received positive feedback.
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Affiliation(s)
- Fareeha Rasheed
- Department of Data Science, University of the Punjab, Lahore, Pakistan
| | - Faisal Bukhari
- Department of Data Science, University of the Punjab, Lahore, Pakistan
| | - Waheed Iqbal
- Department of Data Science, University of the Punjab, Lahore, Pakistan
| | - Muhammad Asif
- Department of Computer Science, National Textile University, Faisalabad, Pakistan
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Objective metrics for hand-sewn bowel anastomoses can differentiate novice from expert surgeons. Surg Endosc 2023; 37:1282-1292. [PMID: 36180753 DOI: 10.1007/s00464-022-09584-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis. MATERIALS AND METHODS Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment. RESULTS A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82 min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037). CONCLUSIONS Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure.
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Juliano JM, Schweighofer N, Liew SL. Increased cognitive load in immersive virtual reality during visuomotor adaptation is associated with decreased long-term retention and context transfer. J Neuroeng Rehabil 2022; 19:106. [PMID: 36199101 PMCID: PMC9532821 DOI: 10.1186/s12984-022-01084-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Complex motor tasks in immersive virtual reality using a head-mounted display (HMD-VR) have been shown to increase cognitive load and decrease motor performance compared to conventional computer screens (CS). Separately, visuomotor adaptation in HMD-VR has been shown to recruit more explicit, cognitive strategies, resulting in decreased implicit mechanisms thought to contribute to motor memory formation. However, it is unclear whether visuomotor adaptation in HMD-VR increases cognitive load and whether cognitive load is related to explicit mechanisms and long-term motor memory formation. METHODS We randomized 36 healthy participants into three equal groups. All groups completed an established visuomotor adaptation task measuring explicit and implicit mechanisms, combined with a dual-task probe measuring cognitive load. Then, all groups returned after 24-h to measure retention of the overall adaptation. One group completed both training and retention tasks in CS (measuring long-term retention in a CS environment), one group completed both training and retention tasks in HMD-VR (measuring long-term retention in an HMD-VR environment), and one group completed the training task in HMD-VR and the retention task in CS (measuring context transfer from an HMD-VR environment). A Generalized Linear Mixed-Effect Model (GLMM) was used to compare cognitive load between CS and HMD-VR during visuomotor adaptation, t-tests were used to compare overall adaptation and explicit and implicit mechanisms between CS and HMD-VR training environments, and ANOVAs were used to compare group differences in long-term retention and context transfer. RESULTS Cognitive load was found to be greater in HMD-VR than in CS. This increased cognitive load was related to decreased use of explicit, cognitive mechanisms early in adaptation. Moreover, increased cognitive load was also related to decreased long-term motor memory formation. Finally, training in HMD-VR resulted in decreased long-term retention and context transfer. CONCLUSIONS Our findings show that cognitive load increases in HMD-VR and relates to explicit learning and long-term motor memory formation during motor learning. Future studies should examine what factors cause increased cognitive load in HMD-VR motor learning and whether this impacts HMD-VR training and long-term retention in clinical populations.
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Affiliation(s)
- Julia M Juliano
- Neuroscience Graduate Program, University of Southern California, 2250 Alcazar St., CSC 133, Los Angeles, CA, 90089, USA.
| | - Nicolas Schweighofer
- Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Sook-Lei Liew
- Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA
- USC Stevens Neuroimaging and Informatics Institute, Department of Neurology, Neurology, University of Southern California, Los Angeles, CA, USA
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Jiang H, Vimalesvaran S, Wang JK, Lim KB, Mogali SR, Car LT. Virtual Reality in Medical Students' Education: Scoping Review. JMIR MEDICAL EDUCATION 2022; 8:e34860. [PMID: 35107421 PMCID: PMC8851326 DOI: 10.2196/34860] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 05/12/2023]
Abstract
BACKGROUND Virtual reality (VR) produces a virtual manifestation of the real world and has been shown to be useful as a digital education modality. As VR encompasses different modalities, tools, and applications, there is a need to explore how VR has been used in medical education. OBJECTIVE The objective of this scoping review is to map existing research on the use of VR in undergraduate medical education and to identify areas of future research. METHODS We performed a search of 4 bibliographic databases in December 2020. Data were extracted using a standardized data extraction form. The study was conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. RESULTS Of the 114 included studies, 69 (60.5%) reported the use of commercially available surgical VR simulators. Other VR modalities included 3D models (15/114, 13.2%) and virtual worlds (20/114, 17.5%), which were mainly used for anatomy education. Most of the VR modalities included were semi-immersive (68/114, 59.6%) and were of high interactivity (79/114, 69.3%). There is limited evidence on the use of more novel VR modalities, such as mobile VR and virtual dissection tables (8/114, 7%), as well as the use of VR for nonsurgical and nonpsychomotor skills training (20/114, 17.5%) or in a group setting (16/114, 14%). Only 2.6% (3/114) of the studies reported the use of conceptual frameworks or theories in the design of VR. CONCLUSIONS Despite the extensive research available on VR in medical education, there continue to be important gaps in the evidence. Future studies should explore the use of VR for the development of nonpsychomotor skills and in areas other than surgery and anatomy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2020-046986.
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Affiliation(s)
- Haowen Jiang
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Sunitha Vimalesvaran
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Jeremy King Wang
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Kee Boon Lim
- School of Biological Sciences, Nanyang Technological University Singapore, Singapore, Singapore
| | | | - Lorainne Tudor Car
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
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Knobel SEJ, Kaufmann BC, Gerber SM, Urwyler P, Cazzoli D, Müri RM, Nef T, Nyffeler T. Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study. JMIR Serious Games 2021; 9:e29182. [PMID: 34255653 PMCID: PMC8285750 DOI: 10.2196/29182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/03/2021] [Accepted: 05/19/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. OBJECTIVE This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. METHODS In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. RESULTS In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. CONCLUSIONS The developed iVR serious game, "bird search task," was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task.
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Affiliation(s)
| | - Brigitte Charlotte Kaufmann
- Perception and Eye Movement Laboratory, Departments of Neurology and BioMedical Research, Inselspital, Bern University Hospital, Bern, Switzerland.,Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Prabitha Urwyler
- Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Dario Cazzoli
- Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland.,Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| | - René M Müri
- Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland.,Perception and Eye Movement Laboratory, Departments of Neurology and BioMedical Research, Inselspital, Bern University Hospital, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Nef
- Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Thomas Nyffeler
- Gerontechnology & Rehabilitation Group, University of Bern, Bern, Switzerland.,Perception and Eye Movement Laboratory, Departments of Neurology and BioMedical Research, Inselspital, Bern University Hospital, Bern, Switzerland.,Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
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Consorti F, Panzera G. Low versus high level of physical resemblance in simulation for the acquisition of basic surgical skill: a meta-analysis. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2021; 7:422-427. [PMID: 35515747 PMCID: PMC8936611 DOI: 10.1136/bmjstel-2020-000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/14/2021] [Indexed: 11/22/2022]
Abstract
Background Many studies explored the use of simulation in basic surgical education, with a variety of devices, contexts and outcomes, with sometimes contradictory results. Objectives The objectives of this meta-analysis were to focus the effect that the level of physical resemblance in a simulation has on the development of basic surgical skill in undergraduate medical students and to provide a foundation for the design and implementation of a simulation, with respect to its effectiveness and alignment with the learning outcomes. Study selection We searched PubMed and Scopus database for comparative randomised studies between simulations with a different level of resemblance. The result was synthesised as the standardised mean difference, under a random effect model. Findings We selected 12 out of 2091 retrieved studies, reporting on 373 undergraduate students (mean of subjects 15.54±6.89). The outcomes were the performance of simple skills and the time to complete a task. Two studies reported a scoring system; seven studies reported time for a task; and three studies reported both. The total number of measures included in the meta-analysis was 456 for score and 504 for time. The pooled effect size did not show any significant advantage in a simulation of a high level of physical resemblance over a lower level, both for the scoring system (−0.19, 95% CI −0.44 to 0.06) and for time (−0.14, 95% CI −0.54 to 0.27). Conclusion Simulations with a low level of physical resemblance showed the same effect as the simulation using a higher level of resemblance on the development of basic surgical skills in undergraduate students.
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Affiliation(s)
- Fabrizio Consorti
- Surgical Sciences, University of Rome La Sapienza Sapienza Faculty of Medicine and Dentistry, Roma, Italy
| | - Gianmarco Panzera
- Surgical Sciences, University of Rome La Sapienza Sapienza Faculty of Medicine and Dentistry, Roma, Italy
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Nemani A, Kamat A, Gao Y, Yucel M, Gee D, Cooper C, Schwaitzberg S, Intes X, Dutta A, De S. Functional brain connectivity related to surgical skill dexterity in physical and virtual simulation environments. NEUROPHOTONICS 2021; 8:015008. [PMID: 33681406 PMCID: PMC7927423 DOI: 10.1117/1.nph.8.1.015008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/11/2021] [Indexed: 05/15/2023]
Abstract
Significance: Surgical simulators, both virtual and physical, are increasingly used as training tools for teaching and assessing surgical technical skills. However, the metrics used for assessment in these simulation environments are often subjective and inconsistent. Aim: We propose functional activation metrics, derived from brain imaging measurements, to objectively assess the correspondence between brain activation with surgical motor skills for subjects with varying degrees of surgical skill. Approach: Cortical activation based on changes in the oxygenated hemoglobin (HbO) of 36 subjects was measured using functional near-infrared spectroscopy at the prefrontal cortex (PFC), primary motor cortex, and supplementary motor area (SMA) due to their association with motor skill learning. Inter-regional functional connectivity metrics, namely, wavelet coherence (WCO) and wavelet phase coherence were derived from HbO changes to correlate brain activity to surgical motor skill levels objectively. Results: One-way multivariate analysis of variance found a statistically significant difference in the inter-regional WCO metrics for physical simulator based on Wilk's Λ for expert versus novice, F ( 10,1 ) = 7495.5 , p < 0.01 . Partial eta squared effect size for the inter-regional WCO metrics was found to be highest between the central prefrontal cortex (CPFC) and SMA, CPFC-SMA ( η 2 = 0.257 ). Two-tailed Mann-Whitney U tests with a 95% confidence interval showed baseline equivalence and a statistically significant ( p < 0.001 ) difference in the CPFC-SMA WPCO metrics for the physical simulator training group ( 0.960 ± 0.045 ) versus the untrained control group ( 0.735 ± 0.177 ) following training for 10 consecutive days in addition to the pretest and posttest days. Conclusion: We show that brain functional connectivity WCO metric corresponds to surgical motor skills in the laparoscopic physical simulators. Functional connectivity between the CPFC and the SMA is lower for subjects that exhibit expert surgical motor skills than untrained subjects in laparoscopic physical simulators.
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Affiliation(s)
- Arun Nemani
- Rensselaer Polytechnic Institute, Center for Modeling, Simulation, and Imaging in Medicine, Troy, New York, United States
| | - Anil Kamat
- Rensselaer Polytechnic Institute, Center for Modeling, Simulation, and Imaging in Medicine, Troy, New York, United States
| | - Yuanyuan Gao
- Rensselaer Polytechnic Institute, Center for Modeling, Simulation, and Imaging in Medicine, Troy, New York, United States
| | - Meryem Yucel
- Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts, United States
| | - Denise Gee
- Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts, United States
| | - Clairice Cooper
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, United States
| | - Steven Schwaitzberg
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, United States
| | - Xavier Intes
- Rensselaer Polytechnic Institute, Center for Modeling, Simulation, and Imaging in Medicine, Troy, New York, United States
| | - Anirban Dutta
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, United States
| | - Suvranu De
- Rensselaer Polytechnic Institute, Center for Modeling, Simulation, and Imaging in Medicine, Troy, New York, United States
- Address all correspondence to Suvranu De,
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Jin C, Dai L, Wang T. The application of virtual reality in the training of laparoscopic surgery: A systematic review and meta-analysis. Int J Surg 2020; 87:105859. [PMID: 33307244 DOI: 10.1016/j.ijsu.2020.11.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Virtual reality becomes popular in laparoscopic surgery especially in the training process. An assessment on the learning curve of virtual reality compared to other methods of training or no training needed to be carried out. MATERIALS AND METHODS A systematic literature search between 2000 and 2020 was performed through PubMed, Cochrane library's Central, Embase, Clinicaltrials.gov, and Web of Science. All randomized controlled studies included kept the consistency of participants at the baseline and set the same time or repetitions of training. This systematic review and meta-analysis was under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the methodological quality of systematic reviews(AMSTAR). RESULTS Twenty-three randomized controlled studies and five non-randomized concurrent controlled studies were included among 2692 searched studies. Virtual reality was recommended to be applied among no experience medical students or novice surgeons in the laparoscopic training. It had steeper learning curve compared to no training and traditional trainers. While there was no significant difference between virtual reality and box training or video training in the aspect of learning curve. Moreover, it seemed effective to improve the initial stage of learning curve in actual surgery. CONCLUSION Virtual reality was not the first choice to be applied into laparoscopic training and it had its applicable surgeons or medical students. The superiority of virtual reality in the skill transfer from training room into operating room needed to be confirmed and complemented with further analyses. More importantly, the cost-effectiveness of virtual reality in the training process and patient safety were badly in need of discussion.
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Affiliation(s)
- Chi Jin
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, , China; Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, China
| | - Liuyan Dai
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, , China
| | - Tong Wang
- Department of General Surgery, Wuxi People's Hospital Affiliated to Nanjing Medical University, China.
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Díez N, Pacheco S, Llorente M, Fernández S. Validation of a Sensor-Fitted Simulator for Upper Airway Examination. Otolaryngol Head Neck Surg 2020; 164:339-345. [PMID: 32689875 DOI: 10.1177/0194599820941017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To validate a simulator for upper airway examination, fitted with sensors, for use as an academic tool for learning how to conduct examination of the upper airway and for evaluation of that learning. STUDY DESIGN Validation study. SETTING Undergraduate medical education. SUBJECTS AND METHODS A group of 18 fifth-year medical students and another of 6 otorhinolaryngology specialists conducted 6 examinations each with the simulator. To investigate concurrent validity, we calculated the correlation between damage scores provided by the simulator and damage assessment by a specialist. To evaluate construct validity, we compared both groups with regard to damage scores, technical procedure, and time spent. To examine content and face validity, we used questionnaires based on a 5-point Likert scale. RESULTS For concurrent validity, the correlation between the simulator's damage scores and the specialist's damage assessment was high: Spearman's ρ was 0.828 (P < .001). For construct validity, the group of students differed from the group of specialists in damage scores (P = .027) and in technical procedures (P < .001) but not in time spent. For content validity, all questionnaire statements were scored highly, and both groups had similar average scores. For face validity, the group of specialists considered the simulator to be realistic, and all statements on the questionnaire were rated with at least 4/5. CONCLUSION Concurrent, construct, content, and face validity have been demonstrated for a sensor-fitted simulator for upper airway examination, which is therefore accurate enough to be used as an academic tool for learning and evaluation of learning.
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Affiliation(s)
- Nieves Díez
- Simulation Center, School of Medicine, Universidad de Navarra, Pamplona, Spain
| | - Sofía Pacheco
- Simulation Center, School of Medicine, Universidad de Navarra, Pamplona, Spain
| | - Marcos Llorente
- Medical Engineering Laboratory, School of Medicine, Universidad de Navarra, Pamplona, Spain
| | - Secundino Fernández
- Medical Engineering Laboratory, School of Medicine, Universidad de Navarra, Pamplona, Spain
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Juliano JM, Liew SL. Transfer of motor skill between virtual reality viewed using a head-mounted display and conventional screen environments. J Neuroeng Rehabil 2020; 17:48. [PMID: 32276664 PMCID: PMC7149857 DOI: 10.1186/s12984-020-00678-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/01/2020] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Virtual reality viewed using a head-mounted display (HMD-VR) has the potential to be a useful tool for motor learning and rehabilitation. However, when developing tools for these purposes, it is important to design applications that will effectively transfer to the real world. Therefore, it is essential to understand whether motor skills transfer between HMD-VR and conventional screen-based environments and what factors predict transfer. METHODS We randomized 70 healthy participants into two groups. Both groups trained on a well-established measure of motor skill acquisition, the Sequential Visual Isometric Pinch Task (SVIPT), either in HMD-VR or in a conventional environment (i.e., computer screen). We then tested whether the motor skills transferred from HMD-VR to the computer screen, and vice versa. After the completion of the experiment, participants responded to questions relating to their presence in their respective training environment, age, gender, video game use, and previous HMD-VR experience. Using multivariate and univariate linear regression, we then examined whether any personal factors from the questionnaires predicted individual differences in motor skill transfer between environments. RESULTS Our results suggest that motor skill acquisition of this task occurs at the same rate in both HMD-VR and conventional screen environments. However, the motor skills acquired in HMD-VR did not transfer to the screen environment. While this decrease in motor skill performance when moving to the screen environment was not significantly predicted by self-reported factors, there were trends for correlations with presence and previous HMD-VR experience. Conversely, motor skills acquired in a conventional screen environment not only transferred but improved in HMD-VR, and this increase in motor skill performance could be predicted by self-reported factors of presence, gender, age and video game use. CONCLUSIONS These findings suggest that personal factors may predict who is likely to have better transfer of motor skill to and from HMD-VR. Future work should examine whether these and other predictors (i.e., additional personal factors such as immersive tendencies and task-specific factors such as fidelity or feedback) also apply to motor skill transfer from HMD-VR to more dynamic physical environments.
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Affiliation(s)
- Julia M Juliano
- Neural Plasticity and Neurorehabilitation Laboratory, Neuroscience Graduate Program, University of Southern California, Los Angeles, CA, USA
| | - Sook-Lei Liew
- Neural Plasticity and Neurorehabilitation Laboratory, Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA.
- USC Stevens Neuroimaging and Informatics Institute, Department of Neurology, University of Southern California, Los Angeles, CA, USA.
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Gao Y, Kruger U, Intes X, Schwaitzberg S, De S. A machine learning approach to predict surgical learning curves. Surgery 2019; 167:321-327. [PMID: 31753325 DOI: 10.1016/j.surg.2019.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Contemporary surgical training programs rely on the repetition of selected surgical motor tasks. Such methodology is inherently open ended with no control on the time taken to attain a set level of proficiency, given the trainees' intrinsic differences in initial skill levels and learning abilities. Hence, an efficient training program should aim at tailoring the surgical training protocols to each trainee. In this regard, a predictive model using information from the initial learning stage to predict learning curve characteristics should facilitate the whole surgical training process. METHODS This paper analyzes learning curve data to train a multivariate supervised machine learning model. One factor is extracted to define the trainees' learning ability. An unsupervised machine learning model is also utilized for trainee classification. When established, the model can predict robustly the learning curve characteristics based on the first few trials. RESULTS We show that the information present in the first 10 trials of surgical tasks can be utilized to predict the number of trials required to achieve proficiency (R2=0.72) and the final performance level (R2=0.89). Furthermore, only a single factor, learning index, is required to describe the learning process and to classify learners with unique learning characteristics. CONCLUSION Using machine learning models, we show, for the first time, that the first few trials contain sufficient information to predict learning curve characteristics and that a single factor can capture the complex learning behavior. Using such models holds the potential for personalization of training regimens, leading to greater efficiency and lower costs.
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Affiliation(s)
- Yuanyuan Gao
- Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic Institute, Troy, NY
| | - Uwe Kruger
- Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic Institute, Troy, NY; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY
| | - Xavier Intes
- Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic Institute, Troy, NY; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY
| | - Steven Schwaitzberg
- Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY; Department of Surgery, The State University of New York, Buffalo, NY; Buffalo General Hospital, NY
| | - Suvranu De
- Center for Modeling, Simulation and Imaging in Medicine, Rensselaer Polytechnic Institute, Troy, NY; Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY.
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Characterizing the learning curve of a virtual intracorporeal suturing simulator VBLaST-SS©. Surg Endosc 2019; 34:3135-3144. [PMID: 31482354 DOI: 10.1007/s00464-019-07081-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 08/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The virtual basic laparoscopic skill trainer suturing simulator (VBLaST-SS©) was developed to simulate the intracorporeal suturing task in the FLS program. The purpose of this study was to evaluate the training effectiveness and participants' learning curves on the VBLaST-SS© and to assess whether the skills were retained after 2 weeks without training. METHODS Fourteen medical students participated in the study. Participants were randomly assigned to two training groups (7 per group): VBLaST-SS© or FLS, based on the modality of training. Participants practiced on their assigned system for one session (30 min or up to ten repetitions) a day, 5 days a week for three consecutive weeks. Their baseline, post-test, and retention (after 2 weeks) performance were also analyzed. Participants' performance scores were calculated based on the original FLS scoring system. The cumulative summation (CUSUM) method was used to evaluate learning. Two-way mixed factorial ANOVA was used to compare the effects of group, time point (baseline, post-test, and retention), and their interaction on performance. RESULTS Six out of seven participants in each group reached the predefined proficiency level after 7 days of training. Participants' performance improved significantly (p < 0.001) after training within their assigned group. The CUSUM learning curve shows that one participant in each group achieved 5% failure rate by the end of the training period. Twelve out of fourteen participants' CUSUM curves showed a negative trend toward achieving the 5% failure rate after further training. CONCLUSION The VBLaST-SS© is effective in training laparoscopic suturing skill. Participants' performance of intracorporeal suturing was significantly improved after training on both systems and was retained after 2 weeks of no training.
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Nemani A, Kruger U, Cooper CA, Schwaitzberg SD, Intes X, De S. Objective assessment of surgical skill transfer using non-invasive brain imaging. Surg Endosc 2019; 33:2485-2494. [PMID: 30334166 PMCID: PMC10756643 DOI: 10.1007/s00464-018-6535-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 10/12/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Physical and virtual surgical simulators are increasingly being used in training technical surgical skills. However, metrics such as completion time or subjective performance checklists often show poor correlation to transfer of skills into clinical settings. We hypothesize that non-invasive brain imaging can objectively differentiate and classify surgical skill transfer, with higher accuracy than established metrics, for subjects based on motor skill levels. STUDY DESIGN 18 medical students at University at Buffalo were randomly assigned into control, physical surgical trainer, or virtual trainer groups. Training groups practiced a surgical technical task on respective simulators for 12 consecutive days. To measure skill transfer post-training, all subjects performed the technical task in an ex-vivo environment. Cortical activation was measured using functional near-infrared spectroscopy (fNIRS) in the prefrontal cortex, primary motor cortex, and supplementary motor area, due to their direct impact on motor skill learning. RESULTS Classification between simulator trained and untrained subjects based on traditional metrics is poor, where misclassification errors range from 20 to 41%. Conversely, fNIRS metrics can successfully classify physical or virtual trained subjects from untrained subjects with misclassification errors of 2.2% and 8.9%, respectively. More importantly, untrained subjects are successfully classified from physical or virtual simulator trained subjects with misclassification errors of 2.7% and 9.1%, respectively. CONCLUSION fNIRS metrics are significantly more accurate than current established metrics in classifying different levels of surgical motor skill transfer. Our approach brings robustness, objectivity, and accuracy in validating the effectiveness of future surgical trainers in translating surgical skills to clinically relevant environments.
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Affiliation(s)
- Arun Nemani
- Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Uwe Kruger
- Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Clairice A Cooper
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, 14228, USA
| | - Steven D Schwaitzberg
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, 14228, USA
| | - Xavier Intes
- Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Suvranu De
- Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA.
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Nemani A, Yücel MA, Kruger U, Gee DW, Cooper C, Schwaitzberg SD, De S, Intes X. Assessing bimanual motor skills with optical neuroimaging. SCIENCE ADVANCES 2018; 4:eaat3807. [PMID: 30306130 PMCID: PMC6170034 DOI: 10.1126/sciadv.aat3807] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/29/2018] [Indexed: 05/12/2023]
Abstract
Measuring motor skill proficiency is critical for the certification of highly skilled individuals in numerous fields. However, conventional measures use subjective metrics that often cannot distinguish between expertise levels. We present an advanced optical neuroimaging methodology that can objectively and successfully classify subjects with different expertise levels associated with bimanual motor dexterity. The methodology was tested by assessing laparoscopic surgery skills within the framework of the fundamentals of a laparoscopic surgery program, which is a prerequisite for certification in general surgery. We demonstrate that optical-based metrics outperformed current metrics for surgical certification in classifying subjects with varying surgical expertise. Moreover, we report that optical neuroimaging allows for the successful classification of subjects during the acquisition of these skills.
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Affiliation(s)
- Arun Nemani
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Meryem A. Yücel
- Department of Radiology, Harvard Medical School, Cambridge, MA 02138, USA
| | - Uwe Kruger
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Denise W. Gee
- Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Clairice Cooper
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14260, USA
| | - Steven D. Schwaitzberg
- University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY 14260, USA
| | - Suvranu De
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
- Corresponding author. (S.D.); (X.I.)
| | - Xavier Intes
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
- Corresponding author. (S.D.); (X.I.)
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