Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study

Assessment of the evolution of psychomotor skills in the robotic surgery simulation process

Robotic surgery is a rapidly expanding field, given the wide variety of new robotic platforms emerging. Looking at the training of surgeons in robotic surgery is of extreme necessity and urgency, considering the ongoing technological advancements. In this research, the performance during the virtual reality simulation phase of training for robotic surgery was analyzed. It was observed that, in addition to the lack of consensus among societies regarding the required simulation hours, there is no guidance on the best curriculum to be adopted. From the data in this study, it can be inferred that the more advanced skills have fewer proficient individuals, meaning that fewer surgeons in training have reached proficiency in all skill exercises. Even with differences in the number of exercises performed proficiently between groups that underwent varying amounts of simulation time, there is no statistically significant difference in the proportion between them.

Relationship between demographic and social variables and performance in virtual reality among healthcare personnel: an observational study

BACKGROUND

Virtual reality is emerging as an important component of medical education. Although the benefits of virtual reality are apparent, the optimal strategy to orient to or differentiate learners in the virtual space have not been delineated. The purpose of this study was to investigate the relationships between demographic variables, social variables, and self-perceived comfort with technology to performance on a standardized non-medical virtual reality experience.

METHODS

This observational study was performed at the International Meeting on Simulation in Healthcare in 2022. This conference includes medical and non-medical attendees. Participants provided demographic information and participated in a scored non-medical VR experience due to the heterogeneity of the sample. Participants then completed a System Usability Index and NASA Task Load Index form. Participants were dividedintolow scoring, medium scoring, and high scoring groups according to their final game score for further analysis.

RESULTS

95 participants were included in final analysis. 55 (57.9%) of participants had prior virtual reality experience. Higher scores were associated with younger age (11.09, p < 0.001), identifying as male (11.09, p < 0.001), and a higher frequency of playing video games in the past (18.96, p < 0.001). The high score group was more likely to report comfort with virtual reality (6.29, p = 0.003) as well as comfort with new technology (4.61, p = 0.012). NASA Task Load Index scores trended down and System Usability Index scores trended up with increasing score. Being a nurse was a positive predictor of a higher score when compared to physicians in the multivariate analysis.

CONCLUSION

Performance during an immersive virtual reality experience was most closely related to age, gender, and frequency of playing video games. Self-perceived comfort with virtual reality was more predictive of score than prior virtual reality experience.

Effects of preoperative surgeon warm-up in video-assisted thoracoscopic surgery lobectomy

BACKGROUND

In various surgical specialties, preoperative surgical warm-up has been demonstrated to affect a surgeon's performance and the perioperative outcomes for patients. However, the influence of warm-up activities on video-assisted thoracoscopic surgery lobectomy (VATSL) remains largely unexplored. This study aims to investigate the potential effects of preoperative surgical warm-up on VATSL.

METHODS

A cohort of 364 patients diagnosed with lung cancer through pathology and undergoing VATSL at the Thoracic Surgery Department of Xuzhou Medical University from January 2018 to September 2022 were included. Patients were categorized into two groups: the warm-up group, comprising 172 patients undergoing their first VATSL of the day, and the warm-up effect group, consisting of 192 patients undergoing their second VATSL on the same day. Propensity score matching was employed to compare operation times and postoperative complications between the two groups, resulting in 159 matched cases in each group.

RESULTS

There were no statistically significant differences in operation time (154.5 ± 54.9 vs. 147.2 ± 54.4 min, p = 0.239) and postoperative complications (including pulmonary infection, atelectasis, long-term pulmonary air leakage requiring incision suture in the operating room, and postoperative pleural effusion) (14:22 cases, p = 0.157) between the warm-up and warm-up effect groups.

CONCLUSION

The findings suggest that preoperative surgical warm-up does not significantly affect the perioperative outcomes of VATSL.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

Society for Simulation in Healthcare Guidelines for Simulation Training

BACKGROUND

Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist.

METHODS

Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

OBJECTIVE

These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare.

RESULTS

Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided.

CONCLUSIONS

The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

The Impact of Just-in-Time Simulation Training for Healthcare Professionals on Learning and Performance Outcomes: A Systematic Review

ABSTRACT

Although just-in-time training (JIT) is increasingly used in simulation-based health professions education, its impact on learning, performance, and patient outcomes remains uncertain. The aim of this study was to determine whether JIT simulation training leads to improved learning and performance outcomes. We included randomized or nonrandomized interventional studies assessing the impact of JIT simulation training (training conducted in temporal or spatial proximity to performance) on learning outcomes among health professionals (trainees or practitioners). Of 4077 citations screened, 28 studies were eligible for inclusion. Just-in-time training simulation training has been evaluated for a variety of medical, resuscitation, and surgical procedures. Most JIT simulation training occurred immediately before procedures and lasted between 5 and 30 minutes. Despite the very low certainty of evidence, this systematic review suggests JIT simulation training can improve learning and performance outcomes, in particular time to complete skills. There remains limited data on better patient outcomes and collateral educational effects.

Effect of pre-operative warm-up on trainee intraoperative performance during robot-assisted hysterectomy: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The objective was to study the effect of immediate pre-operative warm-up using virtual reality simulation on intraoperative robot-assisted laparoscopic hysterectomy (RALH) performance by gynecology trainees (residents and fellows).

METHODS

We randomized the first, non-emergent RALH of the day that involved trainees warming up or not warming up. For cases assigned to warm-up, trainees performed a set of exercises on the da Vinci Skills Simulator immediately before the procedure. The supervising attending surgeon, who was not informed whether or not the trainee was assigned to warm-up, assessed the trainee's performance using the Objective Structured Assessment for Technical Skill (OSATS) and the Global Evaluative Assessment of Robotic Skills (GEARS) immediately after each surgery.

RESULTS

We randomized 66 cases and analyzed 58 cases (30 warm-up, 28 no warm-up), which involved 21 trainees. Attending surgeons rated trainees similarly irrespective of warm-up randomization with mean (SD) OSATS composite scores of 22.6 (4.3; warm-up) vs 21.8 (3.4; no warm-up) and mean GEARS composite scores of 19.2 (3.8; warm-up) vs 18.8 (3.1; no warm-up). The difference in composite scores between warm-up and no warm-up was 0.34 (95% CI: -1.44, 2.13), and 0.34 (95% CI: -1.22, 1.90) for OSATS and GEARS respectively. Also, we did not observe any significant differences in each of the component/subscale scores within OSATS and GEARS between cases assigned to warm-up and no warm-up.

CONCLUSION

Performing a brief virtual reality-based warm-up before RALH did not significantly improve the intraoperative performance of the trainees.

Exploring the use of driving simulation to improve robotic surgery simulator training: an observational case-control study

The correlation between driving skills and the ability to perform robotic surgery have not yet been discussed. Therefore, this study aimed to investigate the impact of driving skills on learning robotic surgery using a driving simulator and a robotic simulator. Sixty robot- and simulator-naïve participants were recruited: 30 with a driver's license and 30 without a driver's license. All participants completed a test on the driving simulator and learned four tasks using a robotic surgical simulator (dV-Trainer). On the driving simulator, the lap time in the driver's license group (D-Group) was significantly lower than that in the non-driver's license group (ND-Group) [217.93 ± 42.79 s vs. 271.24 ± 46.63 s, P < 0.001]. The average number of tires off track in the D-Group was lower than that in the ND-Group (0.13 ± 0.35 vs. 0.57 ± 0.63, P = 0.002). The baseline score of the D-Group on the robotic simulator was higher than that of the ND-Group (467.53 ± 107.62 vs. 385.53 ± 136.30, P = 0.022). In the Pick-and-Place-Clutching, Peg-Board-2, and Thread-the-Rings-1 tasks, the learning curve of the D-Group was steeper than that of the ND-Group. However, no significant difference was observed in the Match-Board-2 task. According to the lap time ranking, participants in the top tertile had a steeper learning curve than those in the bottom tertile, especially for the Pick-and-Place-Clutching and Peg-Board-2 tasks (P < 0.05). Significant differences were also found in the baseline and final stages of the Thread-the-Rings-1 task and in the initial stage of the Match-Board-2 task (P < 0.05). Students with a driver's license or better performance in racing games had more success in learning robotic surgery. Driving simulators may promote robotic surgery training.

The current status of robotic colorectal surgery training programmes

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

The impact of extended reality on surgery: a scoping review

PURPOSE

Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments to enhanced real-world environments. In the past two decades, XR-assisted surgery has seen an increase in its use and also in research and development. This scoping review aims to map out the historical trends in these technologies and their future prospects, with an emphasis on the reported outcomes and ethical considerations on the use of these technologies.

METHODS

A systematic search of PubMed, Scopus, and Embase for literature related to XR-assisted surgery and telesurgery was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Primary studies, peer-reviewed articles that described procedures performed by surgeons on human subjects and cadavers, as well as studies describing general surgical education, were included. Non-surgical procedures, bedside procedures, veterinary procedures, procedures performed by medical students, and review articles were excluded. Studies were classified into the following categories: impact on surgery (pre-operative planning and intra-operative navigation/guidance), impact on the patient (pain and anxiety), and impact on the surgeon (surgical training and surgeon confidence).

RESULTS

One hundred and sixty-eight studies were included for analysis. Thirty-one studies investigated the use of XR for pre-operative planning concluded that virtual reality (VR) enhanced the surgeon's spatial awareness of important anatomical landmarks. This leads to shorter operating sessions and decreases surgical insult. Forty-nine studies explored the use of XR for intra-operative planning. They noted that augmented reality (AR) headsets highlight key landmarks, as well as important structures to avoid, which lowers the chance of accidental surgical trauma. Eleven studies investigated patients' pain and noted that VR is able to generate a meditative state. This is beneficial for patients, as it reduces the need for analgesics. Ten studies commented on patient anxiety, suggesting that VR is unsuccessful at altering patients' physiological parameters such as mean arterial blood pressure or cortisol levels. Sixty studies investigated surgical training whilst seven studies suggested that the use of XR-assisted technology increased surgeon confidence.

CONCLUSION

The growth of XR-assisted surgery is driven by advances in hardware and software. Whilst augmented virtuality and mixed reality are underexplored, the use of VR is growing especially in the fields of surgical training and pre-operative planning. Real-time intra-operative guidance is key for surgical precision, which is being supplemented with AR technology. XR-assisted surgery is likely to undertake a greater role in the near future, given the effect of COVID-19 limiting physical presence and the increasing complexity of surgical procedures.

The effect of continuous at-home training of minimally invasive surgical skills on skill retention

BACKGROUND

Skill deterioration of minimally invasive surgical (MIS) skills may be prevented by continuous training. The aim of this study is to evaluate whether unsupervised continuous at-home training of MIS skills results in better skill retention compared to no training.

METHODS

Medical doctors followed a two-week interval training for two MIS tasks (precise peg transfer and interrupted suture with knot tying), ending with a baseline test. They were randomly assigned to the no-practice group or continuous-practice group. The latter practiced unsupervised at home every two weeks during the study period. Skill retention was measured after three and six months on both tasks by the total time needed, distance traveled by instruments and LS-CAT score (8 best possible score and > 40 worst score).

RESULTS

A total of 38 participants were included. No significant differences in performance were found at pre-test or baseline. At six months the no-practice group needed more time for the suturing task (309 s vs. 196 s at baseline, p = 0.010) and the LS-CAT score was significantly worse (30 vs. 20 at baseline, p < 0.0001). The continuous-practice group performed the suturing task significantly better than the no-practice group at both three and six months (17 vs. 25, p < 0.001 and 17 vs. 30, p < 0.001) and faster as well (p = 0.034 and p = 0.001).

CONCLUSION

This study shows a skill decay after only a few months of non-use and shows better skill retention after continuous unsupervised at-home practice of MIS skills. This indicates an added value of regular at-home practice of surgical skills.

The Impact of Perioperative and Operative Variables on Early Postoperative Complications Following Primary Hypospadias Repair

OBJECTIVES

To evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques.

METHODS

We retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by one of three surgeons over a 10-year period and the surgeon's daily schedule.

RESULTS

The median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning versus afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (p=0.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration versus scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (p=.043).

CONCLUSIONS

A variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled.

Validity of a patient-specific percutaneous nephrolithotomy (PCNL) simulated surgical rehearsal platform: impact on patient and surgical outcomes

INTRODUCTION

Simulators provide a safe method for improving surgical skills without the associated patient risks. Advances in rapid prototyping technology have permitted the reconstruction of patient imaging into patient-specific surgical simulations that require advanced expertise, potentially continuing the learning curve.

OBJECTIVES

To evaluate the impact of preoperative high-fidelity patient-specific percutaneous nephrolithotomy hydrogel simulations on surgical and patient outcomes.

MATERIALS AND METHODS

Between 2016 and 2017, a fellowship-trained endourologist performed 20 consecutive percutaneous nephrolithotomy procedures at an academic referral center. For the first ten patients, only standard review of patient imaging was completed. For the next ten patients, patient imaging was utilized to fabricate patient-specific models including pelvicalyceal system, kidney, stone, and relevant adjacent structures from hydrogel. The models were tested to confirm anatomic accuracy and material properties similar to live tissue. Full procedural rehearsals were completed 24-48 h before the real case. Surgical metrics and patient outcomes from both groups (rehearsal vs. standard) were compared.

RESULTS

Significant improvements in mean fluoroscopy time, percutaneous needle access attempts, complications, and additional procedures were significantly lower in the rehearsal group (184.8 vs. 365.7 s, p < 0.001; 1.9 vs. 3.6 attempts, p < 0.001; 1 vs. 5, p < 0.001; and 1 vs. 5, p < 0.001, respectively). There were no differences in stone free rates, mean patient age, body mass index, or stone size between the two groups.

CONCLUSION

This study demonstrates that patient-specific procedural rehearsal is effective reducing the experience curve for a complex endourological procedure, resulting in improved surgical performance and patient outcomes.

Proficiency Based Progression (PBP) training- the future model for dental operative skills training?: A systematic review and meta-analysis of existing literature

OBJECTIVE

To evaluate the effectiveness of Proficiency-Based Progression (PBP) operative training using validated performance metrics, by comparing this to standard, conventional training methods.

DATA

This systematic review was conducted in accordance with the guidelines of the Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA). Study quality was assessed using the MERSQI tool and the Cochrane Risk of Bias tool. Results were pooled using biased corrected standardized mean difference and ratio-of-means (ROM). Summary effects were evaluated using a series of fixed and random effects models. The primary outcome was the number of procedural errors performed comparing PBP and non-PBP-based training pathways. In quantitative synthesis testing for procedural errors, a pooled meta-analysis on 87 trainees was conducted using random-effects models. In a ROM analysis, PBP was estimated to reduce the mean rate of errors by 62%, when compared to standard training (ROM 0.38, 95% CI: 0.25; 0.58; p < 0.001) Sources: The electronic databases of PubMed, Embase, Web of Science, MEDLINE and Cochrane library's CENTRAL were searched from inception to 8/11/2021. Filters activated were Randomized Controlled trials, clinical trial.

STUDY SELECTION

13 studies were included for review with 11 included in the quantitative synthesis from 174 potentially relevant publications identified by the search strategy. Main inclusion criteria were studies comparing standard surgical/operative training with proficiency-based simulation training using validated metrics based on expert performance.

CONCLUSIONS

Our meta-analysis found that PBP training improved trainees' performances, by decreasing procedural errors. There is sufficient evidence to explore PBP training for use in dental skills training. PBP training was estimated to reduce the mean rate of operative errors by 62%, when compared to standard training. Given that there is a direct correlation between operative skill and patient outcomes, these data suggest that there is sufficient evidence to explore PBP training for use in dental skills training.

The evolution of surgical virtual education and telementoring: One surgeon's journey

The first era of the global proliferation of surgical advancements involved surgical infection rate and technique breakthroughs by Lister, Halsted, and others. This was propagated by letters, academic papers, and international visits. While success was achieved, it was at a suboptimal pace. In the current era of minimally invasive surgical approaches, these methods are inadequate. This paper chronicles the development and application of virtual learning and telementoring as force multipliers to speed procedural adoption and proliferation.

Simulation-Based Training in Robotic Surgery: Contemporary and Future Methods

While robotic surgery has grown in popularity and scope over the past decade, there is a persistent need for simulation-based training as surgeons adapt from the working at the bedside to the immersive and multisensory tasks at the console. From dry laboratory to virtual reality (VR) environments, simulation can be used to train surgeons in basic tasks, complex operative steps, and coordination of whole operations with members of the entire operating room (OR) staff. By integrating simulation into mentored training programs, surgeons can reduce the number of cases required to master a complex operation. Future VR based simulation will become essential to the adaptation of the surgical workforce to new technologies and adoption of emerging robotic platforms. Ultimately, robotic simulation will set standards for credentialing of new surgeons.

Virtual reality simulation in plastic surgery training. Literature review

Major changes have occurred in the medical environment leading to an evolution from the traditional residency programmes to competency-based ones. Virtual reality (VR) represents a promising simulation resource for surgical training. Several types of VR simulators can be considered, depending on the level of immersion they offer. The goal of the article is to review the progress of VR simulation in plastic surgery (PS) training. A systematic search of the literature was performed on PUBMED/MEDLINE with the following key words: (Simulation OR Virtual Reality) AND (Education OR Training) AND Plastic Surgery from January 1998 to September 2019. A total of 244 results were found, and 80 of them were selected for abstract review. Sixty-four articles were selected for complete reading. Several attempts have been made to create VR simulators and most of them are non-immersive or partially immersive. The main conclusions of them are summarized. VR simulation has been proven to have a role in PS training, offering many advantages. Furthermore, VR simulation can be used for safety training, team interaction and decision-making education. Validation is a key point for acceptance of simulators. Further efforts are required to include simulation in PS curricula.

Virtual Reality Warm-up Before Robot-assisted Surgery: A Randomized Controlled Trial

TRIAL DESIGN

This was a randomized controlled trial.

BACKGROUND

Intraoperative errors correlate with surgeon skill and skill declines with intervals of inactivity. The goals of this research were to identify the optimal virtual reality (VR) warm-up curriculum to prime a surgeon's technical skill and validate benefit in the operating room.

MATERIALS AND METHODS

Surgeons were randomized to receive six trial sessions of a designated set of VR modules on the da Vinci Skills Simulator to identify optimal VR warm-up curricula to prime technical skill. After performing their curricula, warm-up effect was assessed based on performance on a criterion task. The optimal warm-up curriculum was chosen from the group with the best task time and video review-based technical skill. Robot-assisted surgery-experienced surgeons were then recruited to either receive or not receive warm-up before surgery. Skill in the first 15 min of surgery was assessed by blinded surgeon and crowdworker review as well as tool motion metrics. The intervention was performing VR warm-up before human robot-assisted surgery. Warm-up effect was measured using objective performance metrics and video review using the Global Evaluative Assessment of Robotic Skills tool. Linear mixed effects models with a random intercept for each surgeon and nonparametric modified Friedman tests were used for analysis.

RESULTS

The group performing only a Running Suture task on the simulator was on average 31.3 s faster than groups performing other simulation tasks and had the highest Global Evaluative Assessment of Robotic Skills scores from 41 surgeons who participated. This was chosen as the optimal curriculum. Thereafter, 34 surgeons completed 347 surgeries with corresponding video and tool motion data. No statistically significant differences in skill were observed with the warm-up intervention.

CONCLUSIONS

We conclude that a robotic VR warm-up before performing the early stages of surgery does not impact the technical skill of the surgeon.

Can video games enhance surgical skills acquisition for medical students? A systematic review

OBJECTIVE

To systematically assess literature examining the impact of being a gamer or participating in video-game-based training on surgical skills acquisition amongst medical students.

BACKGROUND

Video games and surgical procedures share similar skills such as visuospatial abilities and hand-eye coordination; therefore, video games can be a valuable tool for surgical training amongst medical students. However, comprehensive, up-to-date systematic reviews are necessary to confirm.

METHODS

A systematic literature search of PubMed, MEDLINE, and EMBASE was performed in April 2020 with no limits set on the date of publication. Observational and randomized controlled studies were included. Quality and bias were assessed using the Newcastle-Ottawa Scale for nonrandomized studies and the Grading of Recommendations Assessment, Development and Evaluation system for randomized studies.

RESULTS

A total of 575 participants from 16 studies were included. The most common surgical skills tested were laparoscopy (n = 283, from 8 studies) and robotic surgery (n = 199, from 5 studies). A history of gaming and video-game-based training were associated with improved metrics in robotic surgery and laparoscopy, respectively. Neither was beneficial in arthroscopy or bronchoscopy. Studies using the Wii U and Underground reported significant improvement in overall laparoscopic performance.

CONCLUSION

Video games demonstrate potential as adjunctive training in surgical skill education, with a history of gaming and video-game-based training being beneficial in robotic surgery and laparoscopy, respectively. Methodological heterogeneity amongst included studies limit the ability to make conclusive decisions; thus, future studies with long-term follow-up, larger sample sizes, outcomes stratified by video-game characteristics, and up-to-date technology are necessary.

Transoral Robotic Surgical Proficiency Via Real-Time Tactile Collision Awareness System

OBJECTIVES

In 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic-assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS-specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.

METHODS

Design and fidelity testing for a custom TORS training platform with an integrated anatomic collision-sensing system providing real-time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology-head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real-time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0-3, describing the adequacy of resection).

RESULTS

Major anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real-time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.

CONCLUSION

In order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real-time tactile feedback of the occurrence of out-of-field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.

LEVEL OF EVIDENCE

II (Randomized trial) Laryngoscope, 130:S1-S17, 2020.

Application of Universal Design for Learning (UDL) Principles to Surgical Education During the COVID-19 Pandemic

OBJECTIVE

During the COVID-19 pandemic in 2020, we have faced unprecedented challenges in the delivery of surgical education. At the time of writing, changes to the structure and nature of the surgical workforce are occurring rapidly, even daily. Surgical educators are utilizing remote learning solutions, including flipped classroom approaches, online educational materials, telemedicine, and simulations, to continue education for surgical residents despite cancelations of face-to-face instruction. Our objective is to delineate an interdisciplinary strategy, utilizing the principles of Universal Design for Learning (UDL), by which we can optimize learning during this pandemic.

DESIGN

This perspective describes the UDL framework which can be used to situate solutions to issues with delivery of surgical education during this pandemic within the broader view of strategic inclusive instructional design to meet diverse learning needs..

CONCLUSION

The principles of UDL can inform curricular and pedagogical changes in surgical education that may be employed during a time of social distancing, isolation, and quarantine. UDL involves planning flexibility into curricular design from the outset, recognizing that learners are varied in their learning preferences and capabilities, motivational characteristics, and environmental constraints. Viewing the design of remote learning opportunities through the UDL lens aims to remove barriers to learning during this pandemic by targeting three areas: expansion of the means that information is communicated, ways that learners are supported and motivated, and approaches to assessing learning through available distance learning technologies.

VIDA-Nursing v1.0: immersive virtual reality in vacuum blood collection among adults

OBJECTIVE

to develop and validate the first immersive virtual reality simulation addressing vacuum blood collection in adult patients - VIDA-Nursing v1.0.

METHOD

methodological study to validate 14 steps of the vacuum blood collection procedure in adults, designed to develop the immersive virtual reality simulator VIDA-Nursing v1.0. It was assessed by 15 health workers and 15 nursing undergraduate students in terms of visual, interactive, movement simulation reality, teaching and user-friendly aspects.

RESULTS

the workers considered 79.6% of the items to be valid, while the students considered 66.7% of the items valid; most of the demands can be implemented in the system by improving future versions.

CONCLUSION

the simulator was considered a promising and innovative tool to teach vacuum blood collection in adults as it can be combined with other resources currently used to introduce this topic and technique in the education of undergraduate nursing students.

Simulation Training in Urology: State of the Art and Future Directions

There has been a major shift from the old paradigm of 'see one, do one, teach one' in medical training due in large part to resident work-hour restrictions and required oversight in the operating room. In response to this, advancements in technology have allowed for the introduction of more objective measures to assess the skill competency and proficiency of surgical trainees. Patient safety and trainee well-being are important drivers for this new model, and so surgical training programs are adopting simulation into their curriculum. Urology is uniquely positioned at the forefront of new emerging technologies in surgery, because of the field's commitment to safe and efficient minimally invasive surgery and endourological procedures. Due to these technically challenging procedures, urological training must incorporate these educational technologies to allow for objective skills assessment, skills transfer, and ultimately providing optimal patient care with the production of proficient and competent urological trainees.

Cost, training and simulation models for robotic-assisted surgery in pediatric urology

INTRODUCTION

Laparoscopic procedures in pediatric urology have been shown to be safe and effective over the last number of years. Coupled with this is the technological trend to provide minimally invasive options for even the most complex pediatric patients. Whilst robotic platforms continue to try to demonstrate superior patient outcomes in adults with mixed results, the utilization of robotic platforms for pediatric urology is increasing.

METHODS

A review of the current literature was undertaken to assess the evidence for training models and cost-effectiveness of robotic-assisted pediatric urology.

CONCLUSIONS

A growing body of evidence in this field has demonstrated that robotic platforms are safe and effective in children and can provide additional reconstructive benefits due to motion scaling, magnification, stereoscopic views, instrument dexterity and tremor reduction. The main drawbacks remain the financial implications associated with this platform through purchase, maintenance, and disposable costs. This review addresses some of the addresses issues pertaining to cost, training and simulation for robotic-assisted surgery in pediatric urology.

A Pilot Study on Oocyte Retrieval Simulator: A New Tool for Training?

This prospective study was aimed at assessing the usefulness of a box simulator in oocyte pick-up and at establishing whether it could be an appropriate training tool for egg retrieval. Forty-four clinicians, divided in two groups on the grounds of the previous experience (Novices and Experts), participated to two training sessions with a pick-up simulator. Data concerning the mean number of follicles correctly aspired (%OK med), the average time needed to correctly aspirate one follicle (t foll med) and the ratio between the two afore-mentioned parameters (%OK med/t foll med) were collected. At the end of the two sessions all participants completed a questionnaire aimed at assessing the performance of the simulator in terms of realism and acceptability for use. A significant improvement in efficiency (mean number of follicles correctly aspired, 82% versus 75%), speed (mean time needed to aspirate one follicle, 21 versus 28 s) and accuracy (mean percentage of follicles correctly aspirated in one minute, 2.53% versus 1.86%) was noted in the total sample. The performance accuracy was significantly increased in both groups (2.34% versus 1.83% for Novices and 2.50% versus 2.06%, for Experts). Speed was significantly improved in the Novices' group. Simulator-based training has been shown to be effective and useful and it should be considered in training programs.

[Methods for training of robot-assisted radical prostatectomy]

Robotic surgery is a future method of minimal invasive surgery. Robot-assisted radical prostatectomy (RARP) is a common method of surgical treatment of prostate cancer. Due to significant differences of the surgical technique of RARP compared to open or laparoscopic radical prostatectomy (LRP) new methods of training are needed. At the moment there are many opinions how to train physicians best. Which model is the most effective one remains nowadays controversial.

OBJECTIVE

Analyze currently available data of training methods of RARP. Determine the most effective training model and evaluate its advantages and disadvantages. Establish a standardized plan and criteria for proper training and certification of the entire surgical team.

MATERIAL AND METHODS

Literature review based on PubMed database, Web of Science and Scopus by keywords: robot-assisted radical prostatectomy, training of robot-assisted prostatectomy, training in robot-assisted operations, a learning curve of robot-assisted prostatectomy, virtual reality simulators (VR-simulators) in surgery.

RESULTS

According to the literature in average 18 to 45 procedures are required for a surgeon to achieve the plateau of the learning curve of the RARP. Parallel training, pre-operative warm-up and the use of virtual reality simulators (VR-simulators) can significantly increase the learning curve. There are many described models of RARP training.

CONCLUSIONS

The absence of accepted criteria of evaluation of the learning curve does not allow to use this parameter as a guide for the surgeon's experience. Proper training of robotic surgeons is necessary and requires new methods of training. There are different types of training programs. In our opinion the most effective training program is when a surgeon observes the performance of tasks or any steps of operation on the VR-simulator, then he performs them and analyzes mistakes by video recording. Then the surgeon observes real operations and performs some steps of the operation which are already leant on the simulator under supervision of the mentor and analyzes mistakes by video recording. Thus, mastering first the simple stages under supervision of a mentor, the surgeon effectively adopts the surgical experience from him. It is necessary to train not only the surgeons but also the entire surgical team.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure

BACKGROUND

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum.

METHODS

Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method.

RESULTS

The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives).

CONCLUSION

Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

The role of simulation and warm-up in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

The purpose of the review is to update the reader on the current literature and recent studies evaluating the role of simulation and warm-up as part of surgical education and training, and maintenance of surgical skills.

RECENT FINDINGS

Laparoscopic and hysteroscopic simulation may improve psychomotor skills, particularly for early-stage learners. However, data are mixed as to whether simulation education is directly transferable to surgical skill. Data are insufficient to determine if simulation can improve clinical outcomes. Similarly, performance of surgical warm-up exercises can improve performance of novice and expert surgeons in a simulated environment, but the extent to which this is transferable to intraoperative performance is unknown. Surgical coaching, however, can facilitate improvements in performance that are directly reflected in operative outcomes.

SUMMARY

Simulation-based curricula may be a useful adjunct to residency training, whereas warm-up and surgical coaching may allow for maintenance of skill throughout a surgeon's career. These experiences may represent a strategy for maintaining quality and value in a lower volume surgical setting.

Implementing assessments of robot-assisted technical skill in urological education: a systematic review and synthesis of the validity evidence

OBJECTIVES

To systematically review and synthesise the validity evidence supporting intraoperative and simulation-based assessments of technical skill in urological robot-assisted surgery (RAS), and make evidence-based recommendations for the implementation of these assessments in urological training.

MATERIALS AND METHODS

A literature search of the Medline, PsycINFO and Embase databases was performed. Articles using technical skill and simulation-based assessments in RAS were abstracted. Only studies involving urology trainees or faculty were included in the final analysis.

RESULTS

Multiple tools for the assessment of technical robotic skill have been published, with mixed sources of validity evidence to support their use. These evaluations have been used in both the ex vivo and in vivo settings. Performance evaluations range from global rating scales to psychometrics, and assessments are carried out through automation, expert analysts, and crowdsourcing.

CONCLUSION

There have been rapid expansions in approaches to RAS technical skills assessment, both in simulated and clinical settings. Alternative approaches to assessment in RAS, such as crowdsourcing and psychometrics, remain under investigation. Evidence to support the use of these metrics in high-stakes decisions is likely insufficient at present.

Training in Robotic Surgery-an Overview

PURPOSE OF REVIEW

There has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon.

RECENT FINDINGS

A structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice. Robotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.

Influence of videogames and musical instruments on performances at a simulator for robotic surgery

OBJECTIVE

To assess if exposure to videogames, musical instrument playing, or both influence the psychomotor skills level, assessed by a virtual reality simulator for robot-assisted surgery (RAS).

MATERIALS AND METHODS

A cohort of 57 medical students were recruited: playing musical instruments (group 1), videogames (group 2), both (group 3), and no activity (group 4); all students executed four exercises on a virtual simulator for RAS.

RESULTS

Subjects from group 3 achieved the best performances on overall score: 527.09 ± 130.54 vs. 493.73 ± 108.88 (group 2), 472.72 ± 85.31 (group 1), and 403.13 ± 99.83 (group 4). Statistically significant differences (p < .05) between group 3 and group 4 were found for overall score (p = .009) and for time of completion (p = .044). As regards experience with the piano, subjects from group 3 outperformed those from group 1 on overall score (496.98 ± 122.71 vs. 470.25 ± 92.31), but without statistically significant difference (p = .646).

CONCLUSIONS

The present study suggests that the level of psychomotor skills in subjects exposed to both musical instrument playing and videogames is higher than that in those practicing either one alone. The effect of videogames appears negligible in individuals playing the piano.

A systematic examination of preoperative surgery warm-up routines

BACKGROUND

Recent evidence indicates that a preoperative warm-up is a potentially useful tool in facilitating performance. But what factors drive such improvements and how should a warm-up be implemented?

METHODS

In order to address these issues, we adopted a two-pronged approach: (1) we conducted a systematic review of the literature to identify existing studies utilising preoperative simulation techniques; (2) we performed task analysis to identify the constituent parts of effective warm-ups. We identified five randomised control trials, four randomised cross-over trials and four case series. The majority of these studies reviewed surgical performance following preoperative simulation relative to performance without simulation.

RESULTS

Four studies reported outcome measures in real patients and the remainder reported simulated outcome measures. All but one of the studies found that preoperative simulation improves operative outcomes-but this improvement was not found across all measured parameters. While the reviewed studies had a number of methodological issues, the global data indicate that preoperative simulation has substantial potential to improve surgical performance. Analysis of the task characteristics of successful interventions indicated that the majority of these studies employed warm-ups that focused on the visual motor elements of surgery. However, there was no theoretical or empirical basis to inform the design of the intervention in any of these studies.

CONCLUSIONS

There is an urgent need for a more rigorous approach to the development of "warm-up" routines if the potential value of preoperative simulation is to be understood and realised. We propose that such interventions need to be grounded in theory and empirical evidence on human motor performance.

Effect of Rehearsal Modality on Knowledge Retention in Surgical Trainees: A Pilot Study

OBJECTIVE

The operating room is an exciting learning environment. With growing curriculum limitations and increasing complexity of care, existing education opportunities need to be optimized. Rehearsal has benefits for surgeon performance in the operating room, but its role for enhancing operative learning remains unclear. This pilot study aimed to differentiate the effects of physical rehearsal (PR) and cognitive rehearsal (CR) modalities on surgical trainee technical knowledge retention.

DESIGN

Participants took part in a 2-day (sequential Fridays), instructed operative workshop performing midline laparotomy, splenectomy, left nephrectomy, and hand-sewn, side-to-side small bowel anastomosis (SBA). Participants were randomized to 10 minutes of either a (PR; n = 5) or (CR; n = 5) activity each day before operating. PR consisted of practicing SBA on a felt bowel model. CR entailed viewing narrated operative footage detailing the steps of SBA. Participants' technical knowledge of all procedures was assessed at 1 and 12 weeks postworkshop using a 31-question test.

SETTING

Animal operative suites at an academic medical center.

PARTICIPANTS

A total of 10 general surgery postgraduate year 1 interns participated in the workshop; all completed the study. Participants had similar levels of operative exposure at the time of study participation.

RESULTS

At 1-week postworkshop, mean assessment scores for CR were higher than PR (Mean ± Standard Deviation) (CR = 24.7 ± 1.6 vs. PR = 21.8 ± 1.7, p = 0.02). After 12 weeks, there was no difference in mean scores (CR = 23.3 ± 2 vs. PR = 21.7 ± 1.8, p = 0.22). Knowledge decay for the 12-week period was similar between groups (CR = -1.4 ± 1.6 vs. PR = -0.1 ± 2.4, p = 0.36). Study participants performed better on SBA-related questions than unrelated questions (laparotomy, splenectomy, and nephrectomy) at 1-week (related = 81.5% ± 11.3 vs. unrelated = 71.9% ± 6.6, p = 0.03) and 12 weeks (related = 81% ± 13.1 vs. unrelated = 68.6% ± 8.8, p = 0.02).

CONCLUSION

This pilot data suggests the modality of the rehearsal activity may not significantly effect surgical learners' technical knowledge retention. Participants did score higher on questions related to the rehearsal topic, indicating a potential supplementary role for rehearsal activities.

Simulation as a set-up for technical proficiency: can a virtual warm-up improve live fibre-optic intubation?

BACKGROUND

Fibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual 'warm-up' has been used to prime a practitioner's skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents.

METHODS

Clinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents.

RESULTS

Thirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 (SD 3.2) s vs. 57 (SD 3.2) s, P<0.0002) and a 26% decrease for CA2s (mean 23 (SD 1.7) s vs. 31 (SD 1.7) s, P=0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 (SD 1.2) vs. 37.6 (SD 1.2), P=0.0079) and 5.1 points for CA2s (37.7 (SD 1.1) vs. 42.8 (SD 1.1), P=0.0125). Crossover period and sequence did not show a statistically significant association with performance.

CONCLUSIONS

Virtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills.

Learning Curve of Robotic-Assisted Anastomosis: Shorter than the Laparoscopic Technique? An Educational Study

BACKGROUND

Achieving aortic anastomosis in laparoscopic surgery remains a technical challenge. The Da Vinci robot could theoretically counteract this issue by minimizing the technical challenge. The aim of this study was to compare the learning curves of performing vascular anastomoses by trainees without any experience using purely laparoscopic versus robotic-assisted techniques.

METHODS

Surgery residents were randomly included in the laparoscopic group (group A, n = 3) and the robotic group (group B, n = 3). They performed 10 end-to-end anastomoses on 18-mm-diameter tubular expanded polytetrafluoroethylene grafts. The parameters recorded were duration to complete the anastomosis and an indirect sealing quality evaluation (ISQE) defined as the following ratio: number of stitches with a distance of less than 4 mm/total number of stitches.

RESULTS

The mean duration to perform the anastomosis decreased from 2340 s (±64) for the first anastomosis to 651 s (±248) for the last in group A (P < 0.05) and from 1989 s (±556) to 801 s (±120) in group B (P < 0.05). The mean ISQE increased from 74% (±18) for the first anastomosis to 98% (±3) for the last in group A (P < 0.05) and decreased from 100% to 98% (±2) in group B (nonsignificant). The mean duration to perform the first anastomosis was lower in group B than in group A (P < 0.05). The mean duration to perform the last anastomosis was not significantly different between the groups. Sealing tended to be better in group B for the first anastomosis compared with group A.

CONCLUSIONS

Minimally invasive laparoscopic technique training demonstrates a learning curve to perform vascular anastomoses. The robotic-assisted technique tended to improve suturing skills and should be considered as a valuable tool to reduce the technical learning curve.

The Surgical Skill of a Novice Trainee Manifests in Time-Consuming Exercises of a Virtual Simulator Rather Than a Quick-Finishing Counterpart: A Concurrent Validity Study Using an Urethrovesical Anastomosis Model

OBJECTIVE

The purpose of this study is to determine an optimal training curriculum using a robotic virtual simulator (RVS) that enables unexperienced trainees to perform a complex task in a hands-on setting.

PATIENTS AND METHODS

This study was conducted in 2 phases. In the RVS phase, 43 participants sequentially completed 12 exercises consistent with all primary exercises in the EndoWrist manipulation and advanced needle-driving category, until the overall score reached more than 80% by repeated practice. In the hands-on phase using a robotic surgical system, 10 randomly selected trainees performed 8 sutures once, simulating urethrovesical anastomosis, and the console time was recorded.

RESULTS

The median total time and total attempts for the RVS phase was 195.2 minutes and 54 times, respectively. The trainees were divided by median total time, and times to accomplish each RVS exercise were then compared between the early- and the late-completion groups; among 12 exercises trained, 6 exercises (prolonged course) requiring significantly more time in the late-completion group were identified. The prolonged course occupied 88.18% of the total time and 77.61% of the total attempts. For participants the in hands-on phase, a multiple linear regression model showed that the time to accomplish the prolonged course was a single independent predictor of the console time (R(2) = 0.524, B = 0.05; p = 0.018).

CONCLUSION

After establishment of a high standard cutoff score, the time spent for the prolonged course showed a significant association with console time in hands-on training simulating urethrovesical anastomosis, implying educational efficacy of training involving time-consuming exercise in performance of a complex task.