Virtual reality simulators: current status in acquisition and assessment of surgical skills

Changing perspectives: enhancing learning efficacy with the after-action review in virtual reality training for police

The After-Action Review (AAR) in Virtual Reality (VR) training for police provides new opportunities to enhance learning. We investigated whether perspectives (bird's eye & police officer, bird's eye & suspect, bird's eye) and line of fire displayed in the AAR impacted the officers' learning efficacy. A 3 x 2 ANOVA revealed a significant main effect of AAR perspectives. Post hoc pairwise comparisons showed that using a bird's eye view in combination with the suspect perspective elicits significantly greater learning efficacy compared to using a bird's eye view alone. Using the line of fire feature did not influence learning efficacy. Our findings show that the use of the suspect perspective during the AAR in VR training can support the learning efficacy of police officers.Practitioner summary: VR systems possess After-Action Review tools that provide objective performance feedback. This study found that reviewing a VR police training scenario from the bird's eye view in combination with the suspect perspective enhanced police officers' learning efficacy. Designing and applying the After-Action Review effectively can improve learning efficacy in VR.

Remote surgical education using synthetic models combined with an augmented reality headset

Objective

The objective was to investigate the use of an augmented reality headset to remotely train clinicians on medical devices using anatomic models.

Design

Disease-specific phantoms were developed to train physicians in mpMRI-guided fusion prostate biopsy, brachytherapy, and rectal spacer insertion. Training was remotely demonstrated using 1-way virtual video conferencing format. Participants responded to an educational content survey. A heads-up display with software and augmented reality was used for remote 2-way training with the proctor and student using on their own phantoms.

Setting

The virtual video meeting took place during a prostate cancer conference in 2020, while the augmented reality training occurred in 2021. The proctor and student wore a heads-up display containing a projector and webcam where the ultrasound image was displayed onto a see-through optic along with the physician's hands. The heads-up display allowed the proctor to teach by line-of-sight while the student watched and repeated the steps.

Participants

Faculty with expertise with the medical devices used in these procedures provided training to urologists unfamiliar with these techniques.

Results

Participants responded that the 1-way training on the phantoms was realistic and mimicked human tissue. A total of 70.9% requested more training or training on the phantoms. The remote training platform was successfully beta tested at the 2 locations in transperineal prostate biopsy and rectal spacer insertion.

Conclusion

Remote training using augmented reality eliminates the need for travel. For training programs and workshops, this technology may mitigate the risk of infectious exposures, reduce training cost, and increase proctor availability, allowing training from their own institution or clinic.

This investigation qualifies for the Accreditation Council for Graduate Medical Education competency in medical knowledge.

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Disease and medical device specific simulation phantoms improve surgeons' skills.

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Hands-on training using phantoms can be accomplished with both instructor and student at different locations.

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A dedicated headset containing display optics and a webcam allows “line-of sight” instruction.

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Broadcasting of proctor to student and student to proctor content is optimized with specialized telecasting software which organizes the video feeds vertically.

Are multiple views superior to a single view when teaching hip surgery? A single-blinded randomized controlled trial of technical skill acquisition

Purpose

Surgical education videos currently all use a single point of view (POV) with the trainee locked onto a fixed viewpoint, which may not deliver sufficient information for complex procedures. We developed a novel multiple POV video system and evaluated its training outcome compared with traditional single POV.

Methods

We filmed a hip resurfacing procedure performed by an expert attending using 8 cameras in theatre. 30 medical students were randomly and equally allocated to learn the procedure using the multiple POV (experiment group [EG]) versus single POV system (control group [CG]). Participants advanced a pin into the femoral head as demonstrated in the video. We measured the drilling trajectories and compared it with pre-operative plan to evaluate distance of the pin insertion and angular deviations. Two orthopedic attendings expertly evaluated the participants’ performance using a modified global rating scale (GRS). There was a pre-video knowledge test that was repeated post-simulation alongside a Likert-scale questionnaire.

Results

The angular deviation of the pin in EG was significantly less by 29% compared to CG (p = 0.037), with no significant difference in the entry point’s distance between groups (p = 0.204). The GRS scores for EG were 3.5% higher than CG (p = 0.046). There was a 32% higher overall knowledge test score (p<0.001) and 21% improved Likert-scale questionnaire score (p = 0.002) after video-learning in EG than CG, albeit no significant difference in the knowledge test score before video-learning (p = 0.721).

Conclusion

The novel multiple POV provided significant objective and subjective advantages over single POV for acquisition of technical skills in hip surgery.

Basic skin surgery interactive simulation: system description and randomised educational trial

Background

Learning the skills required for open surgery is essential for trainee progression towards more advanced technical procedures. Simulation supports skill enhancement at a time when exposure to actual surgical procedures and traditional apprentice-based teaching has declined. The proliferation of smartphone and tablet devices with rich, touch sensitive displays and increasing processing power makes a compelling argument for expanding accessibility further by development of mobile virtual simulations for training on demand in any setting, at any time.

We present a tablet-based mobile simulation App for educating surgical trainees in the planning and surgical procedures involved in facial lesion resection and local skin flap surgery.

Methods

Novel algorithms were developed and modules included in a mobile simulation App to teach concepts required for three defect reconstruction techniques: elliptical closure, bilateral advancement (H flap) and the semi-circular rotation flap, with additional resources such as videos and formal guidelines made available at relevant points in the simulation. A randomised educational trial was conducted using the mobile simulation App with 18 medical students that were divided equally into two groups: the intervention group learning using the new mobile simulation App, and a control group, undergoing traditional text-based self-study. The students were then assessed on knowledge and skills’ acquisition through an MCQ and a task analysis score.

Results

There was a statistically significant difference between the scores of students in the intervention group and the students in the non-intervention group in both forms of assessment, with an average multiple-choice assessment score of 62.95% points versus 56.73%, respectively (p = 0.0285), and an average task analysis score of 3.53 versus 2.58, respectively (p = 0.0139).

Conclusions

Touch-based simulation provided an efficient and superior method of learning three different local flap techniques for facial soft tissue reconstruction, and helped recalling steps involved in the surgery in a fluid manner that also improved task performance.

An advanced simulator for orthopedic surgical training

PURPOSE

The purpose of creating the virtual reality (VR) simulator is to facilitate and supplement the training opportunities provided to orthopedic residents. The use of VR simulators has increased rapidly in the field of medical surgery for training purposes. This paper discusses the creation of the virtual surgical environment (VSE) for training residents in an orthopedic surgical process called less invasive stabilization system (LISS) surgery which is used to address fractures of the femur.

METHOD

The overall methodology included first obtaining an understanding of the LISS plating process through interactions with expert orthopedic surgeons and developing the information centric models. The information centric models provided a structured basis to design and build the simulator. Subsequently, the haptic-based simulator was built. Finally, the learning assessments were conducted in a medical school.

RESULTS

The results from the learning assessments confirm the effectiveness of the VSE for teaching medical residents and students. The scope of the assessment was to ensure (1) the correctness and (2) the usefulness of the VSE. Out of 37 residents/students who participated in the test, 32 showed improvements in their understanding of the LISS plating surgical process. A majority of participants were satisfied with the use of teaching Avatars and haptic technology. A paired t test was conducted to test the statistical significance of the assessment data which showed that the data were statistically significant.

CONCLUSION

This paper demonstrates the usefulness of adopting information centric modeling approach in the design and development of the simulator. The assessment results underscore the potential of using VR-based simulators in medical education especially in orthopedic surgery.

Virtual reality-based simulators for spine surgery: a systematic review

BACKGROUND CONTEXT

Virtual reality (VR)-based simulators offer numerous benefits and are very useful in assessing and training surgical skills. Virtual reality-based simulators are standard in some surgical subspecialties, but their actual use in spinal surgery remains unclear. Currently, only technical reviews of VR-based simulators are available for spinal surgery.

PURPOSE

Thus, we performed a systematic review that examined the existing research on VR-based simulators in spinal procedures. We also assessed the quality of current studies evaluating VR-based training in spinal surgery. Moreover, we wanted to provide a guide for future studies evaluating VR-based simulators in this field.

STUDY DESIGN AND SETTING

This is a systematic review of the current scientific literature regarding VR-based simulation in spinal surgery.

METHODS

Five data sources were systematically searched to identify relevant peer-reviewed articles regarding virtual, mixed, or augmented reality-based simulators in spinal surgery. A qualitative data synthesis was performed with particular attention to evaluation approaches and outcomes. Additionally, all included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool.

RESULTS

The initial review identified 476 abstracts and 63 full texts were then assessed by two reviewers. Finally, 19 studies that examined simulators for the following procedures were selected: pedicle screw placement, vertebroplasty, posterior cervical laminectomy and foraminotomy, lumbar puncture, facet joint injection, and spinal needle insertion and placement. These studies had a low-to-medium methodological quality with a MERSQI mean score of 11.47 out of 18 (standard deviation=1.81).

CONCLUSIONS

This review described the current state and applications of VR-based simulator training and assessment approaches in spinal procedures. Limitations, strengths, and future advancements of VR-based simulators for training and assessment in spinal surgery were explored. Higher-quality studies with patient-related outcome measures are needed. To establish further adaptation of VR-based simulators in spinal surgery, future evaluations need to improve the study quality, apply long-term study designs, and examine non-technical skills, as well as multidisciplinary team training.

The role and validity of surgical simulation

In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time.

An Analysis of Skills Acquisition During a Training Program for Experienced Laparoscopists in Laparoendoscopic Single-Site Surgery

Background. Laparoendoscopic single-site surgery has been presented in the past few years as an innovative minimally invasive approach, one which despite its advantages is also challenging and requires specific training. We propose to analyze the performance of attendants in a specific LESS training course. Methods. Following the LESSCAR 2010 guidelines, we focused on level 1 hands-on simulator tasks and level 2 hands-on training on animal model for skills acquisition during a LESS-specific training course. Each attendant completed coordination and cut tasks on simulator, followed by a cholecystectomy on an ex vivo porcine liver. Hands-on animal model each trainee performed 1 cholecystectomy and at least 2 nephrectomies (N1, N2). Performance was analyzed through video recording and reviewed by 3 independent observers. Each result was registered according to a modified objective structured assessment of technical skills. Total task or procedure completion time was also determined. Results. Regarding coordination and cut tasks, attendants improved on their performance from first to third attempts with an accompanying decrease in completion time. Surgeons completed the cholecystectomy on animal model significantly faster than on simulator, although with lower performance quality. Regarding N1 and N2, attendants showed improvement both in quality and total completion time. Conclusions. A gradual and positive evolution of attendants was observed throughout the training course. Thus, we believe a structured program for the acquisition of basic skills in new minimally invasive surgical approaches should be recommended. Considering that this is a small study, it would be advisable to increase the number of study subjects on future opportunities.

Simulation in Neurosurgery: A Survey of Experiences and Perceptions in the UK

The traditional, time-intensive apprenticeship model of surgical skill acquisition has become impracticable in the current era of working hour restrictions that limit the total hours available for surgical training.1–3 Trainees feel 'hands on' operative exposure has been reduced, having an impact on training as well as patient safety.4 while working hour restrictions persist, simply increasing the length of surgical training will not adequately overcome reduced exposure to operative training. Improving quality and efficiency of training must therefore utilise learning outside the operating theatre; simulation training could form part of this.

The Role of Simulation in the Learning of Surgical Skills

Many authors have published theories regarding the learning of practical (surgical) skills. Table 1 contains a useful summary of these theories. Simulation has been defined by Allery et al as 'a structured activity designed to reflect reality, real life and real situations',1 and good simulation has been defined by Gorman et al as 'represent [ing] simplified reality, free from the need to include every possible detail'.2 when discussing simulation in education, issenberg, et al stated: 'Simulations are not identical to real-life events. Instead simulations place trainees into lifelike situations that provide immediate feedback about questions, decisions and actions.'3

Simulators in surgery

The introduction of minimally invasive surgery has demonstrated the need for training surgical skills outside the operating room using animal models or simulators. As laparoscopic surgery involves displaying images on a screen, virtual reality simulation of the surgical tasks is feasible. Different types of simulators have become available. The existing trainers can be divided into three groups: mechanical, hybrid, and virtual reality. This article aims at giving an overview of the different simulators available and the potential of simulators in the education of surgeons with focus on virtual reality simulators. All simulators aim at training psychomotoric skills and some simulators also allow training in decision-making and anatomical orientation. In the future virtual reality simulators may become a tool for training and validation of surgical skills and monitoring the training progress.

Training surgical residents: the current Canadian perspective

BACKGROUND

Numerous constraints may limit the practical experience of surgical residents. Current research supports a need for structured curricula, skills acquisition, and feedback outside the operating room (OR) and formal assessment of technical skills. We examined the current state of surgical skill teaching and evaluation for Canadian residents across surgical specialties.

METHODS

One hundred twenty-three surveys were mailed to surgical residency program directors of all 17 Canadian medical schools. Nine surgical specialties were identified. Program demographics, details of surgical skill teaching methods, and several surgical skill assessment modalities used from admission to graduation were surveyed. Obstetrics and Gynecology (ObGyn) survey results were compared with other surgical specialties.

RESULTS

Seventy surveys (57%) from 15 medical schools (88%) were returned. All specialties were represented in responses. ObGyn residents had fewer surgical training months per year than other residents (4.9 versus 8.5 months; p = 0.001). The most common teaching method was didactic lectures (86%; 95% confidence interval [CI], 75%-93%) for all programs. Inanimate and/or animate skills laboratories and didactic lectures were equally used by 90% (95% CI, 55%-100%) of ObGyn programs. Virtual reality simulators for procedure-specific surgical skills ranked low at 30% (95% CI, 7%-65%) use in ObGyn programs. Most programs had a dedicated space to teach and practice skills outside the OR. Assessment, feedback, and determination of surgical competence were most commonly performed via subjective evaluation by surgical mentors. Forty percent of ObGyn programs versus 76% of other programs used a local program-specific surgical training curriculum (p = 0.054). Most program directors who did not have access to a standard training curriculum wished to have one implemented.

CONCLUSIONS

Lectures and subjective evaluations are the most common educational tools in Canadian surgical residencies. Despite the availability of validated surgical teaching and evaluation tools remote from the OR, standard training curricula are not the norm in Canadian ObGyn residency programs.

A novel approach for augmenting percutaneous endoscopic gastrostomy tube placement training

INTRODUCTION

Surgical trainees routinely participate in percutaneous endoscopic gastrostomy (PEG) tube placement. Although simulation has gained widespread acceptance, novice trainees continue learning this procedure on real patients. We designed a novel hands-on training model for practicing PEG tube placement with minimal monetary investment (cost<$10).

METHODS

Our portable low-fidelity bench model has a simulated upper gastrointestinal construct made of foam. Seventeen trainees used our model to acquire and practice skills necessary to perform PEG tube placement, for setting up and troubleshooting upper gastrointestinal endoscope, and for using endoscopic instruments in the state-of-the-art simulated operative room. Thirteen trainees completed the course evaluation, using a 5-point Likert scale (5=strongly agree).

RESULTS

The training resulted in a self-reported increase in equipment familiarity (4.23±0.73) and troubleshooting real endoscope (4.69±0.48), and trainees felt better prepared (4.23±0.93) for performing PEG tube placement on real patients. Trainees agreed that this exercise has more educational value than using virtual reality simulator alone (4.38±0.52).

CONCLUSIONS

Procedural training for PEG tube placement using a simple bench training model is perceived as valuable by trainees. Cost and commercial availability can be overcome by innovation in surgical simulation.

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

BACKGROUND

Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.

METHODS

A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education.

RESULTS

The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.

CONCLUSIONS

In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.

Quantitative electroencephalographic (qEEG) correlates of craving during virtual reality therapy in alcohol-dependent patients

Virtual reality (VR) is an evolving technology that is being applied to treat a wide range of medical and psychiatric diseases. A virtual reality therapy (VRT) with multisensory stimulation has been applied to patients with alcohol dependence (ADP). We hypothesized that the VRTP for alcohol dependence would reduce the craving for alcohol and increase alpha wave activity in frontal areas of individuals with ADP. Twenty ADP and eighteen ADP were exposed to a series of 10 VRTP sessions (VRTP-ADP) and cognitive behavioral therapy (nVRTP-ADP), respectively. Fifteen healthy controls were exposed to VRTP for comparing the changes of craving and EEG during all three phases of VRTP. The VRTP-ADP exhibited a greater decrease in craving after the 10th VRTP session, when compared to the nVRTP-ADP. Compared to the healthy control subjects, VRTP-ADP group showed higher magnitude of the change in craving throughout VRTP sessions. These results suggest that VRTP may be useful as an adjunct to treating alcohol dependence but may also serve as an evaluation tool to identify high-risk patients.

The use of "war games" to enhance high-risk clinical decision-making in students and residents

BACKGROUND

Initial studies found that residents and students performed poorly in simple clinical scenarios. We hypothesized that repeated simulations in the "war games" format would improve performance.

METHODS

Participants included medical students and residents on the trauma and surgical intensive care unit (SICU) services. Subjects were given a nursing report of an unstable patient and asked to verbalize management of the situation. Responses were transcribed and graded.

RESULTS

Eighty subjects and 5 experts participated in 227 simulations. Naive medical students, postgraduate year (PGY)-1, and PGY-2+ subjects performed worse than experts (P <.05). After participation in >/=3 war games sessions, trainees' scores were similar to experts. Subjects with the least amount of clinical experience demonstrated the most improvement.

DISCUSSION

We have designed an educational system that rapidly enhances the cognitive performance of students and residents. This may represent an important tool in assessing and enhancing the competencies of medical trainees in a safe environment.

Learning the surgical craft: a review of skills training options

Surgical practice is undergoing fundamental changes, and this is having a significant effect on the training of surgeons. Learning the craft of surgery is threatened by reduced elective operative exposure and general service cuts within public teaching hospitals, safer working hour legislation and pressures to accelerate the training of young surgeons. Rapid technological changes mean that 'old dogs' have to teach 'young dogs' many new tricks in a relatively adverse environment. This review outlines the great variety of resources available for skills-based training outside the operating room. These resources are ready to be used as a necessary adjunct to the training of competent surgeons in Australasia.

Systems for tracking minimally invasive surgical instruments

Minimally invasive surgery (e.g. laparoscopy) requires special surgical skills, which should be objectively assessed. Several studies have shown that motion analysis is a valuable assessment tool of basic surgical skills in laparoscopy. However, to use motion analysis as the assessment tool, it is necessary to track and record the motions of laparoscopic instruments. This article describes the state of the art in research on tracking systems for laparoscopy. It gives an overview on existing systems, on how these systems work, their advantages, and their shortcomings. Although various approaches have been used, none of the tracking systems to date comes out as clearly superior. A great number of systems can be used in training environment only, most systems do not allow the use of real laparoscopic instruments, and only a small number of systems provide force feedback.

Continuing medical education: AMEE Education Guide No 35

This guide is designed to provide a foundation for developing effective continuing medical education (CME) for practicing physicians. For the purposes of this work, continuing medical education is defined as any activity which serves to maintain, develop, or increase the knowledge, skills and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession (American Medical Association 2007; Accreditation Council for CME 2007). The term continuing professional development (CPD) is broader and has become more popular in many areas of the world. As defined by Stanton and Grant, CPD includes educational methods beyond the didactic, embodies concepts of self-directed learning and personal development and considers organizational and systemic factors (Stanton & Grant 1997). In fact, this guide describes many modalities that may be defined as CME or CPD. In the interest of simplicity, we will use the term continuing medical education (CME) throughout, with the understanding that the same strategies may be applied to non-clinical continuing professional education. For those who do not work exclusively in CME, many terms and processes may be unfamiliar. This guide is intended to provide a broad overview of the discipline of CME as well as a pragmatic approach to the practice of CME. The format provides an overview of CME including history and rationale for the discipline, followed by a practical approach to developing CME activities, the management of the overall CME programme and finally, future trends. At the end of the guide you will find resources including readings, websites and professional associations to assist in the development and management of CME programmes.

Correlating virtual reality and box trainer tasks in the assessment of laparoscopic surgical skills

OBJECTIVE

The purpose of this study was to examine the correlation in the assessment of laparoscopic surgical skills in medical students with the use of a virtual reality laparoscopic trainer and a low-fidelity video box trainer with comparative tasks.

STUDY DESIGN

Third-year medical students were asked to perform 3 basic skills set modules on LapSim (Surgical Science, Gothenburg, Sweden): coordination, grasping and lifting, and handling the intestines. Each task was set at the easiest level, and each student was allowed a maximum of 10 attempts to complete each task. Similar-appearing tasks were chosen for comparison with the use of a standard video box trainer: pegboard, cup drop and rope pass, respectively. Laparoscopic skills were evaluated with the use of both trainers during 1 session. Pearson's correlation coefficients were used to compare paired data on each student using statistical software.

RESULTS

Forty-seven of 65 medical students were assigned to clinical clerkships on-campus at Temple University School of Medicine participated in the study. All 47 students participated in the video box trainer tasks; 34 students completed both the video box trainer and LapSim skills set. Observations that were obtained on the LapSim virtual reality system and video box trainer simulator demonstrated several correlations. The time to completion for the LapSim coordination task and the pegboard task were correlated (r = 0.507; P = .006), as were the grasping and lifting task completion time on LapSim and the comparative box trainer cup drop task completion time (r = 0.404; P = .022). When accounting for errors, the LapSim coordination task tissue damage score was correlated with the sum of all box trainer errors (r = 0.353; P = .040); the average grasping and lifting tissue damage was correlated with the total number of errors during all box trainer tasks (r = 0.374; P = .035).

CONCLUSION

Overall, in evaluating laparoscopic skills, the LapSim and video box trainer were correlated positively with one another. The scoring of laparoscopic skills by both systems appears to be equivalent for the measurement of time to task completion and number of errors.

Extent of innate dexterity and ambidexterity across handedness and gender: Implications for training in laparoscopic surgery

BACKGROUND

As innate dexterity is considered one of the important predictors of eventual operative competence, an experimental human factors study was conducted to determine innate dexterity and ambidexterity across handedness and gender.

METHODS

50 medical students (right-handed males, left-handed males, and right-handed females) were recruited as participants in a study designed to assess innate dexterity and degree of ambidexterity for endoscopic manipulations in a validated virtual-reality simulator. All participants performed unilateral and bilateral tasks with both dominant and nondominant hands in random sequence. The outcome measures were execution time, extent of ambidexterity (ambidexterity index), aiming errors, and maximum tissue damage.

RESULTS

Right-handed males exhibited a greater level of ambidexterity than left-handed males (p = 0.02 for path length, p = 0.001 for angular path) and right-handed females (p = 0.01 for path length, p = 0.02 for angular path), and more-efficient task performance as measured by execution time (p = 0.001 for males and p = 0.03 across gender). The task quality when executed by the dominant hand was best in right-handed males (p = 0.001 vs. left-dominant males and p = 0.03 across gender). No significant difference was observed in terms of precision control and fine movements (aiming errors and maximum tissue damage) between the three groups.

CONCLUSIONS

These findings indicate that training surgical curricula in laparoscopic surgery should be more flexible to accommodate the innate differences across handedness and gender.

The use of haptics in medical applications

Explains the need for haptics (feeling of touch) in medical simulation systems. Describes a variety of laparoscopic training systems and other surgical simulators. Highlights the Reachin Technologies AB Application Programming Interface (API) which is a software tool that significantly speeds up the development of surgical simulators.

Porcine Transfer Study: Virtual Reality Simulator Training Compared with Porcine Training in Endovascular Novices

PURPOSE

To compare the learning of endovascular interventional skills by training on pig models versus virtual reality simulators.

METHODS

Twelve endovascular novices participated in a study consisting of a pig laboratory (P-Lab) and a virtual reality laboratory (VR-Lab). Subjects were stratified by experience and randomized into four training groups. Following 1 hr of didactic instruction, all attempted an iliac artery stenosis (IAS) revascularization in both laboratories. Onsite proctors evaluated performances using task-specific checklists and global rating scales, yielding a Total Score. Participants completed two training sessions of 3 hr each, using their group's assigned method (P-Lab x 2, P-Lab + VR-Lab, VR-Lab + P-Lab, or VR-Lab x 2) and were re-evaluated in both laboratories. A panel of two highly experienced interventional radiologists performed assessments from video recordings. ANCOVA analysis of Total Score against years of surgical, interventional radiology (IR) experience and cumulative number of P-Lab or VR-Lab sessions was conducted. Inter-rater reliability (IRR) was determined by comparing proctored scores with the video assessors in only the VR-Lab.

RESULTS

VR-Lab sessions improved the VR-Lab Total Score (beta = 3.029, p = 0.0015) and P-Lab Total Score (beta = 1.814, p = 0.0452). P-Lab sessions increased the P-Lab Total Score (beta = 4.074, p < 0.0001) but had no effect on the VR-Lab Total Score. In the general statistical model, both P-Lab sessions (beta = 2.552, p = 0.0010) and VR-Lab sessions (beta = 2.435, p = 0.0032) significantly improved Total Score. Neither previous surgical experience nor IR experience predicted Total Score. VR-Lab scores were consistently higher than the P-Lab scores (Delta = 6.659, p < 0.0001). VR-Lab IRR was substantial (r = 0.649, p < 0.0008).

CONCLUSIONS

Endovascular skills learned in the virtual environment may be transferable to the real catheterization laboratory as modeled in the P-Lab.

Proactive versus reactive: the effect of experience on performance in a critical care simulator

BACKGROUND

We sought to study the cognitive performance of residents in a critical care patient simulator.

METHODS

Residents in general surgery and emergency medicine were recruited to participate in the study. Subjects were read a morning report and presented with written data for 4 critical care patients. The subjects were evaluated on completing essential clinical tasks, cognitive errors, and directionality of reasoning.

RESULTS

Nine residents completed the study. Months of clinical residency training did not significantly affect performance. Residents with more than 10 weeks of intensive care unit (ICU) experience (EXP) made significantly fewer cognitive errors than those with less than 10 weeks of ICU experience (N-I) (EXP: .75 +/- .96 vs N-I: 7 +/- 5.6 errors per subject, P < .05). An unexpected finding was that EXP performed far more proactive actions than N-I (EXP: 21.8 +/- 9.9/subject vs N-I: 5.7 +/- .6/subjects, P < .01).

CONCLUSIONS

A unique finding was that residents with more than 10 weeks of ICU experience initiated a large number of proactive actions immediately following presentation of patient information, while N-I rarely performed these actions. In addition, residents with this degree of experience committed significantly fewer cognitive errors. These differences might play a role in efficiency, cost, and overall outcome in the care of ICU patients.

The compactEASIE is a feasible training model for endoscopic novices: a prospective randomised trial

BACKGROUND

The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects.

METHODS

Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n=14) and control group (n=13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1=worst, 10=optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003.

RESULTS

We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p<0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques).

CONCLUSION

Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE.

Human adaptation to interaction forces in visuo-motor coordination

We tested whether humans can learn to sense and compensate for interaction forces in contact tasks. Many tasks, such as use of hand tools, involve significant interaction forces between hand and environment. One control strategy would be to use high hand impedance to reduce sensitivity to these forces. But an alternative would be to learn feedback compensation for the extrinsic dynamics and associated interaction forces, with the potential for lower control effort. We observed subjects as they learned control of a ball-and-beam system, a visuo-motor task where the goal was to quickly position a ball rolling atop a rotating beam, through manual rotation of the beam alone. We devised a ball-and-beam apparatus that could be operated in a real mode, where a physical ball was present; or in a virtual training mode, where the ball's dynamics were simulated in real time. The apparatus presented the same visual feedback in all cases, and optionally produced haptic feedback of the interaction forces associated with the ball's motion. Two healthy adult subject groups, vision-only and vision-haptics (each n= 10), both trained for 80 trials on the simulated system, and then were evaluated on the real system to test for skill transfer effects. If humans incorporate interaction forces in their learning, the vision-haptics group would be expected to exhibit a smoother transfer, as quantified by changes in completion time of a ball-positioning task. During training, both groups adapted well to the task, with reductions of 64%-70% in completion time. At skill transfer to the real system, the vision-only group had a significant 35% increase in completion time (p < 0.05). There was no significant change in the vision-haptics group, indicating that subjects had learned to compensate for interaction forces. These forces could potentially be incorporated in virtual environments to assist with motor training or rehabilitation.

Create a Low-cost Tracheotomy Model for Suctioning Simulation

Use of simulation for nursing skill development can provide effective learning while minimizing risk to patients. However, simulators are expensive and portability can be limited. The author describes how to create a low-cost model for simulating tracheotomy suctioning and care. Construction is simple, with estimated materials cost for making the model less than 100 dollars.

Simulators and Virtual Reality in Surgical Education

This article explores the pros and cons of virtual reality simulators, their abilities to train and assess surgical skills, and their potential future applications. Computer-based virtual reality simulators and more conventional box trainers are compared and contrasted. The virtual reality simulator provides objective assessment of surgical skills and immediate feedback further to enhance training. With this ability to provide standardized, unbiased assessment of surgical skills, the virtual reality trainer has the potential to be a tool for selecting, instructing, certifying, and recertifying gynecologists.

Virtual Reality Simulators in Orthopedic Surgery: What Do the Surgeons Think?

BACKGROUND

There is increasing pressure to develop virtual reality surgical simulation that can be used in surgical training. However, little is known of the attitudes of the surgical community toward such simulation, and which aspects of simulation are most important.

MATERIALS AND METHODS

A postal survey on attitudes to surgical simulation was sent to all New Zealand orthopedic surgeons and advanced trainees. This comprised of 44 questions in 10 sections, using either a visual analogue scale (0 to 10) or free text box replies. Results were analyzed for two sub-groups; surgeons qualified before 1990 and those qualified in or after 1990 or still in training.

RESULTS

Of the 208 possible responses, 142 were received, a response rate of 68%. Only four respondents had tried a surgical based simulator. Earlier qualified surgeons were more likely to agree that simulation was an effective way to practice surgical procedures, median score 7.7 versus 5.6 (P = 0.03). Both groups thought the most important task for simulation was practicing angulation/spatial orientation (median score 8.4/10), while a realistic view of the operation was the most important requirement (median score 9/10). Both groups were unconvinced that simulation would impact on their practice in the next 5 years, with this statement being scored lower by later qualified surgeons, median score 2.4 versus 4.1 (P = 0.04).

CONCLUSIONS

Orthopedic surgeons in New Zealand are supportive of surgical simulation but do not expect simulation to have an impact in the near future. Intriguingly, later qualified surgeons and trainees are more skeptical than their earlier qualified colleagues.

Minimal-access surgery training in the Netherlands: a survey among residents-in-training for general surgery

BACKGROUND

The purpose of this study was to assess the state of surgical training and its possible shortcomings in minimal-access surgery (MAS) among Dutch surgical residents.

METHODS

A pretested questionnaire was distributed to all residents-in-training for general surgery in The Netherlands.

RESULTS

The questionnaire was sent to 407 surgical residents. The response rate was 65%. Overall, 87.7% of all the responders were highly interested in the autonomous performance of laparoscopic surgery. Residents interested in gastrointestinal (GI) or oncologic surgery (n = 137) are significantly more interested than residents interested in non-GI/oncologic surgery. All the residents (100%) thought it was important to be able to perform the three basic MAS procedures (diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy) autonomously at the end of their surgical training. Other MAS procedures were considered to be advanced procedures. Gastrointestinal/oncologic residents were most interested in performing advanced MAS procedures, although only 17.8% expected to be adequately prepared at the end of their surgical training. Most residents had the opportunity to attend MAS skills education. Irrespective of the format or training method, only 26.9% of residents stated their MAS skills training was objectively evaluated. The residents thought every surgical hospital department in the Netherlands should have a surgeon specialized in laparoscopic surgery (86.9%).

CONCLUSIONS

The current study showed that Dutch residents believe it is very important to perform basic MAS autonomously. Of the GI/oncologic-interested residents, the majority want to be able to perform advanced MAS, but expect to be unable to do so at the end of their training. They attribute this discrepancy to "not having enough chance to be the first operator" and to "lack of volume of procedures in the hospital." Specific and properly implemented, monitored, and evaluated MAS skills training programs in skills laboratory settings could offer a promising environment for overcoming this discrepancy.

Measurement of in vivo local shear modulus using MR elastography multiple-phase patchwork offsets

Magnetic resonance elastography (MRE) is a method that can visualize the propagating and standing shear waves in an object being measured. The quantitative value of a shear modulus can be calculated by estimating the local shear wavelength. Low-frequency mechanical motion must be used for soft, tissue-like objects because a propagating shear wave rapidly attenuates at a higher frequency. Moreover, a propagating shear wave is distorted by reflections from the boundaries of objects. However, the distortions are minimal around the wave front of the propagating shear wave. Therefore, we can avoid the effect of reflection on a region of interest (ROI) by adjusting the duration of mechanical vibrations. Thus, the ROI is often shorter than the propagating shear wavelength. In the MRE sequence, a motion-sensitizing gradient (MSG) is synchronized with mechanical cyclic motion. MRE images with multiple initial phase offsets can be generated with increasing delays between the MSG and mechanical vibrations. This paper proposes a method for measuring the local shear wavelength using MRE multiple initial phase patchwork offsets that can be used when the size of the object being measured is shorter than the local wavelength. To confirm the reliability of the proposed method, computer simulations, a simulated tissue study and in vitro and in vivo studies were performed.