Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality (MIST VR)

Surgical training simulation modalities in minimally invasive surgery: How to achieve evidence-based curricula by translational research

BACKGROUND

Surgery has evolved from a hands-on discipline where skills were acquired via the "learning by doing" principle to a surgical science with attention to patient safety, health care effectiveness and evidence-based research. A variety of simulation modalities have been developed to meet the need for effective resident training. So far, research regarding surgical training for minimally invasive surgery has been extensive but also heterogenous in grade of evidence.

METHODS

A literature search was conducted to summarize current knowledge about simulation training and to guide research towards evidence-based curricula with translational effects. This was conducted using a variety of terms in PubMed for English articles up to October 2024. Results are presented in a structured narrative review.

RESULTS

For virtual reality simulators, there is sound evidence for effective training outcomes. The required instruments for the development of minimally invasive surgery curricula combining different simulation modalities to create a clinical benefit are known and published.

CONCLUSION

Surgeons are the main creators for minimally invasive surgery training curricula and often follow a hands-on oriented approach that leaves out equally important aspects of assessment, evaluation, and feedback. Further high-quality research that includes available evidence in this field promises to improve patient safety in surgical disciplines.

High-fidelity pose estimation for real-time extended reality (XR) visualization for cardiac catheterization

Extended reality (XR) technologies are emerging as promising platforms for medical training and procedural guidance, particularly in complex cardiac interventions. This paper presents a high-fidelity methodology to perform real-time 3D catheter tracking and visualization during simulated cardiac interventions. A custom 3D-printed setup with mounted cameras enables biplane video capture of a catheter. A computer vision algorithm processes the biplane images in real-time to reconstruct the 3D catheter trajectory represented by any designated number of points along its length. This method accurately localizes the catheter tip within 1 mm and can reconstruct any arbitrary catheter configuration. The tracked catheter data is integrated into an interactive Unity-based scene rendered on the Meta Quest 3 headset. The visualization seamlessly combines a reconstructed 3D patient-specific heart model with the dynamically tracked catheter, creating an immersive extended reality training environment. Our experimental study, involving six participants, demonstrated that the 3D visualization provided by the proposed XR system significantly outperformed 2D visualization in terms of speed and user experience. This suggests that the XR system has the potential to enhance catheterization training by improving spatial comprehension and procedural skills. The proposed system demonstrates the potential of XR technologies to transform percutaneous cardiac interventions through improved visualization and interactivity.

Eject, Eject, Eject! Conducting a Cognitive Task Analysis to Assess Parachute Descent Training Simulators

We conducted a cognitive task analysis to provide input on the curriculum and technology currently used to train parachute descent procedures in the Naval Aviation Survival Training Program. Subject matter experts provided insight into the correct decision-making thought processes used in parachute descent. Techniques for analysis included focus groups, interviews, and a think-aloud procedure involving a parachute descent simulator at a Naval Aviation Survival Training Center. Results and findings inform the instructional design process to improve the training pipeline’s development, implementation, and evaluation.

A Narrative Review of the Current State of Extended Reality Technology and How it can be Utilised in Sport

Extended reality is an umbrella term used to describe three computer-generated technologies including virtual reality, augmented reality and mixed reality. Extended reality is an emerging technology that has been utilised in many high-performance domains including psychology, medicine and the military, with the aim of enhancing perceptual-cognitive skills and motor skills. However, the use of extended reality in sport, particularly at the elite level, has only recently started to receive attention. While the growth of extended reality technology continues to accelerate at a rapid rate, empirical evidence aimed at understanding how these devices can best be applied in high-performance sport has not followed suit. Therefore, the purpose of this review is to provide clarity for high-performance sport organisations, researchers, sport scientists, coaches and athletes about the current state of extended reality technology and how it has been utilised in sport. In doing so, we first define and give examples of the types of extended reality technology including virtual reality, augmented reality and mixed reality that are available at the present time. Second, we detail how skill acquisition principles underpinned by the theoretical framework of ecological dynamics can be used to help inform the design and assessment of extended reality training tools. Third, we describe how extended reality has been utilised in sport, including how extended reality tools have been assessed for their level of representativeness, and the effectiveness of extended reality training interventions for improving perceptual-cognitive skills and motor skills. Finally, we discuss the future utilisation of extended reality in sport, including the key learnings that can be drawn from other domains, future research directions, practical applications and areas for consideration related to the use of extended reality for training skills in sport.

Development and Validation of a Mixed Reality Configuration of a Simulator for a Minimally Invasive Spine Surgery Using the Workspace of a Haptic Device and Simulator Users

Most surgical simulators leverage virtual or bench models to simulate reality. This study proposes and validates a method for workspace configuration of a surgical simulator which utilizes a haptic device for interaction with a virtual model and a bench model to provide additional tactile feedback based on planned surgical manoeuvers. Numerical analyses were completed to determine the workspace and position of a haptic device, relative to the bench model, used in the surgical simulator, and the determined configuration was validated using device limitations and user data from surgical and nonsurgical users. For the validation, surgeons performed an identical surgery on a cadaver prior to using the simulator, and their trajectories were then compared to the determined workspace for the haptic device. The configuration of the simulator was determined appropriate through workspace analysis and the collected user trajectories. Statistical analyses suggest differences in trajectories between the participating surgeons which were not affected by the imposed haptic workspace. This study, therefore, demonstrates a method to optimally position a haptic device with respect to a bench model while meeting the manoeuverability needs of a surgical procedure. The validation method identified workspace position and user trajectory towards ideal configuration of a mixed reality simulator.

VR Realism Scale-Revalidation of contemporary VR headsets on a Polish sample

This paper presents validation of the VR Simulation Realism Scale on a Polish sample. The scale enables a self-report measurement of perceived realism of a virtual environment in four main aspects of such realism-scene realism, audience behavior realism, audience appearance realism and sound realism. However, since the development of the original scale, the VR technology significantly changed. We aimed to respond to that change and revalidate the original measure in the contemporary setting. For the purpose of scale validation, data was gathered from six studies with 720 participants in total. Five experiments and one online survey were conducted to examine psychometric properties of the scale in accordance with the Standards for Educational and Psychological Testing. Evidence based on internal structure, relations to other variables and test content was obtained. The factorial structure of the original scale was tested and confirmed. The connections between realism and immersion, presence, aesthetics were verified. A suppressed relationship between realism and positive affect was discovered. Moreover, it was confirmed that scale result is dependent on the quality of VR graphics. Results of the analyses provide the evidence that the VR Simulation Realism Scale is a well-established tool that might be used both in science and in VR development. However, further research needs to be done to increase external validity and predictive power of the scale.

Virtual Reality as an Affirmative Spin-Off to Laparoscopic Training: An Updated Review

Latest advancements in science lead to drastic improvements in patient health care. Techniques and technology evolved in surgery over the years have resulted in the improvement of patient outcomes by leaps and bounds. Open surgeries previously done for procedures like appendectomy and cholecystectomy evolved into laparoscopic minimally invasive procedures. Such procedures pose few challenges to the surgeons, like lack of tissue feedback and fulcrum effect of the abdominal wall. But training surgeons for such an advanced skill is still following conventional methods. These procedures can be effectively trained using Virtual Reality (VR), which can simulate operations outside the operating room (OR). To maximize the outcomes of VR training, knowledge on various strategies affecting the skills acquisition and retention in VR training is essential. This review collected information from PubMed, EMBASE, Cochrane Library (CENTRAL) databases. Data from the previous ten years are included in the review. This included documents, clinical trials, meta-analysis, randomized controlled trials, reviews, systematic reviews, letters to editors, and grey literature. After an advanced Medical Subject Headings (MeSH) search, we got 59,532 results, and after the application of filters, 189 results showed up. Out of these, studies that were not exclusively relevant to the use of VR in laparoscopic surgery were manually excluded, and a total of 35 articles were included in the study. VR is found to be an excellent training modality with promising outcomes. It helps the surgeons perform the surgery accurately at a faster pace and improves confidence and multitasking ability in OR. Instructor feedback from mentors and deliberate practice of trainees, and early introduction of haptics in VR resulted in the most effective outcomes of the VR training. Box trainers are also compared with VR trainers as they are the cheaper modalities of training. However, this area needs more research to conclude if box trainers can act as a cheaper alternative to VR training providing similar outcomes.

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.

Assessment of technical skills based on learning curve analyses in laparoscopic surgery training

BACKGROUND

Objective force- and motion-based assessment is currently lacking in laparoscopic skills curricula. This study aimed to evaluate the added value of parameter-based assessment and feedback during training.

METHODS

Laparoscopy-naïve surgical residents that took part in a 3-week skills training curriculum were included. A box trainer equipped with the ForceSense system was used for assessment of tissue manipulation- (MaxForce) and instrument-handling skills (Path length and Time). Learning curves were established using linear regression tests. Pre- and post-course comparisons indicated the overall progression and were compared to predefined proficiency levels. A post-course survey was carried out to assess face validity.

RESULTS

In total, 4,268 trials, executed by 24 residents, were successfully assessed. Median (interquartile range) MaxForce outcomes improved from 2.7 Newton (interquartile range 1.9-3.8) to 1.8 Newton (interquartile range 1.2-2.4) between pre- and post-course assessment (P ≤ .009). Instrument Path length improved from 7,102.2 mm (interquartile range 5,255.2-9,025.9) to 3,545.3 mm (interquartile range 2,842.9-4,563.2) (P ≤.001). Time to execute the task improved from 159.8 seconds (interquartile range 119.8-219.0) to 60.7 seconds (interquartile range 46.0-79.5) (P ≤ .001). The learning curves revealed during what training phase the proficiency benchmarks were reached for each trainee. In the survey outcomes, trainees indicated that this curriculum should be part of a surgical residency program (mean visual analog scale score of 9.2 ± 0.9 standard deviation).

CONCLUSION

Force-, motion-, and time-parameters can be objectively measured during basic laparoscopic skills curricula and do indicate progression of skills over time. The ForceSense parameters enable curricula to be designed for specific proficiency-based training goals and offer the possibility for objective classification of the levels of expertise.

Baseline characteristics in laparoscopic simulator performance: The impact of personal computer (PC)-gaming experience and visuospatial ability

BACKGROUND

Learning via simulators is under constant development, and it is important to further optimize simulator training curricula. This study investigates the impact of personal computer-gaming experience, visuospatial skills, and repetitive training on laparoscopic simulator performance and specifically on the constituent parameters of the simulator score.

METHODS

Forty-seven medical students completed 3 consecutive Minimally Invasive Surgical Trainer-Virtual Reality simulator trials. Previously, they performed a visuospatial test and completed a questionnaire regarding baseline characteristics and personal computer-gaming experience. Linear regression was used to analyze the relationship between simulator performance and type of personal computer-gaming experience and visuospatial ability.

RESULTS

During the first 2 Minimally Invasive Surgical Trainer-Virtual Reality simulation tasks, there was an association between personal computer-gaming experience and the coordination parameters of the score (eg, EconDiath task 1: P = .0047; EconDiath task 2: P = .0102; EconDiath task 3: P = .0836). The type of game category played seemed to have an impact on the coordination parameters (eg, EconDiath task 1-3 for sport games versus no-sport games: P = .01, P = .0013, and P = .01, respectively). In the first Minimally Invasive Surgical Trainer task, visuospatial ability correlated with Minimally Invasive Surgical Trainer simulator performance but was abolished with repetitive training (overall Minimally Invasive Surgical Trainer score task 1-3: P = .0122, P = .0991, and P = .3506, respectively). Sex-specific differences were noted initially but were abolished with training.

CONCLUSION

Sport games versus no-sport games demonstrated a significantly better Minimally Invasive Surgical Trainer performance. Furthermore, repetitive laparoscopic simulator training may compensate for a previous lack of personal computer-gaming experience, low visuospatial ability, and sex differences.

LAPKaans: Tool-Motion Tracking and Gripping Force-Sensing Modular Smart Laparoscopic Training System

Laparoscopic surgery demands highly skilled surgeons. Traditionally, a surgeon's knowledge is acquired by operating under a mentor-trainee method. In recent years, laparoscopic simulators have gained ground as tools in skill acquisition. Despite the wide range of laparoscopic simulators available, few provide objective feedback to the trainee. Those systems with quantitative feedback tend to be high-end solutions with limited availability due to cost. A modular smart trainer was developed, combining tool-tracking and force-using employing commercially available sensors. Additionally, a force training system based on polydimethylsiloxane (PDMS) phantoms for sample stiffness differentiation is presented. This prototype was tested with 39 subjects, between novices (13), intermediates (13), and experts (13), evaluating execution differences among groups in training exercises. The estimated cost is USD $200 (components only), not including laparoscopic instruments. The motion system was tested for noise reduction and position validation with a mean error of 0.94 mm. Grasping force approximation showed a correlation of 0.9975. Furthermore, differences in phantoms stiffness effectively reflected user manipulation. Subject groups showed significant differences in execution time, accumulated distance, and mean and maximum applied grasping force. Accurate information was obtained regarding motion and force. The developed force-sensing tool can easily be transferred to a clinical setting. Further work will consist on a validation of the simulator on a wider range of tasks and a larger sample of volunteers.

European expert consensus on a structured approach to training robotic-assisted low anterior resection using performance metrics

AIM

The aim was to develop and operationally define 'performance metrics' that characterize a reference approach to robotic-assisted low anterior resection (RA-LAR) and to obtain face and content validity through a consensus meeting.

METHOD

Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers' instructions and unedited videos of RA-LAR to deconstruct the operation into defined, measurable components - performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process.

RESULTS

Performance metrics for RA-LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%).

CONCLUSION

A robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA-LAR.

Virtual reality training compared with apprenticeship training in laparoscopic surgery: a meta-analysis

INTRODUCTION

Since its inception, laparoscopic surgery has evolved and new techniques have been developed due to technological advances. This requires a different and more complex skill set in comparison with open surgery. Reduced working hours, less training time and patient safety factors demand that such skills need to be achieved outside the operating theatre environment. Several studies have been published and have determined the effectiveness of virtual reality training. We aimed to compare virtual reality training with the traditional apprenticeship method of training and determine whether it can supplement or replace the traditional apprenticeship model. We also aimed to perform a meta-analysis of the literature and develop conclusions with respect to the benefits achieved by adding virtual reality training on a regular basis to surgical training programmes.

METHODS

A literature search was carried out on PubMed, MEDLINE, EMBASE and Google Scholar academic search engines using the MESH terms 'randomised controlled trials', 'virtual reality', 'laparoscopy', 'surgical education' and 'surgical training'. All randomised controlled trials published to January 2018 comparing virtual reality training to apprenticeship training were included. Data were collected on improved dexterity, operative performance and operating times. Each outcome was calculated with 95% confidence intervals and with intention-to-treat analysis; 24 randomised controlled trials were analysed.

FINDINGS

Meta-analytical data were extracted for time, path length, instrument handling, tissue handling, error scores and objective structure assessment of technical skills scoring. There was significant improvement in individual trainee skill in all meta-analyses (p < 0.0002).

CONCLUSION

This meta-analysis shows that virtual reality not only improves efficiency in the trainee's surgical practice but also improves quality with reduced error rates and improved tissue handling.

Use of a Low-Cost Portable 3D Virtual Reality Gesture-Mediated Simulator for Training and Learning Basic Psychomotor Skills in Minimally Invasive Surgery: Development and Content Validity Study

Background

Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access.

Objective

This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence.

Methods

For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed.

Results

A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67).

Conclusions

The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained.

Simulation-based education for paediatric surgeons: Does it really improve technical skills?

In recent years, there has been an increasing interest in employing simulation methodology for teaching surgical skills. Supposedly, skills achieved in the simulation arena, should lead to an improvement of surgical performance in the operating room. In this article we aim to summarise those areas of simulation-based research that relate to paediatric surgery; we present the current evidence behind low-fidelity simulation and computer-based simulation in improving the acquisition of surgical skills.

Personalized Interventions: A Reality in the Next 20 Years or Pie in the Sky

There is no better representation of the need for personalization of care than the breadth and complexity of congenital heart disease. Advanced imaging modalities are now standard of care in the field, and the advancements being made to three-dimensional visualization technologies are growing as a means of pre-procedural preparation. Incorporating emerging modeling approaches, such as computational fluid dynamics, will push the limits of our ability to predict outcomes, and this information may be both obtained and utilized during a single procedure in the future. Artificial intelligence and customized devices may soon surface as realistic tools for the care of patients with congenital heart disease, as they are showing growing evidence of feasibility within other fields. This review illustrates the great strides that have been made and the persistent challenges that exist within the field of congenital interventional cardiology, a field which must continue to innovate and push the limits to achieve personalization of the interventions it provides.

Validation of a Novel Needle Holder to Train Advanced Laparoscopy Skills to Novices in a Simulator Environment

Background. Our aim was to determine if a newly designed Najar needle holder (NNH) shortens the time for novices to improve advanced laparoscopy (AL) techniques (suturing/knot tying), compared with a conventional macro needle holder (MNH) in a simulator. Furthermore, we aimed to validate a new video scoring system determining AL skills. Methods. Forty-six medical students performed identical surgical tasks in a prospective, crossover study evaluating AL skills (NNH vs MNH). All subjects performed a double-throw knot, 2 single-throw knots following 3 running sutures in the Simball Box (SB) simulator. After resting, subjects switched needle holders. All tasks were videotaped and analyzed using SB software and by 2 independent reviewers using the Objective Video Evaluation Scoring Table (OVEST). Trial performance expressed as SB Overall Score (SBOS) and OVEST. Results. In the group starting with NNH (followed by MNH) OVEST was consistently high during both trials (median = 12.5, range = 6.5-18.0, and median = 13.5, range = 6.5-21.0; P = .2360). However, in the group starting with MNH, OVEST improved significantly when the participants changed to NNH (median = 10.0, range = 2.5-19.5, vs median = 14.5, range = 4.5-18.0; P = .0003); an improvement was also found with SBOS (median = 37%, range = 27% to 92%, vs median = 48%, range = 34% to 70%; P = .0289). In both trials, both independent reviewers' OVEST measures correlated well: Trial 1: β = 0.97, P < .0001; and Trial 2: β = 0.95, P < .0001. A correlation also existed between SBOS and OVEST in both trials (β = 2.1, P < .0001; and β = 1.9, P = .0002). Conclusions. This study indicates a significantly higher improvement in laparoscopic suturing skills in novices training AL skills using NNH compared with MNH. Starting early, AL training in novices using NNH is a feasible option. Furthermore, OVEST used in experimental settings as an evaluation tool is comparable with the validated SBOS.

Trainee Performance After Laparoscopic Simulator Training Using a Blackbox versus LapMentor

BACKGROUND

Training using laparoscopic high-fidelity simulators (LHFSs) to proficiency levels improves laparoscopic cholecystectomy skills. However, high-cost simulators and their limited availability could negatively impact residents' laparoscopic training opportunities. We aimed to assess whether motivation and surgical skill performance differ after basic skills training (BST) using a low-cost (Blackbox) versus LHFS (LapMentor) among medical students.

MATERIALS AND METHODS

Sixty-three medical students from Karolinska Institutet volunteered, completing written informed consent, questionnaire regarding expectations of the simulation training, and a visuospatial ability test. They were randomized into two groups that received BST using Blackbox (n = 32) or LapMentor (n = 31). However, seven students absence resulted in 56 participants, followed by another 9 dropouts. Subsequently, after training, 47 students took up three consecutive tests using the minimally invasive surgical trainer-virtual reality (MIST-VR) simulator, finalizing a questionnaire.

RESULTS

More Blackbox group participants completed all MIST-VR tests (29/31 versus 18/25). Students anticipated mastering LapMentor would be more difficult than Blackbox (P = 0.04). In those completing the simulation training, a trend toward an increase was noted in how well participants in the Blackbox group liked the simulator training (P = 0.07). Subgroup analysis of motivation and difficulty in liking the training regardless of simulator was found only in women (Blackbox [P = 0.02]; LapMentor [P = 0.06]). In the Blackbox group, the perceived difficulty of training, facilitation, and liking the Blackbox training (significant only in women) were significantly correlated with the students' performance in the MIST-simulator. No such correlations were found in the LapMentor group.

CONCLUSIONS

Results indicate an important role for low-tech/low-cost Blackbox laparoscopic BST of students in an otherwise high-tech surrounding. Furthermore, experience of Blackbox BST procedures correlate with students' performance in the MIST-VR simulator, with some gender-specific differences.

Creating 3D models from Radiologic Images for Virtual Reality Medical Education Modules

Virtual Reality (VR) is a powerful tool that has increasingly being used by medical field in recent years. It has been mainly used surgical training in particular laparoscopic procedures. VR can be used for the teaching of anatomy. The aim of the study is to show application of transforming 2D radiologic images into 3D model by using thresholding and segmentation and import into VR interface at an affordable cost. Four anatomy modules are created with inputs to control the rotational and translational movement of 3D models in the virtual space. These movements allow users to explore 3D models by using head tilt and gaze input. 3D models of the Circle of Willis, Vertebral Aneurysm, Spine, and Skull are rendered in the user's field of view at runtime. VR is constructed to have many potentials uses in radiology education. Visualization of 3D anatomic structures in a virtual environment give another tool for teaching to students and patients about anatomy of the body. Four anatomy modules described here demonstrate example user interaction patterns best suited for viewing contexts. Instead viewing stacked 2D images or 3D models confined to desktop applications, virtual reality increases user interactivity of education. An intuitive understanding of anatomic structures in 3D space enhances the learning experience for medical students, residents, and patients we are treating.

Editorial Commentary: Harnessing Surgical Simulation-Saddle up for a Long and Rigorous Ride!

Arthroscopic simulation tools will assist in the training of skills that are transferrable to the operating room. Success in that endeavor requires the following: relevant outcome metrics rather than surrogate measures of performance, evaluation tools that enable scoring of step and error metrics rather than global rating scales, construct validation of simulators and metrics based on actual performance, development of simulators that not only assess performance but also train additional skills and provide feedback, and a focus first on effective training as opposed to high-fidelity realism.

Simulation in paediatric urology and surgery, part 2: An overview of simulation modalities and their applications

Surgical training has changed radically in the last few decades. The traditional Halstedian model of time-bound apprenticeship has been replaced with competency-based training. In our previous article, we presented an overview of learning theory relevant to clinical teaching; a summary for the busy paediatric surgeon and urologist. We introduced the concepts underpinning current changes in surgical education and training. In this next article, we give an overview of the various modalities of surgical simulation, the educational principles that underlie them, and potential applications in clinical practice. These modalities include; open surgical models and trainers, laparoscopic bench trainers, virtual reality trainers, simulated patients and role-play, hybrid simulation, scenario-based simulation, distributed simulation, virtual reality, and online simulation. Specific examples of technology that may be used for these modalities are included but this is not a comprehensive review of all available products.

Effect of Continuous Motion Parameter Feedback on Laparoscopic Simulation Training: A Prospective Randomized Controlled Trial on Skill Acquisition and Retention

OBJECTIVE

To investigate the effect of motion parameter feedback on laparoscopic basic skill acquisition and retention during a standardized box training curriculum.

DESIGN

A Lap-X Hybrid laparoscopic simulator was designed to provide individual and continuous motion parameter feedback in a dry box trainer setting. In a prospective controlled trial, surgical novices were randomized into 2 groups (regular box group, n = 18, and Hybrid group, n = 18) to undergo an identical 5-day training program. In each group, 7 standardized tasks on laparoscopic basic skills were completed twice a day on 4 consecutive days in fixed pairs. Additionally, each participant performed a simulated standard laparoscopic cholecystectomy before (day 1) and after training (day 5) on a LAP Mentor II virtual reality (VR) trainer, allowing an independent control of skill progress in both groups. A follow-up assessment of skill retention was performed after 6 weeks with repetition of both the box tasks and VR cholecystectomy.

SETTING

Muenster University Hospital Training Center, Muenster, Germany.

PARTICIPANTS

Medical students without previous surgical experience.

RESULTS

Laparoscopic skills in both groups improved significantly during the training period, measured by the overall task performance time. The 6 week follow-up showed comparable skill retention in both groups. Evaluation of the VR cholecystectomies demonstrated significant decrease of operation time (p < 0.01), path length of the left and right instrument, and the number of movements of the left and right instruments for the Hybrid group (all p < 0.001), compared to the box group. Similar results were found at the assessment of skill retention.

CONCLUSION

Simulation training on both trainers enables reliable acquisition of laparoscopic basic skills. Furthermore, individual and continuous motion feedback improves laparoscopic skill enhancement significantly in several aspects. Thus, training systems with feedback of motion parameters should be considered to achieve long-term improvement of motion economy among surgical trainees.

LapTrain: multi-modality training curriculum for laparoscopic cholecystectomy-results of a randomized controlled trial

BACKGROUND

Multiple training modalities for laparoscopy have different advantages, but little research has been conducted on the benefit of a training program that includes multiple different training methods compared to one method only. This study aimed to evaluate benefits of a combined multi-modality training program for surgical residents.

METHODS

Laparoscopic cholecystectomy (LC) was performed on a porcine liver as the pre-test. Randomization was stratified for experience to the multi-modality Training group (12 h of training on Virtual Reality (VR) and box trainer) or Control group (no training). The post-test consisted of a VR LC and porcine LC. Performance was rated with the Global Operative Assessment of Laparoscopic Skills (GOALS) score by blinded experts.

RESULTS

Training (n = 33) and Control (n = 31) were similar in the pre-test (GOALS: 13.7 ± 3.4 vs. 14.7 ± 2.6; p = 0.198; operation time 57.0 ± 18.1 vs. 63.4 ± 17.5 min; p = 0.191). In the post-test porcine LC, Training had improved GOALS scores (+ 2.84 ± 2.85 points, p < 0.001), while Control did not (+ 0.55 ± 2.34 points, p = 0.154). Operation time in the post-test was shorter for Training vs. Control (40.0 ± 17.0 vs. 55.0 ± 22.2 min; p = 0.012). Junior residents improved GOALS scores to the level of senior residents (pre-test: 13.7 ± 2.7 vs. 18.3 ± 2.9; p = 0.010; post-test: 15.5 ± 3.4 vs. 18.8 ± 3.8; p = 0.120) but senior residents remained faster (50.1 ± 20.6 vs. 25.0 ± 1.9 min; p < 0.001). No differences were found between groups on the post-test VR trainer.

CONCLUSIONS

Structured multi-modality training is beneficial for novices to improve basics and overcome the initial learning curve in laparoscopy as well as to decrease operation time for LCs in different stages of experience. Future studies should evaluate multi-modality training in comparison with single modalities.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00011040.

Video analysis in basic skills training: a way to expand the value and use of BlackBox training?

Background

Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

Methods

Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

Results

31 students (19 females and 12 males), mean age of 26.2 ± 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

Conclusions

Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

The role of simulation in teaching sinus surgery in otolaryngology residency: A survey of rhinologists

BACKGROUND

Simulation is currently recognized as an effective surgical training tool. However, no standardized curriculum exists for endoscopic sinus surgery (ESS) simulation training. The goal of this study was to obtain an understanding of current ESS simulation use to aid the future development of an ESS training curriculum.

METHODS

A 14-question survey regarding sinus simulation in residency training was developed through the education committee of the American Rhinologic Society. The survey was administered to academic American Rhinologic Society members in the United States, Canada, and Puerto Rico. The participants provided information regarding the type, amount, and effectiveness of simulation use in their residency program.

RESULTS

Responses were received from 67 training programs; 45% of the programs endorsed using simulation training, although only 23.9% used ESS simulation, and all the programs used cadavers. Only 12.5% of respondent programs required ESS simulation training before operating on live patients, and trainees had an average of <6 hours of simulation training before live operations. A majority of respondents observed subjective improvement in residents' endoscope handling, dexterity, and understanding of anatomy after ESS simulation. The greatest obstacles identified were associated cost and lack of realistic simulators.

CONCLUSION

A majority of responders observed improved surgical technique and knowledge in residents after simulation training. However, <25% of the survey responders used ESS simulation and cited cost and limited availability as the most common barriers. A curriculum of validated simulators has potential to improve the quality of ESS training during residency.

Surgical Education's 100 Most Cited Articles: A Bibliometric Analysis

BACKGROUND

Bibliometric analysis highlights the key topics and publications, which have shaped surgical education. Here, the 100 most cited articles in the arena of surgical education were analyzed.

METHODS

Thomson Reuters Web of Science was interrogated using the keyword search terms "surgery" and ("learning" or "skills" or "competence" or "assessment" or "training" or "procedure-based assessments" or "performance" or "technical skills" or "curriculum" or "education" or "mentoring"] to identify all English language full articles, and the 100 most cited articles were analyzed by topic, journal, author, year, institution, and country of origin.

RESULTS

A total of 403,733 eligible articles were returned and the median citation number was 164 (range: 107-1018). The most cited article (by Seymour, Yale University School of Medicine, Annals of Surgery, 1018 citations) focused on the use of virtual reality surgical simulation training. Annals of Surgery published the highest number of articles and received the most citations (n = 16, 3715 citations). The countries with the greatest number of publications were the USA (n = 45), Canada (n = 19), and the UK (n = 18). The commonest topics included simulation (n = 45) and assessment of clinical competence (n = 40).

CONCLUSION

Surgical skill acquisition and assessment was the area of focus of 85% of the most cited contemporary articles, and this study provides the most cited references, serving as a guide as to what makes a citable published work in the field of surgical education.

Sensorimotor Training in a Virtual Reality Environment: Does It Improve Functional Recovery Poststroke?

Objective. To investigate the effectiveness of computerized virtual reality (VR) training of the hemiparetic hand of patients poststroke using a system that provides repetitive motor reeducation and skill reacquisition. Methods. Eight subjects in the chronic phase poststroke participated in a 3-week program using their hemiparetic hand in a series of interactive computer games for 13 days of training, weekend breaks, and pretests and posttests. Each subject trained for about 2 to 2.5 h per day. Outcome measures consisted of changes in the computerized measures of thumb and finger range of motion, thumb and finger velocity, fractionation (the ability to move fingers independently), thumb and finger strength, the Jebsen Test of Hand Function, and a Kinematic reach to grasp test. Results. Subjects as a group improved in fractionation of the fingers, thumb and finger range of motion, and thumb and finger speed, retaining those gains at the 1-week retention test. Transfer of these improvements was demonstrated through changes in the Jebsen Test of Hand Function and a decrease after the therapy in the overall time from hand peak velocity to the moment when an object was lifted from the table. Conclusions. It is difficult in current service delivery models to provide the intensity of practice that appears to be needed to effect neural reorganization and functional changes poststroke. Computerized exercise systems may be a way to maximize both the patients’ and the clinicians’ time. The data in this study add support to the proposal to explore novel technologies for incorporation into current practice.

Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy

BACKGROUND

The pulsatile organ perfusion (POP) trainer provides training of minimally invasive surgery (MIS) with real instruments and cadaveric organs. It provides training of full procedures with simulation of bleeding. Although widely used, the face validity has not yet been evaluated. This study aimed to establish face validity of the POP trainer for laparoscopic cholecystectomy (LC) and its usefulness compared with other training modalities.

MATERIALS AND METHODS

During MIS courses, the participants (n = 52) used the POP trainer to perform LC. Face validity was assessed with questionnaires for realism and usefulness on a five-point Likert scale. Participants were divided into two groups: experts (n = 15) who had performed more than 50 laparoscopic procedures and novices (n = 37) with less than 50 procedures. Secondary aims included the ranking of training modalities, as well as exploration of their specific advantages and disadvantages.

RESULTS

The POP trainer was found to be realistic (3.8 ± 0.9) and useful (4.6 ± 0.9). Differences between experts and novices were only found for "The training modality resembles reality" (3.1 ± 0.8 vs. 3.8 ± 0.7; p = 0.010), "The operation on the POP trainer is realistic" (3.4 ± 1.1 vs. 4.5 ± 0.8; p = 0.003), and "It would be desirable to have a POP trainer at my own hospital" (4.2 ± 1.1 vs. 4.8 ± 0.8; p = 0.040). In the ranking, the animal training (1.1 ± 0.3) placed first, the POP trainer (2.3 ± 0.9) second, and the VR trainer (2.8 ± 0.9) and box trainer (2.8 ± 1.1) third. The realistic simulation of animal training was named as an advantage most often, while the unrealistic simulation of the VR trainer was the most often named disadvantage.

CONCLUSIONS

The POP trainer was rated a highly realistic and useful training modality with face validity for LC. Differences between experts and novices existed concerning realism and desirability. Future studies should evaluate the POP trainer for more advanced surgical procedures. The POP trainer widens the spectrum of modalities for training of MIS in a safe environment outside the operating room.

Design and Validation of an Open-Source, Partial Task Trainer for Endonasal Neuro-Endoscopic Skills Development: Indian Experience

BACKGROUND

Box trainers are ideal simulators, given they are inexpensive, accessible, and use appropriate fidelity.

OBJECTIVE

The development and validation of an open-source, partial task simulator that teaches the fundamental skills necessary for endonasal skull-base neuro-endoscopic surgery.

METHODS

We defined the Neuro-Endo-Trainer (NET) SkullBase-Task-GraspPickPlace with an activity area by analyzing the computed tomography scans of 15 adult patients with sellar suprasellar parasellar tumors. Four groups of participants (Group E, n = 4: expert neuroendoscopists; Group N, n =19: novice neurosurgeons; Group R, n = 11: neurosurgery residents with multiple iterations; and Group T, n = 27: neurosurgery residents with single iteration) performed grasp, pick, and place tasks using NET and were graded on task completion time and skills assessment scale score.

RESULTS

Group E had lower task completion times and greater skills assessment scale scores than both Group N and R (P ≤ 0.03, 0.001). The performance of Groups N and R was found to be equivalent; in self-assessing neuro-endoscopic skill, the participants in these groups were found to have equally low pretraining scores (4/10) with significant improvement shown after NET simulation (6, 7 respectively). Angled scopes resulted in decreased scores with tilted plates compared with straight plates (30° P ≤ 0.04, 45° P ≤ 0.001). With tilted plates, decreased scores were observed when we compared the 0° with 45° endoscope (right, P ≤ 0.008; left, P ≤ 0.002).

CONCLUSIONS

The NET, a face and construct valid open-source partial task neuroendoscopic trainer, was designed. Presimulation novice neurosurgeons and neurosurgical residents were described as having insufficient skills and preparation to practice neuro-endoscopy. Plate tilt and endoscope angle were shown to be important factors in participant performance. The NET was found to be a useful partial-task trainer for skill building in neuro-endoscopy.

Towards immersive virtual reality (iVR): a route to surgical expertise

Surgery is characterized by complex tasks performed in stressful environments. To enhance patient safety and reduce errors, surgeons must be trained in environments that mimic the actual clinical setting. Rasmussen’s model of human behavior indicates that errors in surgical procedures may be skill-, rule-, or knowledge-based. While skill-based behavior and some rule-based behavior may be taught using box trainers and ex vivo or in vivo animal models, we posit that multimodal immersive virtual reality (iVR) that includes high-fidelity visual as well as other sensory feedback in a seamless fashion provides the only means of achieving true surgical expertise by addressing all three levels of human behavior. While the field of virtual reality is not new, realization of the goals of complete immersion is challenging and has been recognized as a Grand Challenge by the National Academy of Engineering. Recent technological advances in both interface and computational hardware have generated significant enthusiasm in this field. In this paper, we discuss convergence of some of these technologies and possible evolution of the field in the near term.

Virtual reality simulators and training in laparoscopic surgery

Virtual reality simulators provide basic skills training without supervision in a controlled environment, free of pressure of operating on patients. Skills obtained through virtual reality simulation training can be transferred on the operating room. However, relative evidence is limited with data available only for basic surgical skills and for laparoscopic cholecystectomy. No data exist on the effect of virtual reality simulation on performance on advanced surgical procedures. Evidence suggests that performance on virtual reality simulators reliably distinguishes experienced from novice surgeons Limited available data suggest that independent approach on virtual reality simulation training is not different from proctored approach. The effect of virtual reality simulators training on acquisition of basic surgical skills does not seem to be different from the effect the physical simulators. Limited data exist on the effect of virtual reality simulation training on the acquisition of visual spatial perception and stress coping skills. Undoubtedly, virtual reality simulation training provides an alternative means of improving performance in laparoscopic surgery. However, future research efforts should focus on the effect of virtual reality simulation on performance in the context of advanced surgical procedure, on standardization of training, on the possibility of synergistic effect of virtual reality simulation training combined with mental training, on personalized training.

Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator - either a video box or a mirrored box - is an option to supplement standard training. However, the impact of this modality on trainees with no prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training versus no training, another box model, animal model, or cadaveric model training for surgical trainees with no prior laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing box model trainers versus no training in surgical trainees with no prior laparoscopic experience. We also included trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager for analysis. For each outcome, we calculated the standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

Twenty-five trials contributed data to the quantitative synthesis in this review. All but one trial were at high risk of bias. Overall, 16 trials (464 participants) provided data for meta-analysis of box training (248 participants) versus no supplementary training (216 participants). All the 16 trials in this comparison used video trainers. Overall, 14 trials (382 participants) provided data for quantitative comparison of different methods of box training. There were no trials comparing box model training versus animal model or cadaveric model training. Box model training versus no training: The meta-analysis showed that the time taken for task completion was significantly shorter in the box trainer group than the control group (8 trials; 249 participants; SMD -0.48 seconds; 95% CI -0.74 to -0.22). Compared with the control group, the box trainer group also had lower error score (3 trials; 69 participants; SMD -0.69; 95% CI -1.21 to -0.17), better accuracy score (3 trials; 73 participants; SMD 0.67; 95% CI 0.18 to 1.17), and better composite performance scores (SMD 0.65; 95% CI 0.42 to 0.88). Three trials reported movement distance but could not be meta-analysed as they were not in a format for meta-analysis. There was significantly lower movement distance in the box model training compared with no training in one trial, and there were no significant differences in the movement distance between the two groups in the other two trials. None of the remaining secondary outcomes such as mortality and morbidity were reported in the trials when animal models were used for assessment of training, error in movements, and trainee satisfaction. Different methods of box training: One trial (36 participants) found significantly shorter time taken to complete the task when box training was performed using a simple cardboard box trainer compared with the standard pelvic trainer (SMD -3.79 seconds; 95% CI -4.92 to -2.65). There was no significant difference in the time taken to complete the task in the remaining three comparisons (reverse alignment versus forward alignment box training; box trainer suturing versus box trainer drills; and single incision versus multiport box model training). There were no significant differences in the error score between the two groups in any of the comparisons (box trainer suturing versus box trainer drills; single incision versus multiport box model training; Z-maze box training versus U-maze box training). The only trial that reported accuracy score found significantly higher accuracy score with Z-maze box training than U-maze box training (1 trial; 16 participants; SMD 1.55; 95% CI 0.39 to 2.71). One trial (36 participants) found significantly higher composite score with simple cardboard box trainer compared with conventional pelvic trainer (SMD 0.87; 95% CI 0.19 to 1.56). Another trial (22 participants) found significantly higher composite score with reverse alignment compared with forward alignment box training (SMD 1.82; 95% CI 0.79 to 2.84). There were no significant differences in the composite score between the intervention and control groups in any of the remaining comparisons. None of the secondary outcomes were adequately reported in the trials.

AUTHORS' CONCLUSIONS

The results of this review are threatened by both risks of systematic errors (bias) and risks of random errors (play of chance). Laparoscopic box model training appears to improve technical skills compared with no training in trainees with no previous laparoscopic experience. The impacts of this decreased time on patients and healthcare funders in terms of improved outcomes or decreased costs are unknown. There appears to be no significant differences in the improvement of technical skills between different methods of box model training. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the impacts of box model training on surgical skills in both the short and long term, as well as clinical outcomes when the trainee becomes competent to operate on patients.

Assessing visual control during simulated and live operations: gathering evidence for the content validity of simulation using eye movement metrics

BACKGROUND

Although virtual reality (VR) simulators serve an important role in the training and assessment of surgeons, they need to be evaluated for evidence of validity. Eye-tracking technology and measures of visual control have been used as an adjunct to the performance parameters produced by VR simulators to help in objectively establishing the construct validity (experts vs. novices) of VR simulators. However, determining the extent to which VR simulators represent the real procedure and environment (content validity) has largely been a subjective process undertaken by experienced surgeons. This study aimed to examine the content validity of a VR transurethral resection of the prostate (TURP) simulator by comparing visual control metrics taken during simulated and real TURP procedures.

METHODS

Eye-tracking data were collected from seven surgeons performing 14 simulated TURP operations and three surgeons performing 15 real TURP operations on live patients. The data were analyzed offline, and visual control metrics (number and duration of fixations, percentage of time the surgeons fixated on the screen) were calculated.

RESULTS

The surgeons displayed more fixations of a shorter duration and spent less time fixating on the video monitor during the real TURP than during the simulated TURP. This could have been due to (1) the increased complexity of the operating room (OR) environment (2) the decreased quality of the image of the urethra and associated anatomy (compared with the VR simulator), or (3) the impairment of visual attentional control due to the increased levels of stress likely experienced in the OR.

CONCLUSIONS

The findings suggest that the complexity of the environment surrounding VR simulators needs to be considered in the design of effective simulated training curricula. The study also provides support for the use of eye-tracking technology to assess the content validity of simulation and to examine psychomotor processes during live operations.

Virtual reality training for surgical trainees in laparoscopic surgery

BACKGROUND

Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known.

OBJECTIVES

To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS

We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group.

AUTHORS' CONCLUSIONS

Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

Virtual reality training for surgical trainees in laparoscopic surgery

BACKGROUND

Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known.

OBJECTIVES

To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS

We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group.

AUTHORS' CONCLUSIONS

Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

Ramifications of single-port laparoscopic surgery: measuring differences in task performance using simulation

INTRODUCTION

Single-port laparoscopic surgery imposes unique psychomotor challenges. We used surgical simulation to define performance differences between surgeons with and without single-port clinical experience and examined whether a short course of training resulted in improved performance.

METHODS

Study participants were assigned to 3 groups: resident group (RES), experienced laparoscopic surgeons with (SP) and without (LAP) prior single-port laparoscopic experience. Participants performed the Fundamentals of Laparoscopic Surgery precision cutting task on a ProMIS trainer through conventional ports or with articulating instruments via a SILS Port (Covidien, Inc). Two iterations of each method were performed. Then, 6 residents performed 10 successive single-port iterations to assess the effect of practice on task performance.

RESULTS

The SP group had faster task times for both laparoscopic (P = .0486) and single-port (P = .0238) methods. The LAP group had longer path lengths for the single-port task than for the laparoscopic task (P = .03). The RES group was slower (P = .0019), with longer path length (P = .0010) but with greater smoothness (P = .0186) on the single-port task than the conventional laparoscopic task. Resident performance task time (P = .005) and smoothness (P = .045) improved with successive iterations.

DISCUSSION

Our data show that surgeons with clinical single-port surgery experience perform a simulated single-port surgical task better than inexperienced single-port surgeons. Furthermore, this performance is comparable to that achieved with conventional laparoscopic techniques. Performance of residents declined dramatically when confronted with the challenges of the single-port task but improved with practice. These results suggest a role for lab-based single-port training.

Gaze training improves the retention and transfer of laparoscopic technical skills in novices

BACKGROUND

Gaze training is an effective way of training basic laparoscopic skills, resulting in faster acquisition periods and more robust subsequent performance under pressure. The current study is a randomized control trial which examines whether the performance benefits of gaze training stand the test of time (delayed retention) and transfer to more complex skills.

METHODS

Thirty-six medical students were trained to proficiency (50 trials) on a one-handed laparoscopic task (picking and dropping balls) in either a discovery learning (DL) or gaze training (GT) group. Both groups performed the one-handed task in baseline, retention and delayed retention (1 month) tests. They also performed baseline, retention and delayed retention tests of a two-handed task (grasping and cutting). Performance (completion time) and gaze control (target locking) were assessed throughout.

RESULTS

For the one-handed task, the GT group displayed superior performance at retention (p < .001), underpinned by more expert-like gaze control (p < .05). The GT group also displayed superior performance in the one-handed task at delayed retention (p < .005), underpinned by more expert-like gaze control strategies (p < .001). Although the DL group's performance fell to 84% of performance at retention, the GT group maintained performance at 100% of retention. There were no differences between the groups for the two-handed task at retention (p = .140); however, at delayed retention, the GT group outperformed the DL group (p < .005) and displayed more expert-like gaze control (p < .001).

CONCLUSIONS

Novices trained to adopt an expert-like gaze control strategy were able to attain higher levels of performance more quickly than novices who learned by discovery alone. Furthermore, these skills were more durable over time and were transferable to more complex skills. Gaze training is a beneficial intervention to aid the acquisition of the basic motor skills required for laparoscopy.

Validation of virtual reality simulators: Key to the successful integration of a novel teaching technology into minimal access surgery

Minimal access surgery (MAS) requires additional training in the surgical curriculum, as skills needed to perform MAS are quite different from those used in open surgery. Moreover, residents do not seem to experience ample opportunity to gain such skills in the current surgical curriculum. Virtual reality (VR) simulation offers an interesting opportunity to train such skills in a safe, supporting environment. As with any new development, one should be careful about integrating costly technology into practice before it has been properly validated.This article outlines the requirements for a valid and integrated approach towards the integration of novel VR simulation systems in minimal access surgery.

Construct validity of fresh frozen human cadaver as a training model in minimal access surgery

BACKGROUND

The construct validity of fresh human cadaver as a training tool has not been established previously. The aims of this study were to investigate the construct validity of fresh frozen human cadaver as a method of training in minimal access surgery and determine if novices can be rapidly trained using this model to a safe level of performance.

METHODS

Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers. Expert laparoscopists (>100 laparoscopic procedures) performed 3 repetitions of identical tasks. Performances were scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. Scores for 3 consecutive repetitions were compared between experts and novices to determine construct validity. Furthermore, to determine if the novices reached a safe level, a trimmed mean of the experts score was used to define a benchmark. Mann-Whitney Utest was used for construct validity analysis and 1-sample t test to compare performances of the novice group with the benchmark safe score.

RESULTS

Ten novices and 2 experts were recruited. Four out of 5 tasks (nondominant to dominant hand transfer; simulated appendicectomy; intracorporeal and extracorporeal knot tying) showed construct validity. Novices' scores became comparable to benchmark scores between the eighth and tenth repetition.

CONCLUSION

Minimal access surgical training using fresh frozen human cadavers appears to have construct validity. The laparoscopic skills of novices can be accelerated through to a safe level within 8 to 10 repetitions.