The development of a virtual reality training curriculum for colonoscopy. Ann Surg. 2012;256:188-192. [PMID: 22664561 DOI: 10.1097/sla.0b013e31825b6e9c]

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective

Objectives

The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights.

Methods

Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis.

Results

Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide.

Conclusions

There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

To social with social distance: a case study on a VR-enabled graduation celebration amidst the pandemic

This paper introduces a timely case study on a 3D virtual reality-enabled graduation celebration project that provided an alternative approach to celebrating university graduation amidst the COVID-19 pandemic. The project was carefully designed with fun, engaging, and interactive activities to compensate for the cancelation of the conventional commencement in spring 2020 due to the pandemic. More than 20 graduating students, faculty and staff members participated in a 2-h virtual reality live event appearing as 3D avatars on their own computers. Quantitative and qualitative data collected from 10 participants were analyzed for user experience, cognitive contribution, technology acceptance, and the feasibility. Results revealed that such a project was technologically sound, functionally acceptable, user-friendly, and practically implementable. The results also informed the lessons learned from the current design and the places to improve.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10055-022-00646-2.

Educating Outpatients for Bowel Preparation Before Colonoscopy Using Conventional Methods vs Virtual Reality Videos Plus Conventional Methods: A Randomized Clinical Trial

IMPORTANCE

Adequate bowel preparation is essential for diagnostic, screening, and surveillance colonoscopy. Virtual reality (VR) has the characteristics of immersion, interaction, and imagination and has been widely used in medicine for training and teaching, indicating that it could be used in the education of outpatients for bowel preparation before colonoscopy.

OBJECTIVE

To investigate whether using VR videos for patient education before colonoscopy could improve bowel preparation.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-blinded, randomized clinical trial of 346 patients undergoing colonoscopy with local anesthesia in a tertiary care hospital was conducted between October 1, 2018, and November 1, 2020. Outpatients who had indications for colonoscopy and had not received one before were enrolled. Statistical analysis was performed from November 1 to December 31, 2020. All data were analyzed according to the intention-to-treat approach.

EXPOSURES

Conventional bowel preparation education (oral instructions and written materials that had the same contents) or conventional education plus VR videos.

MAIN OUTCOMES AND MEASURES

The primary outcome was the quality of bowel preparation measured by the Boston Bowel Preparation Scale score (range, 0-9, where 0 indicates extremely unsatisfactory bowel preparation and 9 indicates complete bowel preparation). Secondary outcomes included polyp and adenoma detection rates, compliance with complete bowel cleansing, preprocedure anxiety, overall satisfaction, and willingness to undergo a follow-up colonoscopy.

RESULTS

A total of 346 outpatients were enrolled in the trial, with 173 patients randomly assigned to each group (control group: 87 women [50.3%]; mean [SD] age, 50.5 [12.5] years; VR video group: 84 women [48.6%]; mean [SD] age, 52.6 [11.4] years). Baseline characteristics, including demographic information, medical history, lifestyle, and the characteristics of stool, were comparable between the VR video group and the control group. The mean (SD) Boston Bowel Preparation Scale score was significantly higher in the VR video group than in the control group (7.61 [1.65] vs 7.04 [1.70]; P = .002). The detection rate of polyps (72 of 172 [41.9%] vs 46 of 172 [26.7%]; P = .003) and the detection rate of adenomas (56 of 172 [32.6%] vs 38 of 172 [22.1%]; P = .03) were also higher in the VR video group. Patients who received VR education had better compliance (119 [68.8%] vs 87 [50.3%]; P < .001) and higher mean (SD) overall satisfaction (8.68 [1.70] vs 8.16 [2.15]; P = .01) with bowel preparation.

CONCLUSIONS AND RELEVANCE

Patients who received VR video education before colonoscopy had better bowel preparation, higher polyp and adenoma detection rates, and improved compliance and satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03667911.

A Virtual Reality Training Curriculum for Laparoscopic Colorectal Surgery

OBJECTIVE

Training within a competency-based curriculum (CBC) outside the operating room enhances performance during real basic surgical procedures. This study aimed to design and validate a virtual reality CBC for an advanced laparoscopic procedure: sigmoid colectomy.

DESIGN

This was a multicenter randomized study. Novice (surgeons who had performed <5 laparoscopic colorectal resections as primary operator), intermediate (between 10 and 20), and experienced surgeons (>50) were enrolled. Validity evidence for the metrics given by the virtual reality simulator, the LAP Mentor, was based on the second attempt of each task in between groups. The tasks assessed were 3 modules of a laparoscopic sigmoid colectomy (medial dissection [MD], lateral dissection [LD], and anastomosis) and a full procedure (FP). Novice surgeons were randomized to 1 of 2 groups to perform 8 further attempts of all 3 modules or FP, for learning curve analysis.

SETTING

Two academic tertiary care centers-division of surgery of St. Mary's campus, Imperial College Healthcare NHS Trust, London and Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, were involved.

PARTICIPANTS

Novice surgeons were residents in digestive surgery at St. Mary's and Nord Hospitals. Intermediate and experienced surgeons were board-certified academic surgeons.

RESULTS

A total of 20 novice surgeons, 7 intermediate surgeons, and 6 experienced surgeons were enrolled. Evidence for validity based on experience was identified in MD, LD, and FP for time (p = 0.005, p = 0.003, and p = 0.001, respectively), number of movements (p = 0.013, p = 0.005, and p = 0.001, respectively), and path length (p = 0.03, p = 0.017, and p = 0.001, respectively), and only for time (p = 0.03) and path length (p = 0.013) in the anastomosis module. Novice surgeons' performance significantly improved through repetition for time, movements, and path length in MD, LD, and FP. Experienced surgeons' benchmark criteria were defined for all construct metrics showing validity evidence.

CONCLUSIONS

A CBC in laparoscopic colorectal surgery has been designed. Such training may reduce the learning curve during real colorectal resections in the operating room.

Simulator training in gastrointestinal endoscopy - From basic training to advanced endoscopic procedures

Simulator-based gastrointestinal endoscopy training has gained acceptance over the last decades and has been extensively studied. Several types of simulators have been validated and it has been demonstrated that the use of simulators in the early training setting accelerates the learning curve in acquiring basic skills. Current GI endoscopy simulators lack the degree of realism that would be necessary to provide training to achieve full competency or to be applicable in certification. Virtual Reality and mechanical simulators are commonly used in basic flexible endoscopy training, whereas ex vivo and in vivo models are used in training the most advanced endoscopic procedures. Validated models for the training of more routine therapeutic interventions like polypectomy, EMR, stenting and haemostasis are lacking or scarce and developments in these areas should be encouraged.

Training and competence assessment in GI endoscopy: a systematic review

INTRODUCTION

Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme.

AIMS

The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence.

METHODS

A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round.

RESULTS

The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance.

CONCLUSIONS

The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.

Role of virtual reality simulation in endoscopy training

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simulators and the long-term benefits of their use are also discussed.

Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial

BACKGROUND

GI endoscopy simulation-based training augments early clinical performance; however, the optimal manner by which to deliver training is unknown.

OBJECTIVE

We aimed to validate a simulation-based structured comprehensive curriculum (SCC) designed to teach technical, cognitive, and integrative competencies in colonoscopy.

DESIGN

Single-blinded, randomized, controlled trial.

SETTING

Endoscopic simulation course at an academic hospital.

PARTICIPANTS AND INTERVENTIONS

Thirty-three novice endoscopists were allocated to an SCC group or self-regulated learning (SRL) group. The SCC group received a curriculum consisting of 6 hours of didactic lectures and 8 hours of virtual reality simulation-based training with expert feedback. The SRL group was provided a list of desired objectives and was instructed to practice on the simulator for an equivalent time (8 hours).

MAIN OUTCOME MEASUREMENTS

Clinical transfer was assessed during 2 patient colonoscopies using the Joint Advisory Group Direct Observation of Procedural Skills (JAG DOPS) scale. Secondary outcome measures included differences in procedural knowledge, immediate post-training simulation performance, and delayed post-training (4-6 weeks) performance during an integrated scenario test on the JAG DOPS communication and integrated scenario global rating scales.

RESULTS

There was no significant difference in baseline or post-training performance on the simulator task. The SCC group performed superiorly during their first and second clinical colonoscopies. Additionally, the SCC group demonstrated significantly better knowledge and colonoscopy-specific performance, communication, and global performance during the integrated scenario.

LIMITATIONS

We were unable to measure SRL participants' effort outside of mandatory training. In addition, feedback metrics and number of available simulation cases are limited.

CONCLUSIONS

These results support integration of endoscopy simulation into a structured curriculum incorporating instructional feedback and complementary didactic knowledge as a means to augment technical, cognitive, and integrative skills acquisition, as compared with SRL on virtual reality simulators. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01991522.)

Simulated colonoscopy training leads to improved performance during patient-based assessment

BACKGROUND

Virtual reality (VR) endoscopy simulators are increasingly being used in the training of novice endoscopists. There are, however, insufficient data regarding the effect of simulator training on the early learning curve of novice endoscopists.

OBJECTIVE

The aim of this study was to assess the clinical performance of novice endoscopists during colonoscopy after intensive and prolonged training on a VR endoscopy simulator.

DESIGN

Prospective study.

SETTING

Single university medical center.

PATIENTS

Patient-based assessment (PBA) of performance was carried out on patients routinely scheduled for colonoscopy.

INTERVENTIONS

Eighteen trainees without any endoscopic experience were included in the study. They were divided into 2 groups. The simulator-training program consisted of either 50 (group I) or 100 (group II) VR colonoscopies. After 10, 30, and 50 (group I) and after 20, 60, and 100 (group II) VR colonoscopies, trainees underwent both simulator-based assessment and PBA.

MAIN OUTCOME MEASUREMENTS

Cecal intubation time, colonic insertion depth, and cecal intubation rate.

RESULTS

Eighteen novices participated in the study. All completed VR training and assessments. The mean cecal intubation time on the SBA decreased from a baseline of 9.50 minutes to 2.20 minutes at completion of the training (P = .002). Colonic insertion depth during PBA improved from 29.4 cm to 63.7 cm (P < .001). The learning effect of simulator training ceased after 60 colonoscopies.

LIMITATIONS

Single-center study, no formal sample size calculation.

CONCLUSIONS

VR training by using a colonoscopy simulator leads to a significant improvement in performance with the simulator itself and, more importantly, to significantly improved performances during patient-based colonoscopy. This study demonstrates the rationale for intensive simulator training in the early learning curve of novices performing colonoscopy.

Advanced training in laparoscopic abdominal surgery: a systematic review

BACKGROUND

Simulation has spread widely this last decade, especially in laparoscopic surgery, and training out of the operating room has proven its positive impact on basic skills during real laparoscopic procedures. Few articles dealing with advanced training in laparoscopic abdominal surgery, however, have been published. Such training may decrease learning curves in the operating room for junior surgeons with limited access to complex laparoscopic procedures as a primary operator.

METHODS

Two reviewers, using MEDLINE, EMBASE, and The Cochrane Library conducted a systematic research with combinations of the following keywords: (teaching OR education OR computer simulation) AND laparoscopy AND (gastric OR stomach OR colorectal OR colon OR rectum OR small bowel OR liver OR spleen OR pancreas OR advanced surgery OR advanced procedure OR complex procedure). Additional studies were searched in the reference lists of all included articles.

RESULTS

Fifty-four original studies were retrieved. Their level of evidence was low: most of the studies were case series and one fifth were purely descriptive, but there were eight randomized trials. Pig models and video trainers as well as gastric and colorectal procedures were mainly assessed. The retrieved studies showed some encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly on the training tool itself. Some tools have been proven to be construct-valid.

CONCLUSION

Higher-quality studies are required to appraise educational value in this field.

A virtual reality endoscopic simulator augments general surgery resident cancer education as measured by performance improvement

Colorectal cancer is the second most common cause of death in the USA. The need for screening colonoscopies, and thus adequately trained endoscopists, particularly in rural areas, is on the rise. Recent increases in required endoscopic cases for surgical resident graduation by the Surgery Residency Review Committee (RRC) further emphasize the need for more effective endoscopic training during residency to determine if a virtual reality colonoscopy simulator enhances surgical resident endoscopic education by detecting improvement in colonoscopy skills before and after 6 weeks of formal clinical endoscopic training. We conducted a retrospective review of prospectively collected surgery resident data on an endoscopy simulator. Residents performed four different clinical scenarios on the endoscopic simulator before and after a 6-week endoscopic training course. Data were collected over a 5-year period from 94 different residents performing a total of 795 colonoscopic simulation scenarios. Main outcome measures included time to cecal intubation, "red out" time, and severity of simulated patient discomfort (mild, moderate, severe, extreme) during colonoscopy scenarios. Average time to intubation of the cecum was 6.8 min for those residents who had not undergone endoscopic training versus 4.4 min for those who had undergone endoscopic training (p < 0.001). Residents who could be compared against themselves (pre vs. post-training), cecal intubation times decreased from 7.1 to 4.3 min (p < 0.001). Post-endoscopy rotation residents caused less severe discomfort during simulated colonoscopy than pre-endoscopy rotation residents (4 vs. 10%; p = 0.004). Virtual reality endoscopic simulation is an effective tool for both augmenting surgical resident endoscopy cancer education and measuring improvement in resident performance after formal clinical endoscopic training.

Toward technology-supported surgical training: the potential of virtual simulators in laparoscopic surgery

BACKGROUND AND AIMS

The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery.

MATERIAL AND METHODS

This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills.

RESULTS AND CONCLUSIONS

There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.

The usefulness of 3-dimensional virtual simulation using haptics in training orotracheal intubation

Objectives. Airway control is the most critical treatment. The most common and basic method of endotracheal intubation is orotracheal intubation. To perform accurate and rapid tracheal intubation, appropriate education and training are required. We developed the virtual simulation program utilizing the 3-dimensional display and haptic device to exercise orotracheal intubation, and the educational effect of this program was compared with that of the mannequin method. Method. The control group used airway mannequin and virtual intubation group was trained with new program. We videotaped both groups during objective structured clinical examination (OSCE) with airway mannequin. The video was reviewed and scored, and the rate of success and time were calculated. Result. The success rate was 78.6% in virtual intubation group and 93.3% in control group (P = 0.273). There was no difference in overall score of OSCE (21.14 ± 4.28 in virtual intubation group and 23.33 ± 4.45 in control group, P = 0.188), the time spent in successful intubation (P = 0.432), and the number of trials (P > 0.101). Conclusion. The virtual simulation with haptics had a similar effect compared with mannequin, but it could be more cost effective and convenient than mannequin training in time and space.

Context dependent memory in two learning environments: the tutorial room and the operating theatre

BACKGROUND

Psychologists have previously demonstrated that information recall is context dependent. However, how this influences the way we deliver medical education is unclear. This study aimed to determine if changing the recall context from the learning context affects the ability of medical students to recall information.

METHODS

Using a free recall experimental model, fourteen medical student participants were administered audio lists of 30 words in two separate learning environments, a tutorial room and an operating theatre. They were then asked to recall the words in both environments. While in the operating theatre participants wore appropriate surgical clothing and assembled around an operating table. While in the tutorial room, participants dressed casually and were seated around a table. Students experienced the same duration (15 minutes) and disruption in both environments.

RESULTS

The mean recall score from the 28 tests performed in the same environment was 12.96 +/- 3.93 (mean, SD). The mean recall score from the 28 tests performed in an alternative environment to the learning episode was 13.5 +/- 5.31(mean, SD), indicating that changing the recall environment from the learning environment does not cause any statistical difference (p=0.58). The average recall score of participants who learned and recalled in the tutorial room was 13.0 +/- 3.84 (mean, SD). The average recall score of participants who learnt and recalled in the operating theatre was 12.92 +/- 4.18 (mean, SD), representing no significant difference between the two environments for learning (p=0.4792).

CONCLUSIONS

The results support the continued use of tutorial rooms and operating theatres as appropriate environments in which to teach medical students, with no significant difference in information recall seen either due to a same context effect or specific context effect.

A randomized controlled trial evaluating endoscopic and laparoscopic training in skills transfer for novices performing a simulated NOTES task

BACKGROUND

The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task.

METHODS

A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors.

RESULTS

The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001).

CONCLUSION

This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.