Towards Virtual VATS, Face, and Construct Evaluation for Peg Transfer Training of Box, VR, AR, and MR Trainer

Objective improvement in dexterity for trainees undergoing a video-assisted thoracoscopic surgery simulation program, a prospective single center study

Background

Video-assisted thoracoscopic surgery (VATS) is the recommended approach for the management of early-stage operable non-small cell lung carcinoma as well as for other pathologies of the thoracic cavity. Although VATS approaches have been largely adopted in Europe and North America, teaching the technique to novice thoracic surgery trainees remains challenging and non-standardized. Our objective was to assess the impact of a VATS simulation training program on the dexterity of thoracic surgery residents in a prospective single institution study.

Methods

We developed a 6-month VATS simulation training program on two different dry-lab simulators (Johnson & Johnson Ethicon Stupnik® lobectomy model; CK Surgical Simulation® Crabtree perfused lobectomy model) and assessed the skills of first year thoracic surgery residents (study group, n=7) before and after this program using three standardized exercises on the Surgical Science Simball® Box (peg placement on a board, rope insertion in loops, precision circle cutting). The results were compared to those of last-year medical students who performed the same Simball® Box exercises at a 6-month interval without undergoing a training program (control group, n=5). For each participant, the travel distances of instruments, operation time and absences of periods of extreme motion were assessed for each exercise by the use of the computer-based evaluation of the Simball® Box.

Results

After the 6-month VATS training program, all residents revealed a significant increase of their performance status with respect to instrument travel distances operation times and absence of periods of extreme motion in all three exercises performed. The performance of the control group was not different from the study group prior to the training program and remained unchanged 6 months later, for all exercises and parameters assessed.

Conclusions

Our results suggest that the implementation of a VATS simulation training program objectively increases the dexterity of thoracic surgery residents and could be an interesting training tool for their surgical education.

The Role of Augmented Reality in Surgical Training: A Systematic Review

This review aims to provide an update on the role of augmented reality (AR) in surgical training and investigate whether the use of AR improves performance measures compared to traditional approaches in surgical trainees.

PUBMED, EMBASE, Google Scholar, Cochrane Library, British Library and Science Direct were searched following PRIMSA guidelines. All English language original studies pertaining to AR in surgical training were eligible for inclusion. Qualitative analysis was performed and results were categorised according to simulator models, subsequently being evaluated using Messick's framework for validity and McGaghie's translational outcomes for simulation-based learning.

Of the 1132 results retrieved, 45 were included in the study. 29 platforms were identified, with the highest 'level of effectiveness' recorded as 3. In terms of validity parameters, 10 AR models received a strong 'content validity' score of 2.15 models had a 'response processes' score ≥ 1. 'Internal structure' and 'consequences' were largely not discussed. 'Relations to other variables' was the best assessed criterion, with 9 platforms achieving a high score of 2. Overall, the Microsoft HoloLens received the highest level of recommendation for both validity and level of effectiveness.

Augmented reality in surgical education is feasible and effective as an adjunct to traditional training. The Microsoft HoloLens has shown the most promising results across all parameters and produced improved performance measures in surgical trainees. In terms of the other simulator models, further research is required with stronger study designs, in order to validate the use of AR in surgical training.

Autonomous sequential surgical skills assessment for the peg transfer task in a laparoscopic box-trainer system with three cameras

In laparoscopic surgery, surgeons should develop several manual laparoscopic skills before carrying out real operative procedures using a low-cost box trainer. The Fundamentals of Laparoscopic Surgery (FLS) program was developed as a program to assess fundamental knowledge and surgical skills, required for basic laparoscopic surgery. The peg transfer task is a hands-on exam in the FLS program that assists a trainee to understand the relative minimum amount of grasping force necessary to move the pegs from one place to another place without dropping them. In this paper, an autonomous, sequential assessment algorithm based on deep learning, a multi-object detection method, and, several sequential If-Then conditional statements have been developed to monitor each step of a surgeon’s performance. Images from three different cameras are used to assess whether the surgeon executes the peg transfer task correctly and to display a notification on any errors on the monitor immediately. This algorithm improves the performance of a laparoscopic box-trainer system using top, side, and front cameras and removes the need for any human monitoring during a peg transfer task. The developed algorithm can detect each object and its status during a peg transfer task and notifies the resident about the correct or failed outcome. In addition, this system can correctly determine the peg transfer execution time, and the move, carry, and dropped states for each object by the top, side, and front-mounted cameras. Based on the experimental results, the proposed surgical skill assessment system can identify each object at a high score of fidelity, and the train-validation total loss for the single-shot detector (SSD) ResNet50 v1 was about 0.05. Also, the mean average precision (mAP) and Intersection over Union (IoU) of this detection system were 0.741, and 0.75, respectively. This project is a collaborative research effort between the Department of Electrical and Computer Engineering and the Department of Surgery, at Western Michigan University.

Virtual Reality Head-Mounted Displays in Medical Education: A Systematic Review

SUMMARY STATEMENT

Simulation-based training using virtual reality head-mounted displays (VR-HMD) is increasingly being used within the field of medical education. This article systematically reviews and appraises the quality of the literature on the use of VR-HMDs in medical education. A search in the databases PubMed/MEDLINE, Embase, ERIC, Scopus, Web of Science, Cochrane Library, and PsychINFO was carried out. Studies were screened according to predefined exclusion criteria, and quality was assessed using the Medical Education Research Study Quality Instrument. In total, 41 articles were included and thematically divided into 5 groups: anatomy, procedural skills, surgical procedures, communication skills, and clinical decision making. Participants highly appreciated using VR-HMD and rated it better than most other training methods. Virtual reality head-mounted display outperformed traditional methods of learning surgical procedures. Although VR-HMD showed promising results when learning anatomy, it was not considered better than other available study materials. No conclusive findings could be synthesized regarding the remaining 3 groups.

How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis

Background

Using traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation.

Objective

The aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance.

Methods

We conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration.

Results

Of the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration.

Conclusions

Technical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations.

Application of VR Technology to the Training of Paramedics

The virtual world has long been a focus not only of the gaming sphere, but also of the manufacturing and educational industries. The virtual world and its technology have many advantages, the basic ones being, for example, the use of experiential learning, with which the human brain can remember some things better and faster. It was due to the advantages of virtual reality technology that we decided to create an educational system on safety and health at work, and we focused on the healthcare segment due to the COVID-19 pandemic. Thanks to the cooperation of a professional consortium, we created an educational system for safety and health at work and carried out several extensive laboratory measurements, the results of which we followed up in practical measurements with medical staff. The created system is inherently unique and applicable and can be used across several industries. The article presents three basic types of scenarios as well as an evaluation of satisfaction with the proposed system from test participants, i.e., nurses.

Extended, virtual and augmented reality in thoracic surgery: a systematic review

OBJECTIVES

Extended reality (XR), encompassing both virtual reality (VR) and augmented reality, allows the user to interact with a computer-generated environment based on reality. In essence, the immersive nature of VR and augmented reality technology has been warmly welcomed in all aspects of medicine, gradually becoming increasingly feasible to incorporate into everyday practice. In recent years, XR has become increasingly adopted in thoracic surgery, although the extent of its applications is unclear. Here, we aim to review the current applications of XR in thoracic surgery.

METHODS

A systematic database search was conducted of original articles that explored the use of VR and/or augmented reality in thoracic surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to December 2020.

RESULTS

Our search yielded 1494 citations, of which 21 studies published from 2007 to 2019 were included in this review. Three main areas were identified: (i) the application of XR in thoracic surgery training; (ii) preoperative planning of thoracic procedures; and (iii) intraoperative assistance. Overall, XR could produce progression along the learning curve, enabling trainees to reach acceptable standards before performing in the operating theatre. Preoperatively, through the generation of 3D-renderings of the thoracic cavity and lung anatomy, VR increases procedural accuracy and surgical confidence through familiarization of the patient's anatomy. XR-assisted surgery may have therapeutic use particularly for complex cases, where conventional methods would yield inadequate outcomes due to inferior accuracy.

CONCLUSION

XR represents a salient step towards improving thoracic surgical training, as well as enhancing preoperative planning and intraoperative guidance.

Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

Background

Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective

We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods

We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results

A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions

The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

Human corpse model for video-assisted thoracoscopic lobectomy simulation and training

OBJECTIVES

Minimally invasive surgery simulation is an integral part of surgical education and skills acquisition. Our goal was to present a new video-assisted thoracic surgery simulation model based on the human corpse as an alternative to animal models.

METHODS

Selective cannulation of the cadaver heart was used to fill the pulmonary vessels with a gel to improve the visibility and tactile feedback of the vessels and to simulate any bleeding complications. During surgical simulation, the tutor fills out a questionnaire designed to evaluate the duration of the procedure, the correct completion of the surgical steps and the occurrence of complications. At the end of the simulation session, in order to compare the simulation to clinical practice, all the participants were asked to answer 5 questions using a scale from 1 to 10.

RESULTS

We have performed 2 hands-on sessions using 2 human corpses for each session. Each surgeon performed 1 lobectomy using video-assisted thoracoscopic surgery (VATS) first as the operator and at least 1 lobectomy as an assistant. The median operative time was 83 min in favour of surgeons who had previously performed more than 30 video-assisted lobectomies (P = 0.03). All the surgeons were able to complete all the steps of the procedure; surgeons who had performed fewer than 10 lobectomies required more support by the tutors than the other surgeons. The median total score was 40.5 (interquartile range 39-44.8).

CONCLUSIONS

We believe that this model includes most of the features necessary to validate a surgical simulator and allows realistic training for performing a VATS lobectomy. This model could be an effective alternative to anaesthetized animals for VATS lobectomy training and simulation.