Virtual reality simulation in endoscopy training: Current evidence and future directions

Virtual reality cricothyrotomy - a tool in medical emergency education throughout various disciplines

OBJECTIVES

A cricothyrotomy represents an emergency procedure that may be considered a last option for securing the airway. While fortunately rare, it is important to note that such invasive procedures must be mastered if they are to be used. Therefore, regular training is essential to gain routine. The aim of the present study was to investigate whether professional groups with different levels of experience with the procedure succeed in learning the procedure with a virtual reality trainer.

MATERIALS AND METHODS

In a multicenter approach, 146 employees with four different professional backgrounds-otorhinolaryngologists, anesthesiologists, emergency physicians and certified nurses-were included in the study. The participants were required to complete a virtual reality (VR) cricothyrotomy scenario in three consecutive runs, and the time required and errors in the procedure were recorded. The training experience was subsequently evaluated subjectively using a questionnaire.

RESULTS

The study included 146 participants with an average age of 33 years and an average of 5 years of professional experience. The majority of participants (74%) reported an improvement in the speed of the procedure and in the procedural steps (87%). These subjective improvements were confirmed objectively by the time required for completion of the procedure and the points achieved. Gaming experience had a significant effect on both the score (p = 0.023) and procedure time (p = 0.039), whereas age and medical specialization did not. Real-life experience with cricothyrotomy had no significant effect on performance in VR.

CONCLUSION

Virtual reality provides an effective method for training healthcare professionals in cricothyrotomy, regardless of their specialty or prior experience. The participants showed significant improvements in both the speed and accuracy of the procedure after training, regardless of their prior experience or medical background. Further research is necessary to assess the benefits of VR simulation for training cricothyrotomy in real-world procedures.

TRIAL REGISTRATION

DRKS00031736, registered on the 20th of April 2023.

[The benefits of simulation in bronchial endoscopy]

INTRODUCTION

Bronchoscopy is an invasive procedure that can be difficult for patients to tolerate, especially if the operator is inexperienced. Simulation enables trainees to perfect their skills, while adhering to an ethical approach: "never the first time on a patient". The main aim of our study is to demonstrate the benefits of simulation in learning how to perform bronchial endoscopy, in terms of dexterity, speed of execution and anatomical recognition by the operator.

METHODS

Prospective, monocentric study conducted at SIMU SANTE in the Amiens university hospital. Our study population consisted of volunteer interns or young doctors who were new to bronchoscopy. After filling out a questionnaire and undergoing theoretical training, participants completed three training sessions at regular intervals. We compared three groups according to the interval between sessions (group A: 15 days, group B: 30 days, group C: 60 days). Regarding judgment criteria, we observed several parameters: dexterity, speed and anatomical recognition by the operator.

RESULTS

In terms of speed, median procedure time was reduced by 40% after three sessions. Dexterity improved in the 15-day interval group, with a significant reduction in wall contact. Concerning the precision parameter, we observed a significant difference between the three groups, with greater improvement in the identification score in the 15-day interval group.

CONCLUSION

Simulation has made it possible to acquire basic skills in bronchoscopy. Training sessions with a short time interval (one session every 15 days) most rapidly increase operators' speed, dexterity and precision.

Intraoperative bleeding model for swine gastric endoscopic submucosal dissection via heparinization

Background and study aims: Live swine have a high degree of coagulation and aggregation and using them for training about how to manage intraoperative bleeding during endoscopic submucosal dissection (ESD) is unsatisfactory. This study aimed to identify the appropriate heparin dose in an intraoperative bleeding model and validate its applicability. Methods: First, we explored the dose of heparin required for a swine bleeding model in which the activated clotting time reached and maintained the upper limit of measurement (1500 s) after 10 minutes. Second, we compared intraoperative bleeding and hematoma frequency during ESD for 2-cm lesions between the heparinized bleeding model and control groups. Intraoperative bleeding was classified according to the Forrest classification. Results: The combination of a bolus (300 U/kg), continuous infusion (300 U/kg/h), and a bolus dose (150 U/kg) of heparin 10 minutes after the first infusion was identified as the dose for the bleeding model. Five ESDs were performed in each heparinized bleeding model and the control group. The median number of intraoperative bleeds was significantly higher in the heparinized model than in the control group (5 interquartile range [IQR] 4-7 vs. 3 [IQR 0-4, P = 0.028). All of the intraoperative bleeding events oozing (Forrest Ib) rather than spurting (Forrest Ia). The median number of hematomas was significantly higher in the heparinized model group than in the control group (3 [IQR 1-4] vs. 0 [IQR 0-1], P = 0.023). Conclusions: High doses of heparin significantly increased intraoperative bleeding and hematoma during swine ESD.

Reviewing the current state of virtual reality integration in medical education - a scoping review

BACKGROUND

In medical education, new technologies like Virtual Reality (VR) are increasingly integrated to enhance digital learning. Originally used to train surgical procedures, now use cases also cover emergency scenarios and non-technical skills like clinical decision-making. This scoping review aims to provide an overview of VR in medical education, including requirements, advantages, disadvantages, as well as evaluation methods and respective study results to establish a foundation for future VR integration into medical curricula.

METHODS

This review follows the updated JBI methodology for scoping reviews and adheres to the respective PRISMA extension. We included reviews in English or German language from 2012 to March 2022 that examine the use of VR in education for medical and nursing students, registered nurses, and qualified physicians. Data extraction focused on medical specialties, subjects, curricula, technical/didactic requirements, evaluation methods and study outcomes as well as advantages and disadvantages of VR.

RESULTS

A total of 763 records were identified. After eligibility assessment, 69 studies were included. Nearly half of them were published between 2021 and 2022, predominantly from high-income countries. Most reviews focused on surgical training in laparoscopic and minimally invasive procedures (43.5%) and included studies with qualified physicians as participants (43.5%). Technical, didactic and organisational requirements were highlighted and evaluations covering performance time and quality, skills acquisition and validity, often showed positive outcomes. Accessibility, repeatability, cost-effectiveness, and improved skill development were reported as advantages, while financial challenges, technical limitations, lack of scientific evidence, and potential user discomfort were cited as disadvantages.

DISCUSSION

Despite a high potential of VR in medical education, there are mandatory requirements for its integration into medical curricula addressing challenges related to finances, technical limitations, and didactic aspects. The reported lack of standardised and validated guidelines for evaluating VR training must be overcome to enable high-quality evidence for VR usage in medical education. Interdisciplinary teams of software developers, AI experts, designers, medical didactics experts and end users are required to design useful VR courses. Technical issues and compromised realism can be mitigated by further technological advancements.

The synergistic role of virtual coaching with simulation-based mastery learning for upper endoscopy

Introduction

Our simulation-based mastery learning (SBML) curriculum, delivered in person, has been shown to successfully train novices in structured esophagogastroduodenoscopy (EGD). SBML with virtual coaching (VC) has the potential to improve the effectiveness and efficiency of endoscopy training and expand access to trainees from around the world. We share our observations conducting an EGD training course using SBML with VC.

Methods

We conducted a 1-week virtual SBML course for novice trainees across seven academic centers in the USA and Asia. The cognitive component was delivered using an online learning platform. For technical skills, a virtual coach supervised hands-on training and local coaches provided assistance when needed. At the end of training, an independent rater assessed simulation-based performance using a validated assessment tool. We assessed the clinical performance of 30 EGDs using the ASGE Assessment of Competency in Endoscopy tool. We compared the trainees' scores to our cohort trained using in-person SBML training using non-inferiority t-tests.

Results

We enrolled 21 novice trainees (mean age: 30.8 ± 3.6 years; female: 52%). For tip deflection, the trainees reached the minimum passing standard after 31 ± 29 runs and mastery after 52 ± 37 runs. For structured EGD, the average score for the overall exam was 4.6 ± 0.6, similar to the in-person cohort (4.7 ± 0.5, p = 0.49). The knowledge-based assessment was also comparable (virtual coaching: 81.9 ± 0.1; direct coaching: 78.3 ± 0.1; p = 0.385). Over time, our novice trainees reached clinical competence at a similar rate to our historical in-person control.

Conclusions

VC appears feasible and effective for training novice gastroenterology trainees. VC allowed us to scale our SBML course, expand access to experts, and administer SBML simultaneously across different sites at the highest standards.

Virtual reality cricothyrotomy - a case-control study on gamification in emergency education

BACKGROUND

Cricothyrotomy is an invasive and rare emergency intervention to secure the airway in a "cannot intubate, cannot ventilate" situation. This leads to lack of routine. Cricothyrotomy is performed only hesitantly. Therefore, we aim to improve teaching by including a virtual reality (VR) cricothyrotomy as a learning tool.

METHODS

We programmed the VR cricothyrotomy in the C# programming language on the open-source Unity platform. We could include 149 students that we randomly assigned to either a study group (VR cricothyrotomy) or control group (educational video). We asked the study group to subjectively rate the VR cricothyrotomy. To evaluate our intervention (VR cricothyrotomy) we took the time participants needed to perform a cricothyrotomy on a plastic model of a trachea and evaluated the correct procedural steps.

RESULTS

The majority of students that performed the VR simulation agreed that they improved in speed (81%) and procedural steps (92%). All participants completed the cricothyrotomy in 47s ± 16s and reached a total score of 8.7 ± 0.7 of 9 possible points. We saw no significant difference in time needed to perform a cricothyrotomy between study and control group (p > 0.05). However, the total score of correct procedural steps was significantly higher in the study group than in the control group (p < 0.05).

CONCLUSIONS

Virtual reality is an innovative learning tool to improve teaching of emergency procedures. The VR cricothyrotomy subjectively and objectively improved correct procedural steps. Digitized education fills an educational gap between pure haptic experience and theoretical knowledge. This is of great value when focusing on extension of factual knowledge.

TRIAL REGISTRATION

DRKS00031736, registered on the 20th April 2023.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

Development of a virtual reality-based zygomatic implant surgery training system with global collision detection and optimized finite element method model

BACKGROUND AND OBJECTIVE

Zygomatic implant surgery is challenging due to the complex structure of the zygomatic bone, limited visual range during surgery, and lengthy implant path. Moreover, traditional training methods are costly, and experimental subjects are scarce.

METHODS

To overcome these challenges, we propose a novel training system that integrates visual, haptic, and auditory feedback to create a more immersive surgical experience. The system uses dynamic bounding volume hierarchy (BVH) and Symplectic Euler to detect global collisions between surgical tools and models, while an optimized finite element method (FEM) model simulates soft tissue and detects collisions. Compared to previous works, our system achieves global rigid-body collisions between surgical tools and patient models, while also providing stable and realistic simulation and collisions of soft tissues. This advancement offers a more realistic simulation for zygomatic implant surgery.

RESULTS

We conducted three experiments and evaluations. The first experiment measured the axial force generated during the zygomatic implant simulation process and compared it with actual surgery, demonstrating the realistic force rendering feedback of our system. The second evaluation involved 15 novice surgeons who experienced the system and completed a questionnaire survey focusing on five aspects. The results showed satisfactory evaluations. The third experiment involved six surgeons who underwent in-depth training for two hours daily and were tested on the first, third, and fifth days. We collected data and combined it with the doctors' feedback to prove that our system can improve surgeons' proficiency in zygomatic implant surgery and provide a novel training solution for this procedure.

CONCLUSION

We have innovatively integrated global collision detection and optimized soft tissue simulation into our system. Furthermore, we have conducted experimental validation to demonstrate the effectiveness of this implementation. We present a novel solution for zygomatic implant surgery training.

Enhancing the Quality of Upper Gastrointestinal Endoscopy: Current Indicators and Future Trends

The quality of upper gastrointestinal endoscopy (EGD) is crucial and carries significant consequences for patient outcomes, the employment of healthcare resources, and the future course of gastroenterology as a medical specialty. In this review, we navigate through the terrain of the Quality Indicators (QIs) for EGD, shedding light on their indispensable function in ensuring and augmenting the quality of patient care throughout the pre-procedural, intra-procedural, post-procedural, and outcome-oriented facets of the practice. We delve into the comprehensive scope of the QIs and the challenges impeding the delivery of high-quality EGD, from variability in practitioner training and patient compliance to the systemic limitations of current QIs and the barriers hindering the adoption of advanced techniques. Future directions for bolstering the quality of EGD are highlighted, encapsulating the integration of emergent endoscopic technologies, the evolution of patient-centered metrics, the refinement of endoscopist training and credentialing processes, and the promise held by Artificial Intelligence (AI). Particular emphasis is placed on the role of advanced endoscopic techniques and equipment in enhancing EGD quality. This article presents a cogent narrative, promoting the pursuit of excellence in EGD as an ever-evolving endeavor that necessitates the collective dedication of clinicians, researchers, educators, and policymakers.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

Development and validation of a simulation-based assessment tool in colonoscopy

BACKGROUND

Colonoscopy is difficult to learn. Virtual reality simulation training is helpful, but how and when novices should progress to patient-based training has yet to be established. To date, there is no assessment tool for credentialing novice endoscopists prior to clinical practice. The aim of this study was to develop such an assessment tool based on metrics provided by the simulator. The metrics used for the assessment tool should be able to discriminate between novices, intermediates, and experts and include essential checklist items for patient safety.

METHODS

The validation process was conducted based on the Standards for Educational and Psychological Testing. An expert panel decided upon three essential checklist items for patient safety based on Lawshe's method: perforation, hazardous tension to the bowel wall, and cecal intubation. A power calculation was performed. In this study, the Simbionix GI Mentor II simulator was used. Metrics with discriminatory ability were identified with variance analysis and combined to form an aggregate score. Based on this score and the essential items, pass/fail standards were set and reliability was tested.

RESULTS

Twenty-four participants (eight novices, eight intermediates, and eight expert endoscopists) performed two simulated colonoscopies. Four metrics with discriminatory ability were identified. The aggregate score ranged from 4.2 to 51.2 points. Novices had a mean score of 10.00 (SD 5.13), intermediates 24.63 (SD 7.91), and experts 30.72 (SD 11.98). The difference in score between novices and the other two groups was statistically significant (p<0.01). Although expert endoscopists had a higher score, the difference was not statistically significant (p=0.40). Reliability was good (Cronbach's alpha=0.86). A pass/fail score was defined at 17.1 points with correct completion of three essential checklist items, resulting in three experts and three intermediates failing and one novice passing the assessment.

CONCLUSION

We established a valid and reliable assessment tool with a pass/fail standard on the simulator. We suggest using the assessment after simulation-based training before commencing work-based learning.

The effects of virtual reality-based bronchoscopy simulator on learning outcomes of medical trainees: A systematic review

Background and Aims

Conventional medical training routes of bronchoscopy may decrease patients' comfort and increase procedure-related morbidity. Virtual reality (VR)-based bronchoscopy is a beneficial and safe solution for teaching trainees. The aim of this systematic review was to study the effectiveness of VR-based bronchoscopy simulators on the learning outcomes of medical trainees.

Methods

Well-known sources (i.e., Scopus, ISI Web of Science, and Medline via PubMed) were systematically searched using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on December, 2021. Peer-reviewed English papers that used VR-based simulation for bronchoscopy training were included. The articles that were studying other technologies, or those that were unrelated to the topic, were excluded. The risk of bias was assessed using the Joanna Briggs Institute checklists for quasi-experimental studies and randomized controlled trials (RCTs).

Results

Out of 343 studies, 8 of them met our inclusion criteria. An appropriate control group and statistical analysis were the most common and unavoidable sources of bias in included non-RCTs, and lack of blinding in participants was the most common source of bias in RCTs. The included studies evaluated learning outcomes regarding dexterity (N = 5), speed (N = 3), the accuracy of procedures (N = 1), and the need for verbal assistance (N = 1). Based on the results, 100% (5/5) and 66% (2/3) of studies showed that the use of VR-based simulation on the learning outcomes of medical trainees led to improvement in manual ability (i.e., dexterity) and swiftness of execution (i.e., speed in performance), respectively. Additionally, improving the accuracy of subjects' performance, and reducing the need for verbal guidance and physical assistance was reported in studies that evaluated these variables.

Conclusion

VR bronchoscopy simulator as a training method for teaching medical trainees, especially for novices has the potential to improve medical trainees' performance and reduce complications. Further studies are needed to evaluate the positive effects of VR-based simulation on the learning outcomes of medical trainees.

Virtual reality psychological intervention helps reduce preoperative anxiety in patients undergoing carotid artery stenting: a single-blind randomized controlled trial

Objective

This study aimed to explore the effectiveness and applicability of a psychological intervention using virtual reality (VR) to reduce preoperative anxiety in patients undergoing carotid artery stenting (CAS).

Methods

A total of 114 patients aged 18-86 years who were scheduled to undergo CAS were randomized to the VR and control groups. Patients in the VR group used a VR headset to view a 16-min psychological intervention video, while those in the control group used a tablet for viewing. The primary assessment instrument was the State Anxiety Inventory (S-AI), which was given 20 min before and after the intervention and 24 h after surgery. Secondary assessment tools were the Self-efficacy for Managing Chronic Disease (SEMCD-6) scale, which was completed before the intervention and 24 h after the operation, a smart bracelet to assess sleep quality, monitored in the evening before the operation, and the VR Suitability and Satisfaction Questionnaire, completed 24 h after the operation.

Results

The two groups were similar in terms of demographic information, preintervention STAI scores and preintervention SEMCD-6 scores (p > 0.05). S-AI scores were lower in both groups after the intervention and surgery, and the scores of the VR group were lower than those of the control group (p = 0.036, p = 0.014). SEMCD-6 scores post-surgery had improved in both groups, but the VR group had significantly higher scores than the control group (p = 0.005). Smart bracelet measurements showed no significant differences in postintervention sleep quality between the two groups (p = 0.540). For satisfaction, the VR group scored higher in all aspects except scheduling. A total of 47 (85.45%) patients reported having a comfortable experience, and only 5 (9.09%) experienced mild adverse effects.

Conclusion

The use of a virtual reality psychological intervention was beneficial to reduce the anxiety of patients before CAS and improved their self-efficacy. As virtual reality devices evolve and demonstrate better comfort and safety, more comprehensive and in-depth research of the use of VR to reduce patient anxiety should be performed in the future.Clinical trial registration:https://www.chictr.org.cn/showproj.aspx?proj=186412, identifier ChiCTR2200066219.

Virtual reality simulation of panoramic radiographic anatomy for dental students

PURPOSE

This work aimed to utilize virtual reality (VR) in dental radiographic anatomical interpretation in junior dental students and test if it can enhance student learning, engagement, and performance.

METHODS

VR software for panoramic anatomy was developed. Sixty-nine first-year dental students were divided into a control group (lecture-based) and an experimental group (VR) to learn panoramic radiographic anatomy. Both groups were then tested on knowledge via a 20-question quiz. Student feedback on VR experience was collected via an online survey.

RESULTS

There was a statistically significant difference between lecture-based and VR students in the correct identification of anatomical landmarks. Lecture-based students scored higher in identifying the ear lobe, hyoid bone, condylar neck, and external oblique ridge, whereas VR students scored higher in identifying zygoma (Chi-squared test, p < 0.005). The VR group reported high evaluation on all perception items of the online feedback survey on their experience (Student t-test, p < 0.005).

CONCLUSIONS

Lecture-based students generally showed better performance in panoramic radiographic anatomy. Several structures were not correctly identified in both groups of novice students. The positive feedback of VR experience encourages future implementation in education to augment conventional methods of radiographic anatomy in dentistry with considerations to repeated exposures throughout undergraduate dental education.

Simulator-based training method in gastrointestinal endoscopy training and currently available simulators

The apprenticeship-based training method (ABTM) is highly effective for gastrointestinal (GI) endoscopic training. However, the conventional ABTM has significant issues. Although many supplementary training methods (TMs) have been developed and utilized, they cannot entirely replace the ABTM, which remains the major TM strategy. Currently, new TM construction is crucial and necessary due to financial constraints, difficulty of obtaining sufficient training time due to patient safety-related regulations, and catastrophic damage caused by disasters such as the coronavirus disease 2019 pandemic. The simulator-based TM (SBTM) is widely accepted as an alternative to the ABTM, owing to the SBTM's advantages. Since the 1960s, many GI endoscopy training simulators have been developed and numerous studies have been published on their effectiveness. While previous studies have focused on the simulator's validity, this review focused on the accessibility of simulators that were introduced by the end of 2021. Although the current SBTM is effective in GI endoscopic education, extensive improvements are needed to replace the ABTM. Incorporating simulator-incorporated TMs into an improved ABTM is an attempt to overcome the incompleteness of the current SBTM. Until a new simulator is developed to replace the ABTM, it is desirable to operate a simulator-integrated and well-coordinated TM that is suitable for each country and institution.

Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.

Application of Virtual Reality Technology in Clinical Practice, Teaching, and Research in Complementary and Alternative Medicine

Background

The application of virtual reality (VR) in clinical settings is growing rapidly, with encouraging results. As VR has been introduced into complementary and alternative medicine (CAM), a systematic review must be undertaken to understand its current status.

Aim

This review aims to evaluate and summarize the current applications of VR in CAM, as well as to explore potential directions for future research and development.

Methods

After a brief description of VR technology, we discuss the past 20 years of clinical VR applications in the medical field. Then, we discuss the theoretical basis of the combination of VR technology and CAM, the research thus far, and practical factors regarding usability, etc., from the following three main aspects: clinical application, teaching, and scientific research. Finally, we summarize and propose hypotheses on the application of VR in CAM and its limitations.

Results

Our review of the theoretical underpinnings and research findings to date leads to the prediction that VR and CAM will have a significant impact on future research and practice.

Conclusion

Although there is still much research needed to advance the science in this area, we strongly believe that VR applications will become indispensable tools in the toolbox of CAM researchers and practitioners and will only grow in relevance and popularity in the era of digital health.

Endoscopy Training in Small Animal Internal Medicine: A Survey of Residency Training Programs in North America

Competency in multiple endoscopic techniques is a major goal of small animal internal medicine (SAIM) residency programs. Training relies predominantly on mentored supervision of procedures performed on patients. Supplementation of this apprenticeship model with classroom sessions and hands-on laboratories can be advantageous to trainees and patients. Few veterinary resources describe supplemental training options, and no single source exists for mentors to consult for program development. The purpose of this study was to describe the supplemental training opportunities currently available to SAIM residents at academic hospitals in the US and Canada and to compare their timing during the residency, resident and faculty time commitment, and perceived helpfulness. Data were collected by an electronic survey distributed to one faculty member per institution. The response rate was 80% (24/30). Most programs (22/24; 92%) offered some form of supplemental training, including classroom sessions (9/24) and hands-on laboratories using physical models (7/24), virtual reality simulators (2/24), and cadaver (2/24) and anesthetized (2/24) dogs. Fifteen programs provided residents with the opportunity to attend external endoscopy workshops. Only three programs required any training prior to residents performing procedures on patients. There was considerable variability in training between programs, precluding statistical comparisons. The survey identified topics for classroom sessions and several inexpensive physical models, rated very or extremely helpful, that would be suitable for programs with limited budgets. A human-based virtual reality simulator was also rated highly by two programs. Comprehensive, external workshops evoked numerous positive comments with perceived value ranging from somewhat to extremely helpful.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

Use of a Dry Surgical Simulator Improves Orthopaedic Residents’ Competency and Technical Skills for Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Clinical Relevance

Virtual reality distraction during upper gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND AND AIM

Virtual reality (VR) is an established and effective tool in reducing autonomic and somatic pain. We aimed to examine the analgesic effects of VR distraction during esophagogastroduodenoscopy (EGD).

METHODS

We conducted a randomized controlled trial and enrolled patients who had indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensional specific software content (standalone VR headset), sham VR or without VR during EGD. The primary outcome was patient pain scores during EGD.

RESULTS

A total of 96 patients undergoing diagnostic EGD were randomized to receive VR (n = 32), sham VR (n = 32), and no VR defined as the control group (n = 32). Patients in all groups reported no statistically different pain during esophageal intubation. The mean pain score was 2.7 ± 2.4 in the VR group, 2.7 ± 2.5 in the sham VR and 2.3 ± 2.3 in the control group, (P value = 0.751). No significant difference was observed in heart rate and blood pressure, and the endoscopists reported higher overall satisfaction scores in VR (4.3 ± 0.5) compared with the control group (4 ± 0.8) but without significance (P value = 0.156).

CONCLUSION

Virtual reality-assisted anesthesia during EGD did not significantly reduce patient pain during esophageal intubation. There was no superiority in using VR distraction regarding patient's and endoscopist's satisfaction compared with standard EGD without VR Further studies are required to detect any true clinical advantage of VR distraction during EGD.

Innovation in Gastroenterology-Can We Do Better?

The health system can reap significant benefits by adopting and implementing innovative measures, as was recently demonstrated and emphasized during the COVID-19 pandemic. Herein, we present our bird's eye view of gastroenterology's innovative technologies via utilizing a text-mining technique. We analyzed five research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy. According to gastroenterology literature, the two most innovative fields were the microbiome and advanced endoscopy. Though artificial intelligence (AI), virtual reality (VR), and telemedicine trailed behind, the number of AI publications in gastroenterology has shown an exponential trend in the last couple of years. While VR and telemedicine are neglected compared to other fields, their implementation could improve physician and patient training, patient access to care, cost reduction, and patient outcomes.

Innovation in Gastroenterology-Can We Do Better?

The health system can reap significant benefits by adopting and implementing innovative measures, as was recently demonstrated and emphasized during the COVID-19 pandemic. Herein, we present our bird's eye view of gastroenterology's innovative technologies via utilizing a text-mining technique. We analyzed five research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy. According to gastroenterology literature, the two most innovative fields were the microbiome and advanced endoscopy. Though artificial intelligence (AI), virtual reality (VR), and telemedicine trailed behind, the number of AI publications in gastroenterology has shown an exponential trend in the last couple of years. While VR and telemedicine are neglected compared to other fields, their implementation could improve physician and patient training, patient access to care, cost reduction, and patient outcomes.

Endoscopic training during fellowship: A nationwide French study: Impact of theoretical courses and simulation-based training during fellowship

BACKGROUND

In France, it is mandatory that gastroenterology fellows have mastered the basic level of endoscopy by the end of training. The aim of this study was to assess improvement in the quality of fellows' endoscopy training in France during the last four years.

METHODS

All fellows in France in training were eligible for participation. A 21-item questionnaire was sent out. The primary outcome was the completion by fourth year fellows of all the number of procedures recommended. Results were compared with those of a 2016 survey.

RESULTS

Two-hundred-and-sixty-five fellows responded to the survey. The participation rate was 47.0%. The mean age was 27.3 ± 1.0 years and 56.4% were female. Access to theoretical courses (63.7% vs. 30.6%, p < 0.001) and simulation-based training (virtual reality simulator: 58.4% vs. 28.2%, p < 0.001, animal models: 29.4% vs. 17.2%, p < 0.001) was significantly higher in 2020. Although the number of procedures did not increase, significantly higher perception of skill acquisition in colonoscopy as well as diminished pressure to advance procedures were noted.

CONCLUSION

Access to theoretical courses and simulation-based training and perceived acquisition of numerous skills has gotten better. However, the quality of training in endoscopy still needs improvement.

Virtual Reality and Three-Dimensional Printed Models Improve the Morphological Understanding in Learning Mandibular Sagittal Split Ramus Osteotomy: A Randomized Controlled Study

Background: The mandibular sagittal split ramus osteotomy (SSRO) is a routine operation performed to correct mandibular deformity including mandibular retrusion, protrusion, deficiency, and asymmetry. The SSRO remains a challenging procedure for junior surgeons due to a lack of adequate morphological knowledge necessary for success in clinical practice. Virtual reality (VR) and three-dimensional printed (3DP) models have been widely applied in anatomy education. The present randomized, controlled study was performed to evaluate the effect of traditional educational instruments, VR models, and 3DP models on junior surgeons learning the morphological information required to perform SSRO.

Methods: Eighty-one participants were randomly assigned to three learning groups: Control, VR, and 3DP. Objective and subjective tests were used to evaluate the learning effectiveness of each learning instrument. In the objective test, participants were asked to identify 10 anatomical landmarks on normal and deformed models, draw the osteotomy line, and determine the description of SSRO. In the subjective test, participants were asked to provide feedback regarding their subjective feelings about the learning instrument used in their group.

Results: The objective test results showed that the VR and 3DP groups achieved better accuracy in drawing the osteotomy line (p = 0.027) and determining the description of SSRO (p = 0.023) than the Control group. However, there was no significant difference among the three groups regarding the identification of anatomical landmarks. The VR and 3DP groups gave satisfactory subjective feedback about the usefulness in learning, good presentation, and enjoyment. The Control and 3DP groups reported positive feelings about ease of use.

Conclusion: The current findings suggest that VR and 3DP models were effective instruments that assisted in the morphological understanding of SSRO-related anatomical structures. Furthermore, 3DP models may be a promising supplementary instrument to bridge the gap between conventional learning and clinical practice.

Virtual, Augmented, and Alternate Reality in Medical Education: Socially Distanced but Fully Immersed

BACKGROUND

Advancements in technology continue to transform the landscape of medical education. The need for technology-enhanced distance learning has been further accelerated by the coronavirus disease (COVID-19) pandemic. The relatively recent emergence of virtual reality (VR), augmented reality (AR), and alternate reality has expanded the possible applications of simulation-based education (SBE) outside of the traditional simulation laboratory, making SBE accessible asynchronously and in geographically diverse locations.

OBJECTIVE

In this review, we will explore the evidence base for use of emerging technologies in SBE as well as the strengths and limitations of each modality in a variety of settings.

METHODS

PubMed was searched for peer-reviewed articles published between 1995 and 2021 that focused on VR in medical education. The search terms included medical education, VR, simulation, AR, and alternate reality. We also searched reference lists from selected articles to identify additional relevant studies.

RESULTS

VR simulations have been used successfully in resuscitation, communication, and bronchoscopy training. In contrast, AR has demonstrated utility in teaching anatomical correlates with the use of diagnostic imaging, such as point-of-care ultrasound. Alternate reality has been used as a tool for developing clinical reasoning skills, longitudinal patient panel management, and crisis resource management via multiplayer platforms.

CONCLUSION

Although each of these modalities has a variety of educational applications in health profession education, there are benefits and limitations to each that are important to recognize prior to the design and implementation of educational content, including differences in equipment requirements, cost, and scalability.

Endoscopic simulators: training the next generation

PURPOSE OF REVIEW

To provide a review of current evidence evaluating endoscopic simulators as teaching platforms in gastroenterology training, with emphasis on upper gastrointestinal anatomy.

RECENT FINDINGS

Endoscopic simulators have leveraged mechanical, virtual reality and ex-vivo or live animal platforms to deliver training in both general and therapeutic endoscopy. Simulators have demonstrated their greatest utility in training novice endoscopists. Intermediate and expert endoscopists may additionally benefit from simulator exposure when learning advanced therapeutic techniques including large tissue resection or natural orifice transluminal endoscopic surgery.

SUMMARY

Simulator-based learning offers promise to complement conventional endoscopic training modalities for novice trainees. Nevertheless, additional evidence demonstrating a clear benefit is required for simulators to become an integral part of gastroenterology training. As novel advanced endoscopic therapies are developed, endoscopic simulators may assume a larger role in training prior to clinical practice.

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 Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity

Purpose

We evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit.

Methods

Participants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion.

Results

In total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD ± 5 ) ,  intermediates a mean of 5.8 strikes (SD ± 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% ± 19 vs 55% ± 22 vs 50% ± 23 , P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics.

Conclusions

This hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience.

Clinical Relevance

This study demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.

Virtual Reality vs. High-Fidelity Mannequin-Based Simulation: A Pilot Randomized Trial Evaluating Learner Performance

Background Virtual Reality (VR) simulation has been found to be useful in learning technical and non-technical skills. However, empirical data about its efficacy in clinical education are limited. This pilot study compares the efficacy of VR to mannequin-based simulation for learners managing status epilepticus (SE). Methods Pediatric and emergency medicine interns at an academic tertiary care referral center were randomized to either VR (intervention, using an Oculus Rift^Ⓡ (Occulus from Facebook, Facebook Inc., USA)) or mannequin-based (control) simulation for the same SE scenario. The control group participated in two mannequin-based simulation sessions while the intervention group had a VR session followed by a mannequin-based session. Sessions were one-one with an instructor and held three months apart. Performance was assessed by measuring the time-to-critical actions during the second session. Results Of 42 interns, 22 were in the intervention group and 20 in the control group. There was no statistical difference in time-to-critical actions for VR vs. standard groups; for example, VR times (in seconds) compared to standard times were 18.1 (SD 10.5) and 18.9 (SD 15.8) (p=.90) for oral suction, and 61.6 (SD 24.8) and 62.8 (SD 26.9) (p=.82) for IV lorazepam completion. Conclusion This pilot trial suggests that VR is feasible for clinical simulation. We did not find a significant difference between the two groups in learner performance. Larger studies are needed to corroborate our findings, investigate the best applications of VR in clinical training, and determine if it could lead to more rapid learning at a lower cost.

A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator

AIMS

This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure. Secondary outcomes included perceived use of simulation in surgical training, with structured feedback from participants.

METHODS

A comparative interventional study was carried out in a regional orthopaedics trauma unit hospital. Volunteers were stratified into novice, intermediate and expert groups based on self-reported levels of experience. Each participant carried out a simulated proximal femoral nail on an immersive virtual platform following instruction on its use, with objective metrics such as time and x-rays, and novel metrics calculated by the simulation module recorded. Face validity was also assessed.

RESULTS

The proximal femoral nail module demonstrated construct validity. Kruskal Wallis test demonstrated a statistically significant difference across all group's novel performance (p=.018). Intermediate surgeons performed significantly better than novices (P=.022), with shorter procedural times (P=.018) Three of the intermediate group achieved the proficiency level set by the expert group, with no significant difference noted between these two groups (=.06). Time taken to completion for expert surgeons was less than intermediate group, although this did not reach significance (P=.19).

CONCLUSION

The proximal femoral nail module on the Precision OS platform demonstrated good face, and construct validity. Further research evaluating use of virtual platform simulation in surgical trauma training is needed.

Teaching with Disruptive Technology: The Use of Augmented, Virtual, and Mixed Reality (HoloLens) for Disease Education

Modern technologies are often utilised in schools or universities with a variety of educational goals in mind. Of particular interest is the enhanced interactivity and engagement offered by mixed reality devices such as the HoloLens, as well as the ability to explore anatomical models of disease using augmented and virtual realities. As the students are required to learn an ever-increasing number of diseases within a university health science or medical degree, it is crucial to consider which technologies provide value to educators and students. This chapter explores the opportunities for using modern disruptive technologies to teach a curriculum surrounding disease. For relevant examples, a focus will be placed on asthma as a respiratory disease which is increasing in prevalence, and stroke as a neurological and cardiovascular disease. The complexities of creating effective educational curricula around these diseases will be explored, along with the benefits of using augmented reality and mixed reality as viable teaching technologies in a range of use cases.

Virtual Reality Assisted Cardiac Catheterization

Cardiac catheterization is a delicate strategy often used during various heart procedures. However, the procedure carries a myriad of risks associated with it, including damage to the vessel or heart itself, blood clots, and arrhythmias. Many of these risks increase in probability as the length of the operation increases, creating a demand for a more accurate procedure while reducing the overall time required. To this end, we developed an adaptable virtual reality simulation and visualization method to provide essential information to the physician ahead of time with the goal of reducing potential risks, decreasing operation time, and improving the accuracy of cardiac catheterization procedures. We additionally conducted a phantom study to evaluate the impact of using our virtual reality system prior to a procedure.

Use of Augmented and Virtual Reality in Remote Higher Education: A Systematic Umbrella Review

In this systematic umbrella review we aggregate the current knowledge of how virtual and augmented reality technologies are applicable to and impact remote learning in higher education; specifically, how they impact such learning outcomes as performance and engagement in all stages of higher education from course preparation to student evaluation and grading. This review was done as part of a state wide research effort of Latvia, to mitigate the impact of COVID-19 and specifically to provide a framework for a technological transformation of education in this context. In this work we search the Scopus and Web of Science databases for articles describing the use of virtual and/or augmented reality technologies in remote learning for higher education and their impact on learning outcomes. We identified 68 articles from which, after multiple screening and eligibility phases, nine review articles were left for extraction phase in which 30 structural elements with corresponding interventions and measured effects were extracted. Of these, 24 interventions had a measured effect on student performance (11 positive, seven negative, six no impact) and six interventions had a measured effect on student engagement (all six positive).

Simulation in surgical education

Simulation is becoming an important tool in surgical education. Surgical faculty have been forced to modify how they teach technical skills. Instead of a complete reliance on teaching in the operating room, a structured curriculum and dedicated time in the simulation center are being used in many centers. Some of the advantages of this approach include the ability to learn and practice new procedures in a safe and nurturing environment. The disadvantages include the significant cost of virtual reality simulators and the competition, between various training programs, to gain access to simulation.

Fabrication and Validation of a Cost-Effective Upper Endoscopy Simulator

Purpose:

Beginning with the graduating class of 2018, the American Board of Surgery (ABS) requires that residents complete the ABS Flexible Endoscopy Curriculum, Fundamentals of Endoscopic Surgery (FES). This curriculum includes both didactic and simulator training. In the ideal setting residents gain proficiency using simulation prior to performing endoscopies in the clinical setting. This new requirement creates an increased demand for endoscopic simulators in all General Surgery residency programs. Due to the cost prohibitive nature of virtual reality simulators an economic alternative is needed.

Methods:

A mechanical simulator was created from inexpensive items easily acquired at a hardware store and in the hospital. Total cost of the simulator was approximately $120 USD. To validate the simulator, experienced endoscopists completed a training session with the device. A seven-question Likert scale survey (1 - strongly disagree to 5 - strongly agree) was completed after the session evaluated the simulated experience versus live upper endoscopies and the device’s ability to meet the goals of the FES curriculum.

Results:

Eight proficient endoscopists completed the training session and survey and agreed that the device closely replicated live colonoscopies and would meet all training requirements in the FES curriculum. Mean responses to all seven survey questions ranged from 3.8–4.4.

Conclusion:

This device is a cost-effective method for simulating live upper endoscopies and is appropriate for use in FES training.

The role of virtual reality in the changing landscape of surgical training

BACKGROUND

The current coronavirus disease 2019 pandemic has caused unprecedented challenges to surgical training across the world. With the widespread cancellations of clinical and academic activities, educators are looking to technological advancements to help 'bridge the gap' and continue medical education.

SOLUTIONS

Simulation-based training as the 'gold standard' for medical education has limitations that prevent widespread adoption outside suitably resourced centres. Virtual reality has the potential to surmount these barriers, whilst fulfilling the fundamental aim of simulation-based training to provide a safe, effective and realistic learning environment.

CURRENT LIMITATIONS AND INSIGHTS FOR FUTURE

The main limitations of virtual reality technology include comfort and the restrictive power of mobile processors. There exists a clear developmental path to address these restrictions. Continued developments of the hardware and software set to deepen immersion and widen the possibilities within surgical education.

CONCLUSION

In the post coronavirus disease 2019 educational landscape, virtual, augmented and mixed reality technology may prove invaluable in the training of the next generation of surgeons.

Non-technical skills curriculum incorporating simulation-based training improves performance in colonoscopy among novice endoscopists: Randomized controlled trial

BACKGROUND AND AIMS

Non-technical skills (NTS), involving cognitive, social and interpersonal skills that complement technical skills, are important for the completion of safe and efficient procedures. We investigated the impact of a simulation-based curriculum with dedicated NTS training on novice endoscopists' performance of clinical colonoscopies.

METHODS

A single-blinded randomized controlled trial was conducted at a single center. Novice endoscopists were randomized to a control curriculum or a NTS curriculum. The control curriculum involved a didactic session, virtual reality (VR) simulator colonoscopy training, and integrated scenario practice using a VR simulator, a standardized patient, and endoscopy nurse. Feedback and training were provided by experienced endoscopists. The NTS curriculum group received similar training that included a small-group session on NTS, feedback targeting NTS, and access to a self-reflective NTS checklist. The primary outcome was performance during two clinical colonoscopies, assessed using the Joint Advisory Group Direct Observation of Procedural Skills (JAG DOPS) tool.

RESULTS

Thirty-nine participants completed the study. The NTS group (n = 21) had superior clinical performance during their first (P < 0.001) and second clinical colonoscopies (P < .0.001), compared to the control group (n = 18). The NTS group performed significantly better on the VR simulator (P < 0.05) and in the integrated scenario (P < 0.05).

CONCLUSION

Our findings demonstrate that dedicated NTS training led to improved performance of clinical colonoscopies among novices.

Evaluation of long-term adherence to oesophagogastroduodenoscopy quality indicators

INTRODUCTION

In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme.

MATERIAL AND METHODS

A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used.

RESULTS

A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p<0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p<0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p<0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p<0.001), photo documentation of the lesion (94% vs. 90%; p<0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p<0.001). There were no differences between subgroups B1 and B2.

CONCLUSIONS

The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

Effects of Using Immersive Media on the Effectiveness of Training to Prevent Ergonomics Risks

In this work, the effects of using immersive media such as virtual reality on the performance of training programs to avoid ergonomics risks are analyzed. The advance of technology has made it possible to use low-cost portable devices able to generate highly immersive experiences in training programs. The effects of using this kind of device in training programs have been studied in several fields such as industrial security, medicine and surgery, rehabilitation, or construction. However, there is very little research on the effects of using immersive media in training workers to avoid ergonomics risk factors. In this study, we compare the effects of using traditional and immersive media in a training program to avoid three common ergonomics risk factors in industrial environments. Our results showed that using immersive media increases the participant’s engagement during the training. In the same way, the learning contents are perceived as more interesting and useful and are better remembered over time, leading to an increased perception of the ergonomics risks among workers. However, we found that little training was finally transferred to the workplace three months after the training session.

Training in bariatric and metabolic endoscopy

The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.

Endoscopic Assessment of the Malignant Potential of the Nonpolypoid (Flat and Depressed) Colorectal Neoplasms: Thinking Fast, and Slow

Current endoscopy training methodology does not meet the learning traits, skills, and needs of the newer generation of gastroenterologists. This article provides information on assessment of the malignant potential of colorectal neoplasms. It takes a modern approach on the topic and integrates relevant information that aligns with the thinking process. The theory of thinking fast (reflex) and slow (rational) is used. By doing so, it is hoped that the learning process can be expedited and practiced immediately. The focus is on preresection assessment of nonpolypoid colorectal neoplasms. Assessment of polypoid, sessile-serrated adenoma/polyp, or inflammatory bowel disease dysplasia is briefly discussed.