"Seeing inside out": revealing the effectiveness of otoscopy training in virtual reality enhanced practical exams - a randomized controlled trial

BACKGROUND

The study aimed to assess the impact of different training modalities on otoscopy performance during a practical exam using a high-fidelity simulator and to determine if objective evaluation of otoscopy is feasible using a simulator that records insertion depth and tympanic membrane coverage.

METHODS

Participants were assigned to one of four groups: control and three intervention groups with varying training approaches. Participants received otoscopy training and then were assessed through a practical exam on a high-fidelity simulator that uses virtual reality to visualize the ear canal and middle ear. Performance was evaluated using a modified Objective Structured Assessment of Technical Skills checklist and Integrated Procedural Performance Instrument checklist. Insertion depth, tympanic membrane coverage, and correct diagnosis were recorded. Data were tested for normal distribution using the Shapiro-Wilk test. One-way ANOVA and, for non-normally distributed data, Kruskal-Wallis test combined with Dunn's test for multiple comparisons were used. Interrater reliability was assessed using Cohen's κ and Intraclass correlation coefficient.

RESULTS

All groups rated their training sessions positively. Performance on the OSATS checklist was similar among groups. IPPI scores indicated comparable patient handling skills. The feedback group examined larger tympanic membrane areas and had higher rates of correct diagnosis. The correct insertion depth was rarely achieved by all participants. Interrater reliability for OSATS was strong. IPPI reliability showed good correlation.

CONCLUSION

Regardless of training modality, participants perceived learning improvement and skill acquisition. Feedback improved examination performance, indicating simulator-guided training enhances skills. High-fidelity simulator usage in exams provides an objective assessment of performance.

Appropriate assessment using virtual reality simulation for a novel reshaped curve sheath during percutaneous left atrial appendage closure: a follow-up case report

Background

We previously reported a case of successful percutaneous left atrial appendage closure (LAAC) for complex left atrial appendage (LAA) morphology using a handmade double-curve delivery sheath (DS) reshaped by a heat gun. However, whether the reshaped curve was appropriately adjusted as an optimal configuration for this patient's anatomy remained uncertain.

Case summary

We established the LAAC procedural simulation model supported by virtual reality (VR) technology. With this VR simulator, the patient's whole heart model with venous access route and atrial septal puncture point of foramen ovale (FO) could be replicated based on the pre-procedural computed tomography image. Multiple views of the VR image provided a deep understanding of the patient-specific anatomy. Additionally, the operators were enabled to perform the virtual LAAC procedure using VR-derived LAAC devices, including various DS types. In the VR simulator, the manually reshaped DS showed better co-axiality from the FO to the LAA orifice than the conventional double-curve DS, resulting in the successful deployment inside the LAA of the VR simulator. However, the perpendicularity of the device towards the LAA orifice of the handmade reshaped DS remained insufficient. The VR simulator suggested that the ideal curve of the DS needed to change relatively posteriorly and have a more aggressive inferior slide than the previously reshaped DS.

Discussion

The post-procedural review of the VR simulator confirmed that the sheath reshaping technique helped ensure successful LAAC. Pre-procedural VR simulation may be useful for procedural planning that includes DS reshaping for patients with challenging anatomy undergoing LAAC.

Examining the utility of a photorealistic virtual ear in otologic education

BACKGROUND

Otolaryngology-head and neck surgical (OHNS) trainees' operating exposure is supplemented by a combination of didactic teaching, textbook reading, and cadaveric dissections. Conventional teaching, however, may not adequately equip trainees with an understanding of complex visuospatial relationships of the middle ear. Both face and content validation were assessed of a novel three-dimensional (3D) photorealistic virtual ear simulation tool underwent face and content validation as an educational tool for OHNS trainees.

METHODS

A three-dimensional mesh reconstruction of open access imaging was generated using geometric modeling, which underwent global illumination, subsurface scattering, and texturing to create photorealistic virtual reality (VR) ear models were created from open access imaging and comiled into a educational platform. This was compiled into an educational VR platform which was explored to validate the face and content validity questionnaires in a prospective manner. OHNS post-graduate trainees were recruited from University of Toronto and University of Calgary OHNS programs. Participation was on a voluntary basis.

RESULTS

Total of 23 OHNS post-graduate trainees from the two universities were included in this study. The mean comfort level of otologic anatomy was rated 4.8 (± 2.2) out of 10. Senior residents possessed more otologic surgical experience (P < 0.001) and higher average comfort when compared to junior residents [6.7 (± 0.7) vs. 3.6 (± 1.9); P = 0.001]. Face and content validities were achieved in all respective domains with no significant difference between the two groups. Overall, respondents believed OtoVIS was a useful tool to learn otologic anatomy with a median score of 10.0 (8.3-10.0) and strongly agreed that OtoVIS should be added to OHNS training with a score of 10.0 (9.3-10.0).

CONCLUSIONS

OtoVIS achieved both face and content validity as a photorealistic VR otologic simulator for teaching otologic anatomy in the postgraduate setting. As an immersive learning tool, it may supplement trainees' understanding and residents endorsed its use.

Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

BACKGROUND

Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module.

METHODS

A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared.

RESULTS

Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366 min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324 min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632 cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7 cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations.

CONCLUSION

Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

Validation of a novel virtual reality simulation system with the focus on training for surgical dissection during laparoscopic sigmoid colectomy

Background

Mastery of technical skills is one of the fundamental goals of surgical training for novices. Meanwhile, performing laparoscopic procedures requires exceptional surgical skills compared to open surgery. However, it is often difficult for trainees to learn through observation and practice only. Virtual reality (VR)-based surgical simulation is expanding and rapidly advancing. A major obstacle for laparoscopic trainees is the difficulty of well-performed dissection. Therefore, we developed a new VR simulation system, Lap-PASS LP-100, which focuses on training to create proper tension on the tissue in laparoscopic sigmoid colectomy dissection. This study aimed to validate this new VR simulation system.

Methods

A total of 50 participants were asked to perform medial dissection of the meso-sigmoid colon on the VR simulator. Forty-four surgeons and six non-medical professionals working in the National Cancer Center Hospital East, Japan, were enrolled in this study. The surgeons were: laparoscopic surgery experts with > 100 laparoscopic surgeries (LS), 21 were novices with experience < 100 LS, and five without previous experience in LS. The participants’ surgical performance was evaluated by three blinded raters using Global Operative Assessment of Laparoscopic Skills (GOALS).

Results

There were significant differences (P-values < 0.044) in all GOALS items between the non-medical professionals and surgeons. The experts were significantly superior to the novices in one item of GOALS: efficiency ([4(4–5) vs. 4(3–4)], with a 95% confidence interval, p = 0.042). However, both bimanual dexterity and total score in the experts were not statistically different but tended to be higher than in the novices.

Conclusions

Our study demonstrated a full validation of our new system. This could detect the surgeons' ability to perform surgical dissection and suggest that this VR simulator could be an effective training tool. This surgical VR simulator might have tremendous potential to enhance training for surgeons.

Influence of patient-specific rehearsal on operative metrics and technical success for endovascular aneurysm repair

INTRODUCTION

Patient-specific rehearsal (PsR) is a recent technology within virtual reality (VR) simulation that lets the operators train on patient-specific data in a simulated environment prior to the procedure. Endovascular aneurysm repair (EVAR) is a complex procedure where operative metrics and technical success might improve after PsR.

MATERIAL AND METHODS

We compared technical success and operative metrics (endovascular procedure time, contralateral gate cannulation time, fluoroscopy time, total radiation dose, number of angiograms and contrast medium use) between 30 patients, where the operators performed PsR (the PsR group), and 30 patients without PsR (the control group).

RESULTS

The endovascular procedure time was significantly shorter in the PsR group than in the control group (median 44 versus 55 min, p = .017). The other operative metrics were similar. Technical success rates were higher in the PsR group, 96.7% primary and assisted primary outcome versus 90.0% in the control group. The differences were not significant (p = .076).

CONCLUSIONS

PsR before EVAR reduced endovascular procedure time, and our results indicate that it might improve technical success, but further studies are needed to confirm those results.

Virtual reality simulation to enhance laparoscopic salpingectomy skills

BACKGROUND

To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning.

METHODS

A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series.

RESULTS

26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased.

CONCLUSIONS

The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

Arthroscopy training in France: A resident perception and self-assessment

BACKGROUND

Arthroscopic surgery is a steadily expanding component of orthopaedic practice that changes continuously as new techniques and indications develop. The many arthroscopy training activities offered to residents include fellowships, practice on cadaver specimens and simulators, and teaching in the operating room. Current practices for arthroscopy training of orthopaedic residents in France have not yet been evaluated. The objectives of this study were to describe current arthroscopy training practices and to assess the perceptions and expectations of residents and junior physicians in France, in order to contribute to the development of a new training strategy for residents.

HYPOTHESIS

Residents and junior physicians perceive gaps in their arthroscopy training.

METHODS

Between November 2018 and February 2019, the Junior French Arthroscopy Society (Société Francophone d'Arthroscopie Junior, SFAJ) conducted a descriptive epidemiological survey of 918 residents, clinical fellows, and junior physicians in orthopaedic surgery departments in France. The data were collected via an online questionnaire sent by e-mail. The questionnaire had items on demographics; perceptions of, and expectations about, arthroscopy skills training during the residency; and experience in performing arthroscopic procedures.

RESULTS

Of the 918 residents, 106 responded to the questionnaire. Most respondents were near the end of their training: 26 (24.8%) were 4th-year residents, 23 (21.6%) were 5th-year residents, 15 (14.3%) were clinical fellows, and 13 (12.4%) were junior physicians. Among respondents, 42 (40%) had performed fewer than 5 simple arthroscopy procedures as the main operator and 73 (69.5%) felt they were not, or would not be, capable of performing arthroscopic procedures without supervision by the end of their residency.

CONCLUSION

The survey findings highlighted the challenges encountered by French orthopaedics residents in acquiring satisfactory arthroscopy skills during their residency. They also suggested avenues for improvement such as simulator training or the development of training on cadaver specimens.

LEVEL OF EVIDENCE

IV, descriptive survey.

Simulator training and residents' first laparoscopic hysterectomy: a randomized controlled trial

BACKGROUND

Hysterectomy rates are decreasing in many countries, and virtual reality simulators bring new opportunities into residents' surgical education. The objective of this study was to evaluate the effect of training in laparoscopic hysterectomy module with virtual reality simulator on surgical outcomes among residents performing their first laparoscopic hysterectomy.

METHODS

This randomized study was carried out at the Department of Obstetrics and Gynecology in Helsinki University Hospital and Hyvinkää Hospital. We recruited twenty residents and randomly signed half of them to train ten times with the laparoscopic hysterectomy module on a virtual reality simulator, while the rest represented the control group. Their first laparoscopic hysterectomy was video recorded and assessed later by using the Objective Structured Assessment of Technical Skills (OSATS) forms and Visual Analog Scale (VAS). The scores and surgical outcomes were compared between the groups.

RESULTS

The mean OSATS score for the Global Rating Scale (GRS) was 17.0 (SD 3.1) in the intervention group and 11.2 (SD 2.4) in the control group (p = 0.002). The mean procedure-specific OSATS score was 20.0 (SD 3.3) and 16.0 (SD 2.8) (p = 0.012), and the mean VAS score was 55.0 (SD 14.8) and 29.9 (SD 14.9) (p = 0.001). Operative time was 144 min in the intervention group and 165 min in the control group, but the difference did not reach statistical significance (p = 0.205). There were no differences between the groups in blood loss or direct complications.

CONCLUSION

Residents training with a virtual reality simulator prior to the first laparoscopic hysterectomy seem to perform better in the actual live operation. Thus, a virtual reality simulator hysterectomy module could be considered as a part of laparoscopic training curriculum.

Transferability of laparoscopic skills using the virtual reality simulator

BACKGROUND

Skill transfer represents an important issue in surgical education, and is not well understood. The aim of this randomized study is to assess the transferability of surgical skills between two laparoscopic abdominal procedures using the virtual reality simulator in surgical novices.

METHODS

From September 2016 to July 2017, 44 surgical novices were randomized into two groups and underwent a proficiency-based basic training consisting of five selected simulated laparoscopic tasks. In group 1, participants performed an appendectomy training on the virtual reality simulator until they reached a defined proficiency. They moved on to the tutorial procedural tasks of laparoscopic cholecystectomy. Participants in group 2 started with the tutorial procedural tasks of laparoscopic cholecystectomy directly. Finishing the training, participants of both groups were required to perform a complete cholecystectomy on the simulator. Time, safety and economy parameters were analysed.

RESULTS

Significant differences in the demographic characteristics and previous computer games experience between the two groups were not noted. Both groups took similar time to complete the proficiency-based basic training. Participants in group 1 needed significantly less movements (388.6 ± 98.6 vs. 446.4 ± 81.6; P < 0.05) as well as shorter path length (810.2 ± 159.5 vs. 945.5 ± 187.8 cm; P < 0.05) to complete the cholecystectomy compared to group 2. Time and safety parameters did not differ significantly between both groups.

CONCLUSION

The data demonstrate a positive transfer of motor skills between laparoscopic appendectomy and cholecystectomy on the virtual reality simulator; however, the transfer of cognitive skills is limited. Separate training curricula seem to be necessary for each procedure for trainees to practise task-specific cognitive skills effectively. Mentoring could help trainees to get a deeper understanding of the procedures, thereby increasing the chance for the transfer of acquired skills.

NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

Purpose

Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians.

Methods

We developed NOViSE—the first force-feedback-enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom-built, and the behaviour of the virtual flexible endoscope is based on an established theoretical framework—the Cosserat theory of elastic rods.

Results

We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES.

Conclusions

VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype, and the initial results indicate that it provides promising foundations for further development.

Electronic supplementary material

The online version of this article (doi:10.1007/s11548-016-1401-8) contains supplementary material, which is available to authorized users.

[Interest of complex tasks on laparoscopic virtual reality simulator]

OBJECTIVES

The purpose of this study was to assess the contribution of complex tasks on virtual reality simulator (VRS) for novice surgeons in laparoscopy learning.

MATERIALS AND METHODS

Fifty-five medical students were prospectively randomized in two groups (A: basic skills, n=28 and B: basic and complex skills, n=27) and then trained during two sessions on VRS. Evaluations took place before and after each training. These evaluations consisted of the achievement of an intracorporeal suture, recorded on video, with the left then with the right hand. Two independent experts evaluated those gestures blindly.

RESULTS

A significant progression in terms of times and technical scores was observed in both groups between the first and the last evaluations (P between 0.001 and 0.04). Students in group B improved slower and longer than those in group A. However, left and right hands results confused did not highlight significant differences between the two groups. At the third session, the first hand to train is significantly faster in group B than in group A (P=0.04).

CONCLUSION

This study found only a late and minimal impact of complex skills to reduce the execution time of intracorporeal suture. It also showed an slower and longer overall progression for those who use them compared to subjects using basic skills only.

Virtual reality aided visualization of fluid flow simulations with application in medical education and diagnostics

Medical education, training and preoperative diagnostics can be drastically improved with advanced technologies, such as virtual reality. The method proposed in this paper enables medical doctors and students to visualize and manipulate three-dimensional models created from CT or MRI scans, and also to analyze the results of fluid flow simulations. Simulation of fluid flow using the finite element method is performed, in order to compute the shear stress on the artery walls. The simulation of motion through the artery is also enabled. The virtual reality system proposed here could shorten the length of training programs and make the education process more effective.

Effect of mental imagery rehearsal on gastroscopy training with virtual reality endoscopic simulator

AIM: To use the mental imagery rehearsal in gastroscopy training with virtual reality endoscopic simulator, and to analyze the role of this method in gastroscopy skill acquisition.

METHODS: Thirty male students were selected from our university using stratified sampling method. The participants were randomly divided into three groups: A, B, and C. In group A, mental imagery rehearsal was joined into the conventional practice with simulator, while group B was exercised conventionally. Group C did not receive any practice. All trainees underwent psychological evaluation before and after the training.

RESULTS: There was a significant difference in the operation score among the three groups. Group C was better than the other two groups, and group B was better than group C. There were significant differences in safety score, accuracy score, overinsufflation score, patient pain index score, and operating time score between the three groups. Only overinsufflation score and operating time score differed significantly between group A and group B.

CONCLUSION: Mental imagery rehearsal can improve the study effect of virtual reality endoscopic simulator in training gastroscopy skills, and this method is simple and easy to understand by students, providing a new way for training with the simulator.