A systematic examination of preoperative surgery warm-up routines

The impact of extended reality simulators on ophthalmic surgical training and performance: a systematic review and meta-analysis of 17,623 eyes

BACKGROUND

Extended reality (XR) simulators, including virtual reality and augmented reality, hold significant promise for enhancing surgical training by providing trainees with a controlled practice environment. This is particularly vital in microsurgery, where the steep learning curve and the challenge of mastering surgical skills are significant. Despite notable advancements in XR technology, its role in ophthalmic surgical training remains uncertain.

METHODS

In our systematic review and meta-analysis, eight electronic databases were searched, and studies were evaluated against predefined criteria. Data extraction and random-effects meta-analysis assessed the odds ratio (OR) for posterior capsular rupture (PCR), an important surgical complication.

RESULTS

A meta-analysis of 17,623 eyes that underwent cataract surgery across seven studies revealed a significant decrease in PCR post-Eyesi practice, with low heterogeneity across studies (OR = 0.71, 95% CI = 0.60-0.85, I2 = 9%). Studies that predominantly utilized XR for cataract surgery training (84%) consistently improved surgical outcomes by reducing complications such as PCR, retained lens material, and aphakia. XR training also significantly improved operating scores (p < 0.05), self-efficacy (p < 0.01), and non-dominant hand dexterity (p < 0.01). Of the 25 studies in this review, 22 (88%) found overall XR training benefits.

CONCLUSIONS

XR simulators enhance ophthalmic surgical training by reducing complications like PCR, and improving surgical performance, self-efficacy, and non-dominant hand dexterity. These findings challenge conventional training methods and advocate for integrating XR into residency curricula to optimize learning and patient outcomes.

The Impact of Just-in-Time Simulation Training for Healthcare Professionals on Learning and Performance Outcomes: A Systematic Review

ABSTRACT

Although just-in-time training (JIT) is increasingly used in simulation-based health professions education, its impact on learning, performance, and patient outcomes remains uncertain. The aim of this study was to determine whether JIT simulation training leads to improved learning and performance outcomes. We included randomized or nonrandomized interventional studies assessing the impact of JIT simulation training (training conducted in temporal or spatial proximity to performance) on learning outcomes among health professionals (trainees or practitioners). Of 4077 citations screened, 28 studies were eligible for inclusion. Just-in-time training simulation training has been evaluated for a variety of medical, resuscitation, and surgical procedures. Most JIT simulation training occurred immediately before procedures and lasted between 5 and 30 minutes. Despite the very low certainty of evidence, this systematic review suggests JIT simulation training can improve learning and performance outcomes, in particular time to complete skills. There remains limited data on better patient outcomes and collateral educational effects.

Effect of pre-operative warm-up on trainee intraoperative performance during robot-assisted hysterectomy: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The objective was to study the effect of immediate pre-operative warm-up using virtual reality simulation on intraoperative robot-assisted laparoscopic hysterectomy (RALH) performance by gynecology trainees (residents and fellows).

METHODS

We randomized the first, non-emergent RALH of the day that involved trainees warming up or not warming up. For cases assigned to warm-up, trainees performed a set of exercises on the da Vinci Skills Simulator immediately before the procedure. The supervising attending surgeon, who was not informed whether or not the trainee was assigned to warm-up, assessed the trainee's performance using the Objective Structured Assessment for Technical Skill (OSATS) and the Global Evaluative Assessment of Robotic Skills (GEARS) immediately after each surgery.

RESULTS

We randomized 66 cases and analyzed 58 cases (30 warm-up, 28 no warm-up), which involved 21 trainees. Attending surgeons rated trainees similarly irrespective of warm-up randomization with mean (SD) OSATS composite scores of 22.6 (4.3; warm-up) vs 21.8 (3.4; no warm-up) and mean GEARS composite scores of 19.2 (3.8; warm-up) vs 18.8 (3.1; no warm-up). The difference in composite scores between warm-up and no warm-up was 0.34 (95% CI: -1.44, 2.13), and 0.34 (95% CI: -1.22, 1.90) for OSATS and GEARS respectively. Also, we did not observe any significant differences in each of the component/subscale scores within OSATS and GEARS between cases assigned to warm-up and no warm-up.

CONCLUSION

Performing a brief virtual reality-based warm-up before RALH did not significantly improve the intraoperative performance of the trainees.

Establishing the influence of case complexity on the order of cataract lists: a cross-sectional survey

OBJECTIVE

Order of the theatre list and complexity of the cases are important considerations which are known to influence surgical outcomes. This survey aimed to establish their influence on cataract surgery.

METHODS AND ANALYSIS

Cataract surgeons ordered five cataract cases according to their surgical preference, first using case notes and second using composite ORs (CORs) for posterior capsule rupture. Descriptive and non-parametric statistics were used to analyse the data.

RESULTS

Between 11 June and 14 July 2020, 192 cataract surgeons from 14 countries completed the online survey. Majority of the surgeons (142 vs 50) preferred to choose the order of their list (p<0.01) and to review the case notes prior to the day of surgery (89 vs 53; p=0.04). 39.86% preferred to start with the less risky case and 32.43% reserved the last position on the list for the riskiest case. There was a significant trend to order the list in an ascending level of risk, independent of whether case notes or CORs were used. Additionally, 44.79% of the respondents indicated they would be happy to have their list order planned by an automated program based on their preferred risk score.

CONCLUSION

This survey demonstrates that cataract surgeons prefer to choose the order of their theatre list and that the order is dependent on the complexity of cases. There is support among surgeons for automated list ordering based on an objective score for risk stratification, such as a COR.

Development and Validation of a Virtual Reality Haptic Femoral Nailing Simulator

OBJECTIVE

To create a virtual reality (VR) femoral nailing simulator combining haptics and image intensifier functionality and then carry out validation studies to assess its educational value.

DESIGN

The simulator consisted of a 3D virtual environment, a haptic device and 3D printed drill handle and a VR headset. The environment was created using a video game development engine, interfaced with plugins to allow haptic feedback and image intensifier functionality. Two tasks were created within the simulator as part of an antegrade femoral intramedullary (IM) nail procedure: proximal guidewire entry and distal locking.For the validation study, participants performed the above tasks on the simulator. Metrics were collected including time taken, number of X-rays and tool distance travelled and used to assess construct validity. A questionnaire was then completed to assess authenticity and content validity.

SETTING

Simulator development in centre for simulation and engagement science laboratory. Validation study in a teaching hospital environment.

PARTICIPANTS

Orthopedic specialist trainees and consultants.

RESULTS

Surgeon experience (number of IM nails performed/postgraduate year) correlated with significantly improved task performance. More experienced surgeons took less time, used fewer X-rays and had greater economy of movement than less experienced surgeons. Authenticity and content validity were well rated, with criticisms primarily due to hardware limitations.

CONCLUSIONS

To our knowledge this is the first orthopedic simulator to combine immersive VR with haptics and full image intensifier functionality. By combining multiple aspects of surgical practice within a single device, we aimed to improve participant immersion and educational value. Our work so far has focused on technical skills, demonstrating good authenticity, content and construct validity, however our findings show promise in other applications such as nontechnical skill development and assessment.

The Effect of an Interval Training on Skill Retention of High-Complex Low-Volume Minimal Invasive Pediatric Surgery Skills: A Pilot Study

Background: Current training programs for complex pediatric minimal invasive surgery (MIS) are usually bulk training, consisting of 1- or 2-day courses. The aim of this study was to examine the effects of bulk training versus interval training on the preservation of high-complex, low-volume MIS skills. Materials and Methods: Medical students, without prior surgical experience, were randomly assigned to either a bulk or interval training program for complex MIS (congenital diaphragmatic hernia [CDH] and esophageal atresia [EA] repair). Both groups trained for 5 hours; the bulk group twice within 3 days and the interval groups five times in 3 weeks. Skills retention was assessed at 2 weeks, 6 weeks, and 6 months posttraining, using a composite score (0%-100%) based on the objective parameters tracked by SurgTrac. Results: Seventeen students completed the training sessions (bulk n = 9, interval n = 8) and were assessed accordingly. Retention of the skills for EA repair was significantly better for the interval training group than for the bulk group at 6 weeks (P = .004). However, at 6 months, both groups scored significantly worse than after the training sessions for EA repair (bulk 60 versus 67, P = .176; interval 63 versus 74, P = .028) and CDH repair (bulk 32 versus 67, P = .018; interval 47 versus 62, P = .176). Conclusion: This pilot study suggests superior retention of complex pediatric MIS skills after interval training, during a longer period of time, than bulk training. However, after 6 months, both groups scored significantly worse than after their training, indicating the need for continuous training.

[Surgical Education in the Digital Age - Virtual Reality, Augmented Reality and Robotics in the Medical School]

BACKGROUND

The digital transformation of healthcare is changing the medical profession. Augmented/Virtual Reality (AR/VR) and robotics are being increasingly used in different clinical contexts and require supporting education and training, which must begin within the medical school. There is currently a large discrepancy between the high demand and the number of scientifically proven concepts. The aim of this thesis was the conceptual design and structured evaluation of a newly developed learning/teaching concept for the digital transformation of medicine, with a special focus on the influence of surgical teaching.

METHODS

Thirty-five students participated in three courses of the blended learning curriculum "Medicine in the digital age". The 4th module of this course deals with virtual reality, augmented reality and robotics in surgery. It is divided into the following course parts: (1) immersive surgery simulation of a laparoscopic cholecystectomy, (2) liver surgery planning using AR/VR, (3) basic skills on the VR simulator for robotic surgery, (4) collaborative surgery planning in virtual space and (5) expert discussion. After completing the overall curriculum, a qualitative and quantitative evaluation of the course concept was carried out by means of semi-structured interviews and standardised pre-/post-evaluation questionnaires.

RESULTS

In the qualitative evaluation procedure of the interviews, 79 text statements were assigned to four main categories. The largest share (35%) was taken up by statements on the "expert discussion", which the students consider to be an elementary part of the course concept. In addition, the students perceived the course as a horizon-widening "learning experience" (29% of the statements) with high "practical relevance" (27%). The quantitative student evaluation shows a positive development in the three sub-competences knowledge, skills and attitude.

CONCLUSION

Surgical teaching can be profitably used to develop digital skills. The speed of the change process of digital transformation in the surgical specialty must be considered. Curricular adaptation should be anchored in the course concept.

Effect of mental rehearsal on team performance and non-technical skills in surgical teams: systematic review

BACKGROUND

Simulation-based training in medical education has become a common method to develop both technical and non-technical skills in teams. Mental rehearsal (MR) is the cognitive act of simulating a task in our heads to pre-experience tasks imaginatively. It has been used widely to improve individual and collective performance in fields outside healthcare, and offers potential for more efficient training in time-pressured surgical and medical team contexts. This study aimed to review the available literature to determine the impact of MR on team performance and non-technical skills in healthcare.

METHODS

MEDLINE, Embase, British Educational Index, CINAHL, Web of Science, PsycInfo and Cochrane databases were searched for the period 1994-2018. The primary outcome measure was improvement in team performance and non-technical skills. Study quality of RCTs was assessed using the Medical Education Research Quality Instrument. The reported impacts of MR in all included studies were mapped on to the Kirkpatrick framework for evaluation of educational interventions.

RESULTS

Eight studies with 268 participants were identified that met the inclusion criteria, of which there were six randomized trials, one prospective pragmatic trial and one qualitative study. Three studies found MR to be effective in improving team non-technical skills. MR practices were varied and often poorly defined. MR benefited team non-technical skills when it was specifically designed to do so, but was not an automatic consequence of technical MR alone. The majority of studies demonstrated benefits of MR for technical performance, but only three showed positive impacts on teamwork. Overall the studies were of low quality and lacked sufficient discriminatory focus to examine impacts on teamwork dynamics.

CONCLUSION

MR can improve technical performance, but the benefits on non-technical skills are less clear. Future research should look at longitudinal mixed-method evaluation designs and focus on real clinical teams.

Critical analysis of evidence about the impacts on surgical teams of 'mental practice' in systematic reviews: a systematic rapid evidence assessment (SREA)

BACKGROUND

Mental Rehearsal (MR) the cognitive act of simulating a task in our heads to pre-experience events imaginatively. It has been used widely to improve individual and collective performance in fields outside healthcare and offers potential for more efficient training in time pressured surgical and medical team contexts. The study aims to review the current systematic review literature to determine the impact of MP on surgical performance and learning.

METHODS

Medline, Embase, British Educational Index, CINAHL, Web of Science PsycINFO, Cochrane databased were searched in the period 1994-2018. The primary outcomes measure were performance improvements in surgical technical skills, stress reduction, confidence and team performance. Study quality of the Systematic Reviews was assessed using AMSTAR 2, a critical appraisal tool for systematic reviews. The reported impacts of MP in all included studies were mapped onto Kirkpatrick's framework for the evaluation of educational interventions.

RESULTS

Six Systematic reviews were identified which met the inclusion criteria, of which all reported positive and varying benefits of MP on surgical performance, confidence, and coping strategies. However, reported impacts on a modified Kirkpatrick's framework did not exceed level 3. Mental practice was described in terms of mental imagery and mental rehearsal with most authors using each of the terms in their search strategies. The impacts on transfer to practice and the long- term acquisition of skills, but also personal uptake of mental practice routines were not reported.

CONCLUSION

The majority of studies demonstrate benefits of MP for technical performance. Overall the systematic reviews were of medium to high quality. However, studies lacked a sufficiently articulated evaluation methodology to examine impacts beyond the immediate experimentations. This is also due to the limitations found in the primary studies. Future research should look at longitudinal mixed method evaluation designs and focus on real clinical teams.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

A review of simulation applications in temporal bone surgery

Background

Temporal bone surgery is a technically challenging and high-risk procedure in an anatomically complex area. Safe temporal bone surgery emphasizes a consummate anatomic understanding and technique development that requires the guidance of an experienced otologic surgeon and years of practice. Temporal bone simulation can augment otologic surgical training and enable rehearsal of surgical procedures.

Objectives

The purpose of this article is to provide an updated review of temporal bone simulation platforms and their uses.

Data Sources

PubMed literature search. Search terms included temporal bone, temporal bone simulation, virtual reality (VR), and presurgical planning and rehearsal.

Discussion

Various simulation platforms such as cadaveric bone, three-dimensional (3D) printed models, and VR simulation have been used for temporal bone surgery training. However, each simulation method has its drawbacks. There is a need to improve upon current simulation platforms to enhance surgical training and skills assessment, as well as a need to explore other clinically significant applications of simulation, such as preoperative planning and rehearsal, in otologic surgery.

Conclusions

There is no replacement for actual surgical experience, but high-fidelity temporal bone models such as those produced with 3D printing and computer simulation have emerged as promising tools in otolaryngologic surgery. Improvements in the fidelity of both 3D printed and VR simulators as well as integration of a standardized assessment format would allow for an expansion in the use of these simulation platforms in training and assessment.

Level of Evidence

5.

Construct, content and face validity of the eoSim laparoscopic simulator on advanced suturing tasks

Background

The purpose of this study was to validate the eoSim, an affordable and mobile inanimate laparoscopic simulator with instrument tracking capabilities, regarding face, content and construct validity on complex suturing tasks.

Methods

Participants recruited for this study were novices (no laparoscopic experience), target group for this training (surgical/gynaecologic/urologic residents, > 10 basic and < 20 advanced laparoscopic procedures) and experts (> 20 advanced laparoscopic procedures). Each participant performed the intracorporeal suturing exercise (Task 1), an upside down needle transfer (Task 2, developed for this study) and an anastomosis needle transfer (Task 3). Following, the participants completed a questionnaire regarding their demographics and opinion on the eoSim in terms of realism, didactic value and usability. Measured outcome parameters were time, distance, percentage of instrument tip off-screen, working area, speed, acceleration and smoothness.

Results

In total, 104 participants completed the study, of which 60 novices, 31 residents and 13 experts. Face and content validity results showed a mean positive opinion on realism (3.9 Task 1, 3.6 Task 2 and 3.7 Task 3), didactic value (4.0, 3.4 and 3.7, respectively) and usability (4.2. 3.7 and 4.0, respectively). There were no significant differences in these outcomes between the specified expertise groups. Construct validity results showed significant differences between experts, target group or novices for Task 1 in terms of time (means 339, 607 and 1224 s, respectively, p < 0.001) and distance (means 8.1, 15.6 and 21.7 m, respectively, p < 0.001). Task 2 showed significant differences between groups regarding time (p < 0.001), distance (p 0.003), off-screen (p < 0.001) and working area (p < 0.001). Task 3 showed significant differences between groups, after subanalyses, on total number of stitches (p < 0.001), time per stitch (p < 0.001) and distance per stitch (p < 0.001).

Conclusions

The results of this study indicate that the eoSim is a potential meaningful and valuable simulator in the training of suturing tasks.

High-Performance Virtual Reality Volume Rendering of Original Optical Coherence Tomography Point-Cloud Data Enhanced With Real-Time Ray Casting

Purpose

Feasibility testing of a novel volume renders technology to display optical coherence tomography data (OCT) in a virtual reality (VR) environment.

Methods

A VR program was written in C++/OpenGL to import and display volumetric OCT data in real time with 180 frames per second using a high-end computer and a tethered head-mounted display. Following exposure, participants completed a Simulator Sickness Questionnaire (SSQ) to assess for nausea, disorientation, and oculomotor disturbances. A user evaluation study of this software was conducted to explore the potential utility of this application.

Results

Fifty-seven subjects completed the user testing (34 males and 23 females). Mean age was 48.5 years (range, 21–77 years). Mean acquired work experience of the 35 ophthalmologists (61.40%) included in the group was 15.46 years (range, 1–37 years). Twenty-nine participants were VR-naïve. The SSQ showed a mean total score of 5.8 (SD = 9.44) indicating that the system was well tolerated and produced minimal side effects. No difference was reported between VR-naïve participants and experienced users. Overall, immersed subjects reported an enjoyable VR-OCT presence effect.

Conclusions

A usable and satisfying VR imaging technique was developed to display and interact with original OCT data.

Translational Relevance

An advanced high-end VR image display method was successfully developed to provide new views and interactions in an ultra high-speed projected digital scenery using point-cloud OCT data. This represents the next generation of OCT image display technology and a new tool for patient engagement, medical education, professional training, and telecommunications.

Operating list composition and surgical performance

BACKGROUND

Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance.

METHOD

Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored.

RESULTS

The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity.

CONCLUSION

There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

Contributory factors in surgical incidents as delineated by a confidential reporting system

Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.