Participants’ opinions of laparoscopic training devices after a basic laparoscopic training course

The impact of preclinical clerkship in general surgery on medical students' attitude to a surgical career

PURPOSE

With the advent of a new program for postgraduate medical students in 2004, the number of applicants choosing surgical careers in Japan has been declining. We conducted this study to evaluate the impact of preclinical clerkship and how it affects students' attitudes toward a surgical career.

METHODS

The subjects of our study were fifth-year medical students who participated in a clinical clerkship in general surgery in our department between April 2021 and March 2022. We conducted pre- and post-preclinical clerkship surveys to assess the perceived image of surgeons and the impact of clerkship on surgical career interest.

RESULTS

Among 132 medical students (77 men and 55 women) who rotated through preclinical clerkship in our department, 125 participated in the survey and 66% expressed interest in a surgical career. In the post-clerkship survey, an increased interest in a surgical career was expressed by 79% of the students; notably, including those who initially expressed interest. Approximately 77% of students were satisfied with the practical skill training they received.

CONCLUSION

Engaging medical students early in surgical experience through a preclinical clerkship for general surgery appears to promote their interest in a surgical career.

Is there proof of transferability of laparoscopic psychomotor skills from the simulator laboratory to the operating room? Results from a systematic review

This systematic review aims to understand better the translation of laparoscopic psychomotor skills, acquired in dry lab training, into a direct patient benefit in actual clinical practice in the operating room. The review was performed according to PRISMA guidance, searching database-specific filters for controlled trials: 'laparoscopy', 'simulator', 'surgical training', 'dry lab', 'psychomotor skills'. We included only RCTs in which the study population was the surgical trainee or novice surgeon with no prior simulation training, and the intervention was simulation training in laparoscopic surgery, regardless of subspecialty. Ten studies were included in this systematic review. The mean performance score was higher compared to the control groups. Fewer errors were noted in the intervention groups. No clinical patient outcomes (mortality, morbidity, quality of life) were addressed in these studies. All the trials were at high risk of bias. Training outside the operating room may lead to better surgical performance and less operative time. Nevertheless, additional studies with better designs are needed to provide more robust evidence.

The comparison of teaching efficiency between virtual reality and traditional education in medical education: a systematic review and meta-analysis

Background

Virtual reality (VR) technology has developed rapidly in recent years and has been applied in many fields, including medical education. A meta-analysis was performed to compare the examination pass rate of medical students educated using VR and those receiving traditional education to evaluate the teaching effect of VR in medical education.

Methods

The PubMed, Springer Link, Science Direct, and Wiley Online Library were searched from inception to May 2020. Articles meeting the inclusion criteria were then evaluated, relevant information extracted and a meta-analysis conducted. Students were allocated to a VR group, those trained using VR technology, and a traditional education group, those who received a traditional medical education.

Results

Six studies were included in the meta-analysis. The results indicate a significant difference between the pass rate of students educated using VR and those receiving traditional medical education. The odds ratios and confidence intervals of individual studies and our meta-analysis are illustrated with a forest plot.

Conclusions

Students in the VR group performed better than those in the traditional education group. Teaching with VR may enhance student learning in medical education. Medical schools should consider making greater use of VR when educating students.

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.

Simulation-based Education for Endoscopic Third Ventriculostomy: A Comparison Between Virtual and Physical Training Models

BACKGROUND

The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."

OBJECTIVE

To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.

METHODS

Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.

RESULTS

The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P < .001 and 3.9; SD = 0.8 vs 4.2, SD = 0.6; P = .02, respectively). Overall task fidelity across the 2 simulators was not perceived as significantly different.

CONCLUSION

Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators

BACKGROUND

Simulation-based education has made its entry into surgical residency training, particularly as an adjunct to hands-on clinical experience. However, one of the ongoing challenges to wide adoption is the capacity of simulators to incorporate educational features required for effective learning. The aim of this study was to identify strengths and limitations of spine simulators to characterize design elements that are essential in enhancing resident education.

METHODS

We performed a mixed qualitative and quantitative cohort study with a focused survey and interviews of stakeholders in spine surgery pertaining to their experiences on 3 spine simulators. Ten participants were recruited spanning all levels of training and expertise until qualitative analysis reached saturation of themes. Participants were asked to perform lumbar pedicle screw insertion on 3 simulators. Afterward, a 10-item survey was administrated and a focused interview was conducted to explore topics pertaining to the design features of the simulators.

RESULTS

Overall impressions of the simulators were positive with regards to their educational benefit, but our qualitative analysis revealed differing strengths and limitations. Main design strengths of the computer-based simulators were incorporation of procedural guidance and provision of performance feedback. The synthetic model excelled in achieving more realistic haptic feedback and incorporating use of actual surgical tools.

DISCUSSION

Stakeholders from trainees to experts acknowledge the growing role of simulation-based education in spine surgery. However, different simulation modalities have varying design elements that augment learning in distinct ways. Characterization of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

Face validity of the pulsatile organ perfusion trainer for laparoscopic cholecystectomy

BACKGROUND

The pulsatile organ perfusion (POP) trainer provides training of minimally invasive surgery (MIS) with real instruments and cadaveric organs. It provides training of full procedures with simulation of bleeding. Although widely used, the face validity has not yet been evaluated. This study aimed to establish face validity of the POP trainer for laparoscopic cholecystectomy (LC) and its usefulness compared with other training modalities.

MATERIALS AND METHODS

During MIS courses, the participants (n = 52) used the POP trainer to perform LC. Face validity was assessed with questionnaires for realism and usefulness on a five-point Likert scale. Participants were divided into two groups: experts (n = 15) who had performed more than 50 laparoscopic procedures and novices (n = 37) with less than 50 procedures. Secondary aims included the ranking of training modalities, as well as exploration of their specific advantages and disadvantages.

RESULTS

The POP trainer was found to be realistic (3.8 ± 0.9) and useful (4.6 ± 0.9). Differences between experts and novices were only found for "The training modality resembles reality" (3.1 ± 0.8 vs. 3.8 ± 0.7; p = 0.010), "The operation on the POP trainer is realistic" (3.4 ± 1.1 vs. 4.5 ± 0.8; p = 0.003), and "It would be desirable to have a POP trainer at my own hospital" (4.2 ± 1.1 vs. 4.8 ± 0.8; p = 0.040). In the ranking, the animal training (1.1 ± 0.3) placed first, the POP trainer (2.3 ± 0.9) second, and the VR trainer (2.8 ± 0.9) and box trainer (2.8 ± 1.1) third. The realistic simulation of animal training was named as an advantage most often, while the unrealistic simulation of the VR trainer was the most often named disadvantage.

CONCLUSIONS

The POP trainer was rated a highly realistic and useful training modality with face validity for LC. Differences between experts and novices existed concerning realism and desirability. Future studies should evaluate the POP trainer for more advanced surgical procedures. The POP trainer widens the spectrum of modalities for training of MIS in a safe environment outside the operating room.

Porcine cadaver organ or virtual-reality simulation training for laparoscopic cholecystectomy: a randomized, controlled trial

OBJECTIVES

As conventional laparoscopic procedural training requires live animals or cadaver organs, virtual simulation seems an attractive alternative. Therefore, we compared the transfer of training for the laparoscopic cholecystectomy from porcine cadaver organs vs virtual simulation to surgery in a live animal model in a prospective randomized trial.

DESIGN

After completing an intensive training in basic laparoscopic skills, 3 groups of 10 participants proceeded with no additional training (control group), 5 hours of cholecystectomy training on cadaver organs (= organ training) or proficiency-based cholecystectomy training on the LapMentor (= virtual-reality training). Participants were evaluated on time and quality during a laparoscopic cholecystectomy on a live anaesthetized pig at baseline, 1 week (= post) and 4 months (= retention) after training.

SETTING

All research was performed in the Center for Surgical Technologies, Leuven, Belgium.

PARTICIPANTS

In total, 30 volunteering medical students without prior experience in laparoscopy or minimally invasive surgery from the University of Leuven (Belgium).

RESULTS

The organ training group performed the procedure significantly faster than the virtual trainer and borderline significantly faster than control group at posttesting. Only 1 of 3 expert raters suggested significantly better quality of performance of the organ training group compared with both the other groups at posttesting (p < 0.01). There were no significant differences between groups at retention testing. The virtual trainer group did not outperform the control group at any time.

CONCLUSIONS

For trainees who are proficient in basic laparoscopic skills, the long-term advantage of additional procedural training, especially on a virtual but also on the conventional organ training model, remains to be proven.

Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator - either a video box or a mirrored box - is an option to supplement standard training. However, the impact of this modality on trainees with no prior laparoscopic experience is unknown.

OBJECTIVES

To compare the benefits and harms of box model training versus no training, another box model, animal model, or cadaveric model training for surgical trainees with no prior laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing box model trainers versus no training in surgical trainees with no prior laparoscopic experience. We also included trials comparing different methods of box model training.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager for analysis. For each outcome, we calculated the standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

Twenty-five trials contributed data to the quantitative synthesis in this review. All but one trial were at high risk of bias. Overall, 16 trials (464 participants) provided data for meta-analysis of box training (248 participants) versus no supplementary training (216 participants). All the 16 trials in this comparison used video trainers. Overall, 14 trials (382 participants) provided data for quantitative comparison of different methods of box training. There were no trials comparing box model training versus animal model or cadaveric model training. Box model training versus no training: The meta-analysis showed that the time taken for task completion was significantly shorter in the box trainer group than the control group (8 trials; 249 participants; SMD -0.48 seconds; 95% CI -0.74 to -0.22). Compared with the control group, the box trainer group also had lower error score (3 trials; 69 participants; SMD -0.69; 95% CI -1.21 to -0.17), better accuracy score (3 trials; 73 participants; SMD 0.67; 95% CI 0.18 to 1.17), and better composite performance scores (SMD 0.65; 95% CI 0.42 to 0.88). Three trials reported movement distance but could not be meta-analysed as they were not in a format for meta-analysis. There was significantly lower movement distance in the box model training compared with no training in one trial, and there were no significant differences in the movement distance between the two groups in the other two trials. None of the remaining secondary outcomes such as mortality and morbidity were reported in the trials when animal models were used for assessment of training, error in movements, and trainee satisfaction. Different methods of box training: One trial (36 participants) found significantly shorter time taken to complete the task when box training was performed using a simple cardboard box trainer compared with the standard pelvic trainer (SMD -3.79 seconds; 95% CI -4.92 to -2.65). There was no significant difference in the time taken to complete the task in the remaining three comparisons (reverse alignment versus forward alignment box training; box trainer suturing versus box trainer drills; and single incision versus multiport box model training). There were no significant differences in the error score between the two groups in any of the comparisons (box trainer suturing versus box trainer drills; single incision versus multiport box model training; Z-maze box training versus U-maze box training). The only trial that reported accuracy score found significantly higher accuracy score with Z-maze box training than U-maze box training (1 trial; 16 participants; SMD 1.55; 95% CI 0.39 to 2.71). One trial (36 participants) found significantly higher composite score with simple cardboard box trainer compared with conventional pelvic trainer (SMD 0.87; 95% CI 0.19 to 1.56). Another trial (22 participants) found significantly higher composite score with reverse alignment compared with forward alignment box training (SMD 1.82; 95% CI 0.79 to 2.84). There were no significant differences in the composite score between the intervention and control groups in any of the remaining comparisons. None of the secondary outcomes were adequately reported in the trials.

AUTHORS' CONCLUSIONS

The results of this review are threatened by both risks of systematic errors (bias) and risks of random errors (play of chance). Laparoscopic box model training appears to improve technical skills compared with no training in trainees with no previous laparoscopic experience. The impacts of this decreased time on patients and healthcare funders in terms of improved outcomes or decreased costs are unknown. There appears to be no significant differences in the improvement of technical skills between different methods of box model training. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the impacts of box model training on surgical skills in both the short and long term, as well as clinical outcomes when the trainee becomes competent to operate on patients.

A prospective randomized controlled blinded study to evaluate the effect of short-term focused training program in laparoscopy on operating room performance of surgery residents (CTRI /2012/11/003113)

INTRODUCTION

Laparoscopic surgery requires certain specific skills. There have been several attempts to minimize the learning curve with training outside the operation room. Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Several randomized controlled trials and systematic reviews have demonstrated that the technical skills learned on these simulators transfer to the operating room. Currently, however, the integration of these simulated models into formal residency training curricula is lacking. In our institute, we have adopted the Tuebingen Trainer devised by Professor GF Buess from Germany. The purpose of this study was to evaluate the training of surgical residents on an ex vivo phantom model for basic laparoscopic skill acquisition and its transferability to the OR performance.

MATERIALS AND METHODS

Seventeen general surgery residents were randomized into 2 groups: Laparoscopic Training Group (n = 9, Group A) and Standard Training Group (n = 8, Group B). Group A underwent training in the Minimally Invasive Surgery Training Centre on the porcine phantom model and did 10 laparoscopic cholecystectomies, whereas Group B did not undergo training in the Minimally Invasive Surgery Training Centre. All the participants performed a laparoscopic cholecystectomy in the operation theater in the presence of a consultant who was blinded to the training status of the participants. The performance of the residents in both groups in the operation theater was assessed using GOALS criteria, surgical performance assessment parameters, task-specific checklists, and visual analog scale for gallbladder perforation difficulty and overall competence.

RESULTS

The Laparoscopic Training Group had better performance than the Standard Training Group regarding operation time, GOALS criteria, and Task-specific checklists. Although the surgical performance assessments, i.e. cystic duct and artery identification scores, gallbladder perforation scores, and liver injury scores, were better in the Laparoscopic Training Groups, they were not statistically significant. The overall difficulty of the surgery was comparable in both the groups. The Laparoscopic Training Group exhibited significant overall competence on visual analog scale scores.

CONCLUSION

Our study has clearly shown that training on the Tuebingen Trainer with integrated porcine organs results in a statistically significant improvement in the operating room performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to the operating room.

A systematic review on low-cost box models to achieve basic and advanced laparoscopic skills during modern surgical training

INTRODUCTION

Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills.

MATERIALS AND METHODS

A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011.

RESULTS

Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees.

CONCLUSIONS

BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.

Virtual reality does not meet expectations in a pilot study on multimodal laparoscopic surgery training

BACKGROUND

The purpose of the present study was to determine the value of virtual reality (VR) training for a multimodality training program of basic laparoscopic surgery.

MATERIALS AND METHODS

Participants in a two-day multimodality training for laparoscopic surgery used box trainers, live animal training, and cadaveric training on the pulsating organ perfusion (POP) trainer in a structured and standardized training program. The participants were divided into two groups. The VR group (n = 13) also practiced with VR training during the program, whereas the control group (n = 14) did not use VR training. The training modalities were assessed using questionnaires with a five-point Likert scale after the program. Concerning VR training, members of the control group assessed their expectations, whereas the VR group assessed the actual experience of using it. Skills performance was evaluated with five standardized test tasks in a live porcine model before (pre-test) and after (post-test) the training program. Laparoscopic skills were measured by task completion time and a general performance score for each task. Baseline tests were compared with laparoscopic experience of all participants for construct validity of the skills test.

RESULTS

The expected benefit from VR training of the control group was higher than the experienced benefit of the VR group. Box and POP training received better ratings from the VR group than from the control group for some purposes. Both groups improved their skill parameters significantly from pre-training to post-training tests [score +17 % (P < 0.01), time -29 % (P < 0.01)]. No significant difference was found between the two groups for laparoscopic skills improvement except for the score in the instrument coordination task. Construct validity of the skills test was significant for both time and score.

CONCLUSIONS

At its current level of performance, VR training does not meet expectations. No additional benefit was observed from VR training in our multimodality training program.

Virtual reality training for surgical trainees in laparoscopic surgery

BACKGROUND

Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known.

OBJECTIVES

To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS

We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group.

AUTHORS' CONCLUSIONS

Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

Virtual reality training for surgical trainees in laparoscopic surgery

BACKGROUND

Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known.

OBJECTIVES

To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS

We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group.

AUTHORS' CONCLUSIONS

Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

Feasibility and fidelity of practising surgical fixation on a virtual ulna bone

BACKGROUND

Surgical simulators provide a safe environment to learn and practise psychomotor skills. A goal for these simulators is to achieve high levels of fidelity. The purpose of this study was to develop a reliable surgical simulator fidelity questionnaire and to assess whether a newly developed virtual haptic simulator for fixation of an ulna has comparable levels of fidelity as Sawbones.

METHODS

Simulator fidelity questionnaires were developed. We performed a stratified randomized study with surgical trainees. They performed fixation of the ulna using a virtual simulator and Sawbones. They completed the fidelity questionnaires after each procedure.

RESULTS

Twenty-two trainees participated in the study. The reliability of the fidelity questionnaire for each separate domain (environment, equipment, psychological) was Cronbach α greater than 0.70, except for virtual environment. The Sawbones had significantly higher levels of fidelity than the virtual simulator (p < 0.001) with a large effect size difference (Cohen d < 1.3).

CONCLUSION

The newly developed fidelity questionnaire is a reliable tool that can potentially be used to determine the fidelity of other surgical simulators. Increasing the fidelity of this virtual simulator is required before its use as a training tool for surgical fixation. The virtual simulator brings with it the added benefits of repeated, independent safe use with immediate, objective feedback and the potential to alter the complexity of the skill.

Virtual reality simulator training of laparoscopic cholecystectomies - a systematic review

BACKGROUND AND AIMS

Simulators are widely used in occupations where practice in authentic environments would involve high human or economic risks. Surgical procedures can be simulated by increasingly complex and expensive techniques. This review gives an update on computer-based virtual reality (VR) simulators in training for laparoscopic cholecystectomies.

MATERIALS AND METHODS

From leading databases (Medline, Cochrane, Embase), randomised or controlled trials and the latest systematic reviews were systematically searched and reviewed. Twelve randomised trials involving simulators were identified and analysed, as well as four controlled studies. Furthermore, seven studies comparing black boxes and simulators were included.

RESULTS

The results indicated any kind of simulator training (black box, VR) to be beneficial at novice level. After VR training, novice surgeons seemed to be able to perform their first live cholecystectomies with fewer errors, and in one trial the positive effect remained during the first ten cholecystectomies. No clinical follow-up data were found. Optimal learning requires skills training to be conducted as part of a systematic training program. No data on the cost-benefit of simulators were found, the price of a VR simulator begins at EUR 60 000.

CONCLUSIONS

Theoretical background to learning and limited research data support the use of simulators in the early phases of surgical training. The cost of buying and using simulators is justified if the risk of injuries and complications to patients can be reduced. Developing surgical skills requires repeated training. In order to achieve optimal learning a validated training program is needed.

Voluntary autonomous simulator based training in minimally invasive surgery, residents' compliance and reflection

BACKGROUND

Knot tying and suturing skills in minimally invasive surgery (MIS) differ markedly from those in open surgery. Appropriate MIS training is mandatory before implementation into practice. The Advanced Suturing Course (ASC) is a structured simulator based training course that includes a 6-week autonomous training period at home on a traditional laparoscopic box trainer. Previous research did not demonstrate a significant progress in laparoscopic skills after this training period. This study aims to identify factors determining autonomous training on a laparoscopic box trainer at home.

METHODS

Residents (n = 97) attending 1 of 7 ASC courses between January 2009 and June 2011 were consecutively included. After 6 weeks of autonomous, training a questionnaire was completed. A random subgroup of 30 residents was requested to keep a time log. All residents received an online survey after attending the ASC. We performed outcome comparison to examine the accuracy of individual responses.

RESULTS

Out of 97 residents, the main motives for noncompliant autonomous training included a lack of (training) time after working hours (n = 80, 83.3%), preferred practice time during working hours (n = 76, 31.6%), or another surgical interest than MIS (n = 79, 15.2%). Previously set training goals would encourage autonomous training according to 27.8% (n = 18) of residents. Thirty participants submitted a time log and reported an average 76.5-minute weekly training time. All residents confirmed that autonomous home practice on a laparoscopic box trainer is valuable.

CONCLUSIONS

Autonomous practice should be structured and inclusive of adequate and sufficient feedback points. A minimally required practice time should be set. An obligatory assessment, including corresponding consequence should be conducted. Compliance herewith may result in increased voluntary (autonomous) simulator based (laparoscopic) training by residents.

Single versus multimodality training basic laparoscopic skills

Introduction

Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills.

Methods

Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S) (n = 18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M) (n = 18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks + one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test.

Results

Both groups improved their performance significantly (Wilcoxon signed-rank, P < 0.05). The performances of group S and group M in the additional basic task and the salpingectomy did not differ significantly (Mann–Whitney U test, P > 0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P ≤ 0.05), which can be explained by the fact that they were much more familiar with these tasks.

Conclusions

Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.

Mapping the maze of minimally invasive surgery simulators

BACKGROUND

Conforming to, among other considerations, legal and ethical concerns for patient safety, there is an increasing demand to assess a surgeon's skills prior to performance in the operating room in pursuit of higher-quality treatment. Training in minimally invasive surgery (MIS) must therefore be intensified, including team training. New methods to train and assess minimally invasive surgical skills are gaining interest. The goal of this review is to provide instructors with an overview of available MIS training tools. In this review, we discuss currently available simulators for MIS training. Applicability, validity, and construction of simulators are reviewed. Also, some of the leading training programs and assessment methods in MIS are reviewed.

METHODS

A literature search was performed on studies evaluating surgical task performance on a simulator, reviewing satisfaction with laparoscopic training programs, or validating simulators or assessment methods.

RESULTS

Simulators may be divided into simple box trainers and computer-based systems, such as virtual and augmented simulators. All have advantages and disadvantages. An overview is provided of currently available training systems, validity, trainee assessment, and the importance of training programs in MIS.

CONCLUSIONS

No simulator yet provides the ability to train the entire set of required psychomotor skills or procedures for MIS. A multiyear training program combining various simulators for multiple-level training, including team training, should be constructed.

Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects

PURPOSE

To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in subjects who have had no previous laparoscopic experience.

MATERIALS AND METHODS

Twenty-nine medical students were given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group subjects were advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared.

RESULTS

Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. The facility group did objectively better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 vs 2.4 point average increase, P=0.03).

CONCLUSIONS

Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is comparable to the standard trainer for improvement of basic laparoscopic skills.

A tale of two trainers: virtual reality versus a video trainer for acquisition of basic laparoscopic skills

BACKGROUND

This study aimed to assess the transferability of basic laparoscopic skills between a virtual reality simulator (MIST-VR) and a video trainer box (D-Box).

METHODS

Forty-six medical students were randomized into 2 groups, training on MIST-VR or D-Box. After training with one modality, a crossover assessment on the other was performed.

RESULTS

When tested on MIST-VR, the MIST-VR group showed significantly shorter time (90.3 seconds vs 188.6 seconds, P <.001), better economy of movements (4.40 vs 7.50, P <.001), and lower score (224.7 vs 527.0, P <.001). However, when assessed on the D-Box, there was no difference between the groups for time (402.0 seconds vs 325.6 seconds, P = .152), total hand movements (THC) (289 vs 262, P = .792), or total path length (TPL) (34.9 m vs 34.6 m, P = .388).

CONCLUSION

Both simulators provide significant improvement in performance. Our results indicate that skills learned on the MIST-VR are transferable to the D-Box, but the opposite cannot be demonstrated.

How far will simulators be involved into training?

The expansion of laparoscopy and endoscopic surgery has promoted a change in surgical skills acquisition. This review aims to identify problems that modulate surgical skills acquisition and the role of simulation in the current training programs. Social, medical, and working time constraints, together with patient safety issues, lead to a decreased availability of operating room (OR) training opportunities. Systematic reviews show that there is a positive "model to model" transfer of skills more evident for virtual reality (VR) simulation, although transfer from video tower exists for naïve trainees, both of which supplement standard laparoscopic training. VR to OR positive transfer is proven for laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, although not for all parameters analyzed. A mixed model integrating both types of trainers into surgical curricula may strengthen their respective possibilities. To what extent simulation will be included in the surgical training programs depends on development of objective and finer assessment tools and proficiency-based criteria.

ProMIS augmented reality training of laparoscopic procedures face validity

BACKGROUND

Conventional video trainers lack the ability to assess the trainee objectively, but offer modalities that are often missing in virtual reality simulation, such as realistic haptic feedback. The ProMIS augmented reality laparoscopic simulator retains the benefit of a traditional box trainer, by using original laparoscopic instruments and tactile tasks, but additionally generates objective measures of performance.

METHODS

Fifty-five participants performed a "basic skills" and "suturing and knot-tying" task on ProMIS, after which they filled out a questionnaire regarding realism, haptics, and didactic value of the simulator, on a 5-point-Likert scale. The participants were allotted to 2 experience groups: "experienced" (>50 procedures and >5 sutures; N = 27), and "moderately experienced" (<50 procedures and <5 sutures; N = 28).

RESULTS

General consensus among all participants, particularly the experienced, was that ProMIS is a useful tool for training (mean: 4.67, SD: 0.48). It was considered very realistic (mean: 4.44, SD: 0.66), with good haptics (mean: 4.10, SD: 0.97) and didactic value (mean 4.10, SD: 0.65).

CONCLUSIONS

This study established the face validity of the ProMIS augmented reality simulator for "basic skills" and "suturing and knot-tying" tasks. ProMIS was considered a good tool for training in laparoscopic skills for surgical residents and surgeons.

Virtual reality training for surgical trainees in laparoscopic surgery

BACKGROUND

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training.

OBJECTIVES

To determine whether virtual reality training can supplement or replace conventional laparoscopic surgical training (apprenticeship) in surgical trainees with limited or no prior laparoscopic experience.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and grey literature until March 2008.

SELECTION CRITERIA

We included all randomised clinical trials comparing virtual reality training versus other forms of training including video trainer training, no training, or standard laparoscopic training in surgical trainees with little or no prior laparoscopic experience. We also included trials comparing different methods of virtual reality training.

DATA COLLECTION AND ANALYSIS

We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the standardised mean difference with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS

We included 23 trials with 612 participants. Four trials compared virtual reality versus video trainer training. Twelve trials compared virtual reality versus no training or standard laparoscopic training. Four trials compared virtual reality, video trainer training and no training, or standard laparoscopic training. Three trials compared different methods of virtual reality training. Most of the trials were of high risk of bias. In trainees without prior surgical experience, virtual reality training decreased the time taken to complete a task, increased accuracy, and decreased errors compared with no training; virtual reality group was more accurate than video trainer training group. In the participants with limited laparoscopic experience, virtual reality training reduces operating time and error better than standard in the laparoscopic training group; composite operative performance score was better in the virtual reality group than in the video trainer group.

AUTHORS' CONCLUSIONS

Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Further research of better methodological quality and more patient-relevant outcomes are needed.

Choosing the right physical laparoscopic simulator? Comparison of LTS2000-ISM60 with MISTELS: validation, correlation, and user satisfaction

BACKGROUND

The LTS 2000-ISM60 (LTS; Realsim Systems, Alburquerque, NM, USA) is a computer enhanced video-laparoscopic training system. Our purpose was to validate the LTS and to correlate its scoring performance with that of the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), a widely used and well-validated physical simulator.

METHODS

Participants (n = 124) included medical students, residents, fellows, and attending surgeons from general surgery, gynecology, and urology in 3 Canadian universities. They were classified in groups based on laparoscopic experience: novice, intermediate, competent, and expert. Participants (n = 124) were tested on the LTS, and 74 were tested on both the LTS and the MISTELS. A user satisfaction questionnaire was completed after each performance.

RESULTS

LTS metrics showed a progressive improvement in total scores according to academic level as well as level of laparoscopic experience (P < .001). Good correlation was found between the LTS and the MISTELS (r = .79). Level of user satisfaction was highest with LTS.

CONCLUSIONS

Based on laparoscopic experience and academic level, the LTS has a comparable discriminating capability for level of performance with that of the MISTELS. The higher degree of user satisfaction attributed to the LTS could justify its use as a training and assessment tool for surgical specialties.

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery

Background

Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience.

Methods

Randomized clinical trials addressing this issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, grey literature and reference lists. Standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.

Results

Twenty-three trials (mostly with a high risk of bias) involving 622 participants were included in this review. In trainees without surgical experience, VR training decreased the time taken to complete a task, increased accuracy and decreased errors compared with no training. In the same participants, VR training was more accurate than video trainer (VT) training. In participants with limited laparoscopic experience, VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training. In these participants, the composite performance score was better in the VR group than the VT group.

Conclusion

VR training can supplement standard laparoscopic surgical training. It is at least as effective as video training in supplementing standard laparoscopic training.

A Simple, Low-Cost Platform for Basic Laparoscopic Skills Training

Laparoscopic basic skills' training relies mainly on costly video trainers. The aim of this study was to evaluate a simple, low-cost devise for laparoscopic training. In all, 32 participants with varying levels of skill were recruited. A Simulab LapTrainer (Simulab, Seattle, Washington), using a simple plastic box, a webcam, and a Universal Serial Bus 2 card, was used together with standard operating tools. Participants performed 3 tasks (rope passing, peg transfer, and intracorporeal knot tying), which were video recorded and blindly assessed by 2 experts using error scores, checklists, and time. Statistical analysis included nonparametric tests and Cronbach α for inter-rater reliability. A P <.05 was deemed significant. Highly significant differences were noted between groups in all tasks and for all parameters ( P = .001). Inter-rater reliability was 0.88. Simulator ratings were good: 63%, excellent: 28%, and only 9% rated it as average. The Simulab LapTrainer provides a valid alternative for skills training. Its simplicity, portability, and relatively low cost make it an attractive surgical training tool.

Nonsurgical skills do not predict baseline scores in inanimate box or virtual-reality trainers

INTRODUCTION

Laparoscopic basic skills are best trained in the nonclinical setting. Box trainers and virtual-reality trainers have been shown to be useful in training laparoscopic skills. Certain nonsurgical skills may predict baseline skills in these trainers. This study tested the hypothesis that baseline scores could be predicted in inanimate box trainers and virtual-reality trainers by nonsurgical skills.

METHODS

Only preclinical medical students were included in the study. All students were given a survey ascertaining if they played computer games, typed, sew, played a musical instrument, and utilized chopsticks. Students utilized a box trainer (BT) and/or virtual-reality trainer (VR). Nonparametric two-tailed Mann-Whitney tests were utilized to compare students that possessed certain nonsurgical skills versus those who did not.

RESULTS

There were 18 students in the VR group and 33 students in the BT group. In the VR group, students who played computer games, typed, utilized chopsticks, or played a musical instrument had better scores and fewer errors than those who did not but this did not reach statistical significance in any comparison (p = NS). In the BT group, none of the nonsurgical skills predicted times or errors. Males performed better than females in the VR group (p < 0.001); but this gender discrepancy was not seen in the BT group.

CONCLUSIONS

Nonsurgical skills do not predict baseline scores in either trainer. The gender differences in VR training need to be further explored.

Augmented versus virtual reality laparoscopic simulation: what is the difference? A comparison of the ProMIS augmented reality laparoscopic simulator versus LapSim virtual reality laparoscopic simulator

Background

Virtual reality (VR) is an emerging new modality for laparoscopic skills training; however, most simulators lack realistic haptic feedback. Augmented reality (AR) is a new laparoscopic simulation system offering a combination of physical objects and VR simulation. Laparoscopic instruments are used within an hybrid mannequin on tissue or objects while using video tracking. This study was designed to assess the difference in realism, haptic feedback, and didactic value between AR and VR laparoscopic simulation.

Methods

The ProMIS AR and LapSim VR simulators were used in this study. The participants performed a basic skills task and a suturing task on both simulators, after which they filled out a questionnaire about their demographics and their opinion of both simulators scored on a 5-point Likert scale. The participants were allotted to 3 groups depending on their experience: experts, intermediates and novices. Significant differences were calculated with the paired t-test.

Results

There was general consensus in all groups that the ProMIS AR laparoscopic simulator is more realistic than the LapSim VR laparoscopic simulator in both the basic skills task (mean 4.22 resp. 2.18, P < 0.000) as well as the suturing task (mean 4.15 resp. 1.85, P < 0.000). The ProMIS is regarded as having better haptic feedback (mean 3.92 resp. 1.92, P < 0.000) and as being more useful for training surgical residents (mean 4.51 resp. 2.94, P < 0.000).

Conclusions

In comparison with the VR simulator, the AR laparoscopic simulator was regarded by all participants as a better simulator for laparoscopic skills training on all tested features.

Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition

BACKGROUND

Laparoscopic surgery requires a different set of skills than traditional open surgery. The acquisition of basic laparoscopic skills may help novices when learning laparoscopic procedures. This study tested the hypothesis that the combination of virtual reality and box trainers leads to better basic laparoscopic skill acquisition than either method alone or no training.

METHODS

A randomized control trial involving preclinical medical students with no prior operative experience was performed. The students were grouped according to four training methods: virtual reality training, inanimate box training, a combination of both, and no training (control). The pre- and posttraining scores for four skills in the porcine laboratory were the metrics chosen for this study.

RESULTS

A total of 65 students participated in this study. There were no differences among any of the pretraining scores (p > 0.05). The posttraining times differed between the four groups. Post hoc analyses showed statistically significant differences (p < 0.05) between the participants trained with both trainers and the control subjects.

CONCLUSIONS

Our data demonstrate that the combination of virtual reality training and inanimate box training leads to better laparoscopic skill acquisition than either training method alone or no training at all. Optimal preclinical laparoscopic training should incorporate both virtual reality trainers and inanimate box trainers.

[Purpose of the practical training courses]

Laparoscopy surgery started in the 90's decade and it is rapidly developing in the first years of this century; it is therefore a very recent surgical alternative. This has made that each teams formation has gone along very different ways, today that we have already expert services it is essential to systematize the training and to shorten the learning curve. For that purpose we have the practical training courses that combine surgery in patients with surgery in experimental operating theatres, which are absolutely indispensable.

Simulators and Virtual Reality in Surgical Education

This article explores the pros and cons of virtual reality simulators, their abilities to train and assess surgical skills, and their potential future applications. Computer-based virtual reality simulators and more conventional box trainers are compared and contrasted. The virtual reality simulator provides objective assessment of surgical skills and immediate feedback further to enhance training. With this ability to provide standardized, unbiased assessment of surgical skills, the virtual reality trainer has the potential to be a tool for selecting, instructing, certifying, and recertifying gynecologists.

Surgical Residents’ Perception of Simulation Training

Laparoscopic surgical simulation is a valuable and validated training tool. We examined its perception and use among general surgery residents at our institution. Questionnaires were sent to all 29 general surgery residents with a 93 per cent response rate. Residents were divided into junior residents (JR; PGY 1–2) and senior residents (SR; PGY 3–5). JR spent more hours in the simulation center and completed their assigned tasks faster than SR (14 vs 52 days). Thirty-three per cent of SR felt that simulation training should be limited to JR in contrast to only 8 per cent of JR. However, 93 per cent of residents agreed that the program improved their laparoscopic skills. Most residents feel that simulation training is essential and mandatory in current surgical residency (75% of JR and 67% of SR) and needs to be extended to open surgery (67% JR and 60% SR). Seventy-five per cent of JR, but only 13 per cent of SR, feel that residents’ involvement in procedures should be based on performance in surgical simulation. JR ranked simulation training first in useful ways to learn new skills, whereas SR ranked proctorship highest. JR have a higher use of simulation training and a higher perception of its utility.

Simulation: a new frontier in surgical education

Simulation offers a new frontier in surgical education that promises to enhance the current approaches to training. It addresses the operational and fiscal realities of current healthcare deliveries while adhering to principles of educational psychology. Challenges for educators include systematic validation of simulation methods, attracting research funding agencies to support this cause, and development of appropriate funding mechanisms for the sometimes high facility and hardware costs. The greatest challenge, however, is instituting simulation into the minds of a surgical community that is already steeped in a long and entrenched tradition of Halstedian surgical training.