Virtual reality simulators and training in laparoscopic surgery

Mentor-Guided Learning in Immersive Virtual Environments: The Impact of Visual and Haptic Feedback on Skill Acquisition

In the early stages of learning a technical skill, trainees require guidance from a mentor through augmented feedback to develop higher expertise. However, the impact of such feedback and the different modalities used to communicate it remain underexplored in immersive virtual environments (IVE). This paper presents a study in which 27 participants were divided into three groups to learn a tool manipulation trajectory in an IVE. Two experimental groups received guidance from an expert using visual and/or haptic augmented feedback, while the control group received no feedback. The results indicate that both experimental groups showed significantly greater improvement in tool trajectory performance than the control group from pre- to post-test, with no significant differences between them. Analysis of their learning curves revealed similar performance improvements in tool trajectory across trials, outperforming the control group. Additionally, the visual-haptic feedback condition was linked to lower task load in three out of six dimensions of the NASA-TLX and a higher perceived interdependence with the expert's actions. These findings suggest that augmented feedback from an expert enhances the learning of tool manipulation skills. Although adding haptic feedback did not lead to better learning outcomes compared to visual feedback alone, it did enhance the overall user experience. These results offer valuable insights for designing IVEs that support mentor-trainee interactions through augmented feedback.

Effects of training in pairs versus training alone on reaching proficiency in minimally invasive Roux-en-Y-gastric bypass on a virtual reality trainer in medical students: a randomized-controlled trial

BACKGROUND

Minimally invasive surgery (MIS) is the standard approach in bariatric surgery. The most common bariatric procedures are sleeve gastrectomy and Roux-en-Y-Gastric Bypass (RYGB). Simulation training, including virtual reality (VR), is useful when learning MIS. Training in pairs has proven beneficial in acquiring basic MIS skills. However, this has not been tested on more complex procedures such as MIS RYGB. The study aimed to assess the learning effects of training MIS RYGB on a VR trainer in pairs compared to solo training.

METHODS

Medical students (n = 60) were randomized into the intervention group, trained in pairs (n = 30), and the control group, trained solo (n = 30). Both groups needed to train MIS RYGB on a VR trainer under the supervision of trained tutors until proficiency was reached. The MIS RYGB proficiency was defined as 105/110 points according to the Bariatric Objective Structured Assessment of Technical Skills (BOSATS) score. The primary outcome was the number of exercise repetitions until proficiency was reached. Secondary outcomes compared the BOSATS scores, bleeding incidents, and the validated score on current motivation.

RESULTS

The intervention group achieved proficiency with significantly fewer repetitions than the control group (p = 0.002). Most participants in the intervention group reached proficiency by the fifth repetition, and none required an eighth repetition. The intervention group had better BOSATS scores than the control group after the second, fourth, and fifth MIS RYGB (91.1 ± 6.4 vs. 87.1 ± 7.0 points, p = 0.025; 104.0 ± 4.7 vs. 100.3 ± 6.1 points, p = 0.014; 106.2 ± 2.8 vs. 101.9 ± 5.8 points, p = 0.026), respectively. Additionally, the intervention group experienced fewer bleeding complications in the fifth and sixth MIS RYGB repetitions than the control group (2 vs. 10, p = 0.001; 0 vs. 8, p < 0.001, respectively).

CONCLUSIONS

Training MIS RYGB on a VR trainer in pairs enables trainees to reach procedural proficiency with fewer exercise repetitions than training alone.

Identifying key drivers affecting the future of virtual reality in medical education

BACKGROUND

Policymakers must have a forward-looking mindset. Future studies are valuable tools for monitoring upcoming developments and identifying the driving forces that shape the future. This research aimed to identify the drivers or key influencing factors in the future of virtual reality in medical education.

MATERIALS AND METHOD

This study was conducted in 2021-2023 in three phases: conducting literature review, interviewing with experts, and categorizing these results within the STEEPV (Social, Technological, Economic, Environmental, Political, and Values) framework.

RESULTS

Content analysis of the literature review resulted in 273 codes and seven categories. Interviews with 15 experts were analyzed, which led to 220 codes and 30 sub-categories. Ultimately, the results of the two aforementioned stages were categorized within the STEEPV framework, including six, seven, six, two, four, and five drivers in the categories of social, technological, economic, environmental, political, and values drivers, respectively.

CONCLUSION

To successfully introduce virtual reality in universities, it is essential to create a supportive environment, adjust policies, and establish ethical guidelines. This will require initial investments, cost-reduction strategies, and collaboration with knowledge-based companies. In addition, it is vital to leverage existing technology, provide training, and enhance digital literacy to ensure effective utilization. The future of virtual reality in medical education will be influenced by technological advancements, economic factors, environmental concerns, political frameworks, and value-driven approaches.

Construction and implementation of a laparoscopic skill training course based on a smartphone application and virtual reality

BACKGROUND

To develop a laparoscopic training course that combines a smartphone application (APP) and virtual reality (VR), and initially evaluate the feasibility and effectiveness of its implementation.

METHODS

The Exploring Laparoscopy (Ex-Lap) app was developed to meet training demands. The course was designed by integrating the app with a VR simulator (LapSim®) and animal organ perfusion simulators. From January 2021 to December 2023, 91 participants were enrolled in the study and then divided into 5 separate batches to undergo the first stage of the course. The performance of the participants was evaluated by rating scale, the overall Training and Assessment of Basic Laparoscopic Techniques (TABLT) scores, and pass rates. Statistical analyses were conducted using SPSS 26.0, employing Kruskal-Wallis tests, Chi-squared analysis, and Fisher's exact test, depending on the data type.

RESULTS

The Staged Training and Assessment of Laparoscopic Skills (STALS) course was developed, consisting of three stages. The overall pass rates for the first stage across the five batches ranged from 85 to 100%, with no significant difference (P = 0.387). No significant differences were found in the scale scores or TABLT scores for the training tasks among students from different batches (all P > 0.05).

CONCLUSIONS

The STALS course is applicable in residency training, demonstrating satisfactory teaching effectiveness and replicability.

The transition of surgical simulation training and its learning curve: a bibliometric analysis from 2000 to 2023

BACKGROUND

Proficient surgical skills are essential for surgeons, making surgical training an important part of surgical education. The development of technology promotes the diversification of surgical training types. This study analyzes the changes in surgical training patterns from the perspective of bibliometrics, and applies the learning curves as a measure to demonstrate their teaching ability.

METHOD

Related papers were searched in the Web of Science database using the following formula: TS=[(training OR simulation) AND (learning curve) AND (surgical)]. Two researchers browsed the papers to ensure that the topics of articles were focused on the impact of surgical simulation training on the learning curve. CiteSpace, VOSviewer, and R packages were applied to analyze the publication trends, countries, authors, keywords, and references of selected articles.

RESULT

Ultimately, 2461 documents were screened and analyzed. The USA is the most productive and influential country in this field. Surgical endoscopy and other interventional techniques publish the most articles, while surgical endoscopy and other interventional techniques is the most cited journal. Aggarwal Rajesh is the most productive and influential author. Keyword and reference analyses reveal that laparoscopic surgery, robotic surgery, virtue reality, and artificial intelligence were the hotspots in the field.

CONCLUSION

This study provided a global overview of the current state and future trend in the surgical education field. The study surmised the applicability of different surgical simulation types by comparing and analyzing the learning curves, which is helpful for the development of this field.

Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study

BACKGROUND

The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees.

METHODS

This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores.

RESULTS

The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001).

CONCLUSIONS

Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.

The bibliometric analysis of extended reality in surgical training: Global and Chinese perspective

Objectives

The prospect of extended reality (XR) being integrated with surgical training curriculum has attracted scholars. However, there is a lack of bibliometric analysis to help them better understand this field. Our aim is to analyze relevant literature focusing on development trajectory and research directions since the 21st century to provide valuable insights.

Methods

Papers were retrieved from the Web of Science Core Collection. Microsoft Excel, VOSviewer, and CiteSpace were used for bibliometric analysis.

Results

Of the 3337 papers published worldwide, China contributed 204, ranking fifth. The world's enthusiasm for this field has been growing since 2000, whereas China has been gradually entering since 2001. Although China had a late start, its growth has accelerated since around 2016 due to the reform of the medical postgraduate education system and the rapid development of Chinese information technology, despite no research explosive period has been yet noted. International institutions, notably the University of Toronto, worked closely with others, while Chinese institutions lacked of international and domestic cooperation. Sixteen stable cooperation clusters of international scholars were formed, while the collaboration between Chinese scholars was not yet stable. XR has been primarily applied in orthopedic surgery, cataract surgery, laparoscopic training and intraoperative use in neurosurgery worldwide.

Conclusions

There is strong enthusiasm and cooperation in the international research on the XR-based surgical training. Chinese scholars are making steady progress and have great potential in this area. There has not been noted an explosive research phase yet in the Chinese pace. The research on several surgical specialties has been summarized at the very first time. AR will gradually to be more involved and take important role of the research.

A low-cost unity-based virtual training simulator for laparoscopic partial nephrectomy using HTC Vive

Laparoscopic education and surgery assessments increase the success rates and lower the risks during actual surgeries. Hospital residents need a secure setting, and trainees require a safe and controlled environment with cost-effective resources where they may hone their laparoscopic abilities. Thus, we have modeled and developed a surgical simulator to provide the initial training in Laparoscopic Partial Nephrectomy (LPN-a procedure to treat kidney cancer or renal masses). To achieve this, we created a virtual simulator using an open-source game engine that can be used with a commercially available, reasonably priced virtual reality (VR) device providing visual and haptic feedback. In this study, the proposed simulator's design is presented, costs are contrasted, and the simulator's performance is assessed using face and content validity measures. CPU- and GPU-based computers can run the novel simulation with a soft body deformation based on simplex meshes. With a reasonable trade-off between price and performance, the HTC Vive's controlled soft body effect, physics-based deformation, and haptic rendering offer the advantages of an excellent surgical simulator. The trials show that the medical volunteers who performed the initial LPN procedures for newbie surgeons received positive feedback.

Use of Virtual Reality in the Education of Orthopaedic Procedures: A Randomised Control Study in Early Validation of a Novel Virtual Reality Simulator

Background Virtual reality (VR) simulation is a potential solution to the barriers surgical trainees are facing. There needs to be validation for its implementation within current training. We aimed to compare VR simulation to traditional methods in acquiring surgical skills for a TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA; DePuy Synthes, Auckland, New Zealand) femoral nailing system. Methods Thirty-one surgical trainees were randomised to two groups: traditional-training group (control group) and a VR-training group (intervention group) for insertion of a short cephalomedullary TFNA nail. Both groups then inserted the same TFNA system into saw-bone femurs. Surveys evaluated validity of the relevant activities, perception of simulation, confidence, stress and anxiety. The primary outcomes were tip-apex distance (TAD) and user anxiety/confidence levels. Secondary outcomes included number of screw- and nail-guidewire insertion attempts, the time taken to complete and user validity of the VR system. Results There was no statistical difference in TAD between the intervention and control groups (9mm vs 15mm, p=0.0734). The only TAD at risk of cut-out was in the control group (25mm). There was no statistical difference in time taken (2547.5ss vs 2395ss, p=0.668), nail guide-wire attempts (two for both groups, p=0.355) and screw guide-wire attempts (one for both groups, p=0.702). The control group versus intervention had higher anxiety levels (50% vs 33%) and had lower confidence (61% vs 84%). Interpretation There was no objective difference in performance on a saw-bone model between groups. However, this VR simulator resulted in more confidence and lower anxiety levels whilst performing a simulated TFNA. Whilst further studies with larger sample sizes and exploration of transfer validity to the operating theatre are required, this study does indicate potential benefits of VR within surgical training.

Comparison of Smoothness, Movement Speed and Trajectory during Reaching Movements in Real and Virtual Spaces Using a Head-Mounted Display

Virtual reality is used in rehabilitation and training simulators. However, whether movements in real and virtual spaces are similar is yet to be elucidated. The study aimed to examine the smoothness, trajectory, and velocity of participants' movements during task performance in real and virtual space. Ten participants performed the same motor task in these two spaces, reaching for targets placed at six distinct positions. A head-mounted display (HMD) presented the virtual space, which simulated the real space environment. The smoothness of movements during the task was quantified and analysed using normalised jerk cost. Trajectories were analysed using the actual trajectory length normalised by the shortest distance to the target, and velocity was analysed using the time of peak velocity. The analysis results showed no significant differences in smoothness and peak velocity time between the two spaces. No significant differences were found in the placement of the six targets between the two spaces. Conversely, significant differences were observed in trajectory length ratio and peak velocity time, albeit with small effect sizes. This outcome can potentially be attributed to the fact that the virtual space was presented from a first-person perspective using an HMD capable of presenting stereoscopic images through binocular parallax. Participants were able to obtain physiological depth information and directly perceive the distance between the target and the effector, such as a hand or a controller, in virtual space, similar to real space. The results suggest that training in virtual space using HMDs with binocular disparity may be a useful tool, as it allows the simulation of a variety of different environments.

[New perspectives in orthopedics : Developments through neurotechnology and metaverse]

The combination of neurotechnology and metaverse holds high potentials for orthopedics, as it offers a broad spectrum of possibilities to overcome the limits of traditional medical care. The vision of a medical metaverse providing the infrastructure as a link for innovative technologies opens up new opportunities for therapy, medical collaborations and practical, personalized training for aspiring physicians. However, risks and challenges, such as security and privacy, health-related issues, acceptance by patients and doctors, as well as technical hurdles and access to the technologies, remain. Hence, future research and development is paramount. Nonetheless, due to technological progress, the exploration of new research areas, and the improved availability of the technologies paired with cost reduction, the prospects for neurotechnology and metaverse in orthopedics are promising.

Modeling of Learning Processes Using Continuous-Time Markov Chain for Virtual-Reality-Based Surgical Training in Laparoscopic Surgery

Recent usage of Virtual Reality (VR) technology in surgical training has emerged because of its cost-effectiveness, time savings, and cognition-based feedback generation. However, the quantitative evaluation of its effectiveness in training is still not studied thoroughly. This paper demonstrates the effectiveness of a VR-based surgical training simulator in laparoscopic surgery and investigates how stochastic modeling represented as Continuous-time Markov-chain (CTMC) can be used to explicit the training status of the surgeon. By comparing the training in real environments and in VR-based training simulators, the authors also explore the validity of the VR simulator in laparoscopic surgery. The study further aids in establishing learning models of surgeons, supporting continuous evaluation of training processes for the derivation of real-time feedback by CTMC-based modeling.

Simulation-based education in urology - an update

Over the past 30 years surgical training, including urology training, has changed from the Halstedian apprenticeship-based model to a competency-based one. Simulation-based education (SBE) is an effective, competency-based method for acquiring both technical and non-technical surgical skills and has rapidly become an essential component of urological education. This article introduces the key learning theory underpinning surgical education and SBE, discussing the educational concepts of mastery learning, deliberate practice, feedback, fidelity and assessment. These concepts are fundamental aspects of urological education, thus requiring clinical educators to have a detailed understanding of their impact on learning to assist trainees to acquire surgical skills. The article will then address in detail the current and emerging simulation modalities used in urological education, with specific urological examples provided. These modalities are part-task trainers and 3D-printed models for open surgery, laparoscopic bench and virtual reality trainers, robotic surgery simulation, simulated patients and roleplay, scenario-based simulation, hybrid simulation, distributed simulation and digital simulation. This article will particularly focus on recent advancements in several emerging simulation modalities that are being applied in urology training such as operable 3D-printed models, robotic surgery simulation and online simulation. The implementation of simulation into training programmes and our recommendations for the future direction of urological simulation will also be discussed.

Technical skills simulation in transplant surgery: a systematic review

Purpose

 Transplant surgery is a demanding field in which the technical skills of the surgeon correlates with patient outcomes. As such, there is potential for simulation-based training to play an important role in technical skill acquisition. This study provides a systematic assessment of the current literature regarding the use of simulation to improve surgeon technical skills in transplantation.

Methods

 Data were collected by performing an electronic search of the PubMed and Scopus database for articles describing simulation in transplant surgery. The abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 172 abstracts and agreed upon articles that met the inclusion criteria for the systematic review.

Results

 Simulators can be categorized into virtual reality simulators, cadaveric models, animal models (animate or inanimate) and synthetic physical models. No virtual reality simulators in transplant surgery are described in the literature. Three cadaveric models, seven animal models and eight synthetic physical models specific to transplant surgery are described. A total of 18 publications focusing on technical skills simulation in kidney, liver, lung, pancreas, and cardiac transplantation were found with the majority focusing on kidney transplantation.

Conclusions

 This systematic review identifies currently reported simulation models in transplant surgery. This will serve as a reference for general surgery and transplant surgery professionals interested in using simulation to enhance their technical skills.

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Magnetic resonance cholangiopancreatography enhanced by virtual reality as a novel tool to improve the understanding of biliary anatomy and the teaching of surgical trainees

Objective

The novel picture archiving and communication system (PACS), compatible with virtual reality (VR) software, displays cross-sectional images in VR. VR magnetic resonance cholangiopancreatography (MRCP) was tested to improve the anatomical understanding and intraoperative performance of minimally invasive cholecystectomy (CHE) in surgical trainees.

Design

We used an immersive VR environment to display volumetric MRCP data (Specto VRTM). First, we evaluated the tolerability and comprehensibility of anatomy with a validated simulator sickness questionnaire (SSQ) and examined anatomical landmarks. Second, we compared conventional MRCP and VR MRCP by matching three-dimensional (3D) printed models and identifying and measuring common bile duct stones (CBDS) using VR MRCP. Third, surgical trainees prepared for CHE with either conventional MRCP or VR MRCP, and we measured perioperative parameters and surgical performance (validated GOALS score).

Setting

The study was conducted out at Clarunis, University Center for Gastrointestinal and Liver Disease, Basel, Switzerland.

Participants

For the first and second study step, doctors from all specialties and years of experience could participate. In the third study step, exclusively surgical trainees were included. Of 74 participating clinicians, 34, 27, and 13 contributed data to the first, second, and third study phases, respectively.

Results

All participants determined the relevant biliary structures with VR MRCP. The median SSQ score was 0.75 (IQR: 0, 3.5), indicating good tolerability. Participants selected the corresponding 3D printed model faster and more reliably when previously studying VR MRCP compared to conventional MRCP: We obtained a median of 90 s (IQR: 55, 150) and 72.7% correct answers with VR MRCP versus 150 s (IQR: 100, 208) and 49.6% correct answers with conventional MRCP, respectively (p &lt; 0.001). CBDS was correctly identified in 90.5% of VR MRCP cases. The median GOALS score was higher after preparation with VR MRCP than with conventional MRCP for CHE: 16 (IQR: 13, 22) and 11 (IQR: 11, 18), respectively (p = 0.27).

Conclusions

VR MRCP allows for a faster, more accurate understanding of displayed anatomy than conventional MRCP and potentially leads to improved surgical performance in CHE in surgical trainees.

Enabling personalization of a robotic surgery procedure via a surgery training simulator

Although robotic or robot-assisted surgery has been increasingly used by many surgical disciplines, its application in cranial or skull base surgery is still in its infancy. Master-slave teleoperation setting of these robotic systems enables these surgical procedures to be replicated in a virtual reality environment for surgeon training purposes. A variety of teleoperation modes were previously determined with respect to the motion capability of the surgeon’s hand that wears the ring as the surgeon handles a surgical tool inside the surgical workspace. In this surgery training simulator developed for a robot-assisted endoscopic skull base surgery, a new strategy is developed to identify the preferred motion axes of the surgeon. This simulator is designed specifically for tuning the teleoperation system for each surgeon via the identification. This tuning capability brings flexibility to adjust the system operation with respect to the motion characteristics of the surgeon.

Cognitive Computation in Ideological and Political Classroom Teaching Based on Digital Sensor Technology

Numerous new ideas and concepts have changed the behavior and value orientation of university students as a result of the internet's rising popularity on college campuses. This study performs research on digital sensor technologies in order to enhance the intelligent effect of ideological and political classroom instruction. In addition, this study combines the fast Fourier transform principle to enhance digital sensor technology, digital sensor and cognitive computation technology to investigate the ideological and political classroom teaching process, and the actual situation of the ideological and political teaching to digitally process the ideological and political teaching process. In addition, this study employs sensor technology to convey data and digital sensor technology to increase the quality of ideological and political classroom instruction by enhancing the traditional teaching paradigm. In addition, on this premise, this study conducts a performance evaluation of the system, primarily focusing on the digital effect and the enhancement of ideological and political teaching quality. In conclusion, this study proves its teaching system through test research. According to the test results, the intelligent teaching method described in this study has a certain practical effect.

An impact of three dimensional techniques in virtual reality

Three dimensional (3D) imaging play a prominent role in the diagnosis, treatment planning, and post-therapeutic monitoring of patients with Rheumatic Heart Disease (RHD) or mitral valve disease. More interactive and realistic medical experiences take an advantage of advanced visualization techniques like augmented, mixed, and virtual reality to analyze the 3D models. Further, 3D printed mitral valve model is being used in medical field. All these technologies improve the understanding of the complex morphologies of mitral valve disease. Real-time 3D Echocardiography has attracted much more attention in medical researches because it provides interactive feedback to acquire high-quality images as well as timely spatial information of the scanned area and hence is necessary for intraoperative ultrasound examinations. In this article, three dimensional techniques and its impacts in mitral valve disease are reviewed. Specifically, the data acquisition techniques, reconstruction algorithms with clinical applications are presented. Moreover, the advantages and disadvantages of state-of-the-art approaches are discussed in detail.

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Quantitative influence and performance analysis of virtual reality laparoscopic surgical training system

BACKGROUND

Virtual reality (VR) surgery training has become a trend in clinical education. Many research papers validate the effectiveness of VR-based surgical simulators in training medical students. However, most existing articles employ subjective methods to study the residents' surgical skills improvement. Few of them investigate how to improve the surgery skills on specific dimensions substantially.

METHODS

Our paper resorts to physiological approaches to objectively study the quantitative influence and performance analysis of VR laparoscopic surgical training system for medical students. Fifty-one participants were recruited from a pool of medical students. They conducted four pre and post experiments in the training box. They were trained on VR-based laparoscopic surgery simulators (VRLS) in the middle of pre and post experiments. Their operation and physiological data (heart rate and electroencephalogram) are recorded during the pre and post experiments. The physiological data is used to compute cognitive load and flow experience quantitatively. Senior surgeons graded their performance using newly designed hybrid standards for fundamental tasks and Global operative assessment of laparoscopic skills (GOALS) standards for colon resection tasks. Finally, the participants were required to fill the questionnaires about their cognitive load and flow experience.

RESULTS

After training on VRLS, the time of the experimental group to complete the same task could drop sharply (p < 0.01). The performance scores are enhanced significantly (p < 0.01). The performance and cognitive load computed from EEG are negatively correlated (p < 0.05).

CONCLUSION

The results show that the VRLS could highly improve medical students' performance and enable the participants to obtain flow experience with a lower cognitive load. Participants' performance is negatively correlated with cognitive load through quantitative physiological analysis. This might provide a new way of assessing skill acquirement.

Comparative Effectiveness of Training with Simulators Versus Traditional Instruction in Veterinary Education: Meta-Analysis and Systematic Review

One of the greatest challenges in veterinary education is adequately preparing students with the clinical skills they need to be successful health care providers. Integration of simulators, devices used to represent real world phenomena under test conditions, into the veterinary curriculum can help address challenges to clinical instruction. The use of simulators in veterinary education is increasing; however, their effectiveness remains unclear. This meta-analysis seeks to synthesize the evidence for simulator training in veterinary education to provide a consensus of effect, guide the integration of simulators into the curriculum, and direct the development of future simulation-based research in veterinary medicine. A systematic search identified 416 potential manuscripts from which 60 articles were included after application of inclusion criteria. Information was extracted from 71 independent experiments. The overall weighted mean effect size for simulator training was g = 0.49 for the random-effects model. The outcome measures of knowledge, time, process, and product all produced statistically significant mean effect sizes favoring simulation (d = 0.41, 0.35, 0.70, 0.53, respectively). A moderator analysis revealed that study characteristics and instructional design features moderated the effectiveness of simulator training. Overall, the results indicate that simulator training in veterinary education can be effective for knowledge and clinical skill outcomes.

Continuous Monitoring of Mental Load During Virtual Simulator Training for Laparoscopic Surgery Reflects Laparoscopic Dexterity: A Comparative Study Using a Novel Wireless Device

Introduction

Cognitive Load Theory (CLT) relates to the efficiency with which individuals manipulate the limited capacity of working memory load. Repeated training generally results in individual performance increase and cognitive load decrease, as measured by both behavioral and neuroimaging methods. One of the known biomarkers for cognitive load is frontal theta band, measured by an EEG. Simulation-based training is an effective tool for acquiring practical skills, specifically to train new surgeons in a controlled and hazard-free environment. Measuring the cognitive load of young surgeons undergoing such training can help to determine whether they are ready to take part in a real surgery. In this study, we measured the performance of medical students and interns in a surgery simulator, while their brain activity was monitored by a single-channel EEG.

Methods

A total of 38 medical students and interns were divided into three groups and underwent three experiments examining their behavioral performances. The participants were performing a task while being monitored by the Simbionix LAP MENTOR™. Their brain activity was simultaneously measured using a single-channel EEG with novel signal processing (Aurora by Neurosteer^®). Each experiment included three trials of a simulator task performed with laparoscopic hands. The time retention between the tasks was different in each experiment, in order to examine changes in performance and cognitive load biomarkers that occurred during the task or as a result of nighttime sleep consolidation.

Results

The participants’ behavioral performance improved with trial repetition in all three experiments. In Experiments 1 and 2, delta band and the novel VC9 biomarker (previously shown to correlate with cognitive load) exhibited a significant decrease in activity with trial repetition. Additionally, delta, VC9, and, to some extent, theta activity decreased with better individual performance.

Discussion

In correspondence with previous research, EEG markers delta, VC9, and theta (partially) decreased with lower cognitive load and higher performance; the novel biomarker, VC9, showed higher sensitivity to lower cognitive load levels. Together, these measurements may be used for the neuroimaging assessment of cognitive load while performing simulator laparoscopic tasks. This can potentially be expanded to evaluate the efficacy of different medical simulations to provide more efficient training to medical staff and measure cognitive and mental loads in real laparoscopic surgeries.

Virtual Reality Simulator Use Stimulates Medical Students' Interest in Orthopaedic Surgery

Purpose

To investigate whether the use of a VR arthroscopic simulator can influence medical students’ attitudes toward a career in orthopaedic surgery.

Methods

Twenty-five medical students completed seven unsupervised sessions on a VR hip-arthroscopic simulator. All participants completed a pre-simulator and post-simulator pseudo-anonymized questionnaire consisting of 10 questions: six 10-point Likert scale questions addressing their interest in orthopaedics, surgery, and arthroscopy; and four 5-point Likert scale questions addressing their attitudes toward simulation. Prepaired and postpaired datasets were analyzed using Wilcoxon signed rank test.

Results

Interest in both orthopaedics and surgery was found to increase after simulator use (orthopaedics: 5.3 ± .3 to 8.4 ± .2, P = .0001; surgery: 5.8 ± .3 to 9.0 ± .2; P = .0001). It was also found that simulator use increased participants’ interest in arthroscopy (5.4 ± .3 to 8.0 ± .3; P = .0001) and hip-arthroscopy (5.0 ± .3 to 7.6 ± .3; P = .0001). Participants reported they were more likely to attend endoscopic and arthroscopic surgical lists after simulator use (endoscopic: 6.9 ± .3 to 8.4 ± .2; P = .0003; arthroscopic: 5.9 ± .3 to 8.4 ± .2; P = .0001). After using the simulator, participants felt more strongly that VR simulation is a valuable training modality (P = .0025), that simulation should be a mandatory part of orthopaedics and surgical training (P = .0001 and P = .0001), and that access to VR simulators improves the quality of surgical training (P = .0024).

Conclusions

These results demonstrate that exposure to VR arthroscopic simulation increased medical students’ interest in orthopaedics, surgery, and arthroscopy, without the need for direct supervision. Following VR simulator use, students reported they were more likely to engage with training opportunities, including arthroscopic and endoscopic surgery.

Clinical Relevance

Understanding factors that stimulate interest in orthopaedic surgery may help programs attract the broadest pool of potential trainees.

Virtual Reality as an Affirmative Spin-Off to Laparoscopic Training: An Updated Review

Latest advancements in science lead to drastic improvements in patient health care. Techniques and technology evolved in surgery over the years have resulted in the improvement of patient outcomes by leaps and bounds. Open surgeries previously done for procedures like appendectomy and cholecystectomy evolved into laparoscopic minimally invasive procedures. Such procedures pose few challenges to the surgeons, like lack of tissue feedback and fulcrum effect of the abdominal wall. But training surgeons for such an advanced skill is still following conventional methods. These procedures can be effectively trained using Virtual Reality (VR), which can simulate operations outside the operating room (OR). To maximize the outcomes of VR training, knowledge on various strategies affecting the skills acquisition and retention in VR training is essential. This review collected information from PubMed, EMBASE, Cochrane Library (CENTRAL) databases. Data from the previous ten years are included in the review. This included documents, clinical trials, meta-analysis, randomized controlled trials, reviews, systematic reviews, letters to editors, and grey literature. After an advanced Medical Subject Headings (MeSH) search, we got 59,532 results, and after the application of filters, 189 results showed up. Out of these, studies that were not exclusively relevant to the use of VR in laparoscopic surgery were manually excluded, and a total of 35 articles were included in the study. VR is found to be an excellent training modality with promising outcomes. It helps the surgeons perform the surgery accurately at a faster pace and improves confidence and multitasking ability in OR. Instructor feedback from mentors and deliberate practice of trainees, and early introduction of haptics in VR resulted in the most effective outcomes of the VR training. Box trainers are also compared with VR trainers as they are the cheaper modalities of training. However, this area needs more research to conclude if box trainers can act as a cheaper alternative to VR training providing similar outcomes.

The application of artificial intelligence and virtual reality in the auxiliary teaching of American science fiction literature

In order to improve the teaching effect of American science fiction literature, based on artificial intelligence virtual reality technology, this paper constructs an auxiliary teaching system of intelligent American science fiction literature. Moreover, this paper analyzes the time complexity and space complexity of constructing point cloud spatial topological relations and finding the nearest k neighboring points. Simultaneously, this paper uses CUDA to find k nearest neighbors on the GPU, analyzes the point cloud denoising technology, uses the KD-tree to construct the point cloud topology in the DBSCAN-based denoising method, searches for the k nearest neighbors to complete the mark of the core point and the boundary point. In addition, this paper combines artificial intelligence virtual technology and intelligent algorithms to construct the framework of the auxiliary teaching system of American science fiction literature, and analyze its functional modules. Finally, this paper designs experiments to verify the performance of the model. The research results show that the system constructed in this paper can meet the needs of auxiliary teaching of American science fiction literature.

Construction of network open teaching platform of analytical chemistry based on facial recognition and artificial intelligence

The theoretical and experimental teaching part of analytical chemistry is relatively boring, so it is difficult to improve the teaching results of analytical chemistry through the traditional network teaching mode. In this paper, based on the actual situation and based on the facial recognition algorithm, this paper uses artificial intelligence algorithm to build an open network teaching platform for analytical chemistry. Moreover, this paper improves the traditional adaptive genetic algorithm, and introduces a directional perturbation operator to non-linearize the adaptive adjustment probability. In algorithm design and simulation experiments, an improved genetic algorithm based on t distribution is used as an example to prove the effectiveness of the method in this paper. The platform constructed in this article is mainly applied to the teaching of analytical chemistry. The teaching of analytical chemistry includes theoretical teaching and experimental teaching. In addition, according to the actual needs of teaching, this article conducts research and analysis on the platform through theoretical teaching and experimental teaching. The research results show that the constructed teaching platform has good performance.

Space reconstruction of audiovisual media based on artificial intelligence and virtual reality

In the electronic age, the changes in the mirror space constructed by movies are also brought about by changes in the media. Cinematic space is a four-dimensional space illusion including time created by the use of light and shadow, color, perspective, sound, and the movement of characters and cameras. It is not a real four-dimensional space, but a reflection and reproduction of the real space. With the goal of improving the accuracy of spatially coded structured light 3D reconstruction, this paper conducts in-depth research on several key technologies that affect the reconstruction accuracy and makes corresponding innovations and improvements. Moreover, this paper respectively proposes an adaptive structured light spatial coding algorithm based on geometric features and a color structured light decoding algorithm based on color shift technology. In addition, this paper implements a spatially coded structured light three-dimensional reconstruction system and calibration system. The simulation research shows that the method in this paper has certain reliability.

Simulation of public art communication in colleges based on smart cloud platform and artificial intelligence algorithm

Public art communication in colleges and universities needs to be launched with the support of artificial intelligence systems. According to the current situation of public art communication in colleges and universities, this paper builds a smart cloud platform for public art communication in colleges and universities with the support of artificial intelligence algorithms. Moreover, this paper introduces the bandwidth offset coefficient to judge the change of network throughput, introduces the slice download rate difference to first judge the consistency change trend of bandwidth, and then further proposes the calculation method of bandwidth prediction value by situation. In addition, this paper proposes a flexible transmission mechanism based on smart collaborative networks. Through in-depth perception of network status and component behavior, this mechanism implements the selection of the optimal path in the network according to the current network status and user service requirements to complete the transmission of service resources. If the current transmission path fails, the mechanism should ensure the continuity and reliability of the service. The research results show that the system constructed in this paper has good performance and can be applied to practice.

Three-dimensional image art design based on dynamic image detection and genetic algorithm

The three-dimensional intelligent simulation of image art design is an important means of current image art design, which is affected by many factors. The traditional 3D intelligent simulation technology has certain defects, which leads to certain defects in 3D artwork. This paper builds a three-dimensional art design system based on dynamic image detection and genetic algorithm. The system simulates the actual dehazing method, and this paper proposes a dehazing algorithm suitable for this system and proposes to use bilateral filtering instead of median filtering. Because bilateral filtering has good edge retention, it can eliminate the blockiness caused by median filtering. Moreover, this paper uses FMM (Fast Marching Method) algorithm to repair the image. In order to verify the performance of the model, this paper conducts quantitative evaluation through system simulation and user satisfaction survey methods. The research results show that the method proposed in this paper has a certain effect and can be applied to practice.

Virtual design of urban planning based on GIS big data and machine learning

In order to build a virtual urban planning model and improve the effect of urban planning, this paper builds a virtual urban planning design model based on GIS big data technology and machine learning algorithms, and proposes a solution that combines multiple features. With the development of polarized SAR in the direction of high resolution, a single feature often cannot fully express the detailed information of ground objects, resulting in poor classification results and low accuracy. The combination of multiple features can express feature information well. In addition, this paper uses the ELM method to plan SAR ground object classification, uses an extreme learning machine classification algorithm with fast learning speed and good classification effect, and uses ELM as a classifier. Finally, this paper designs experiments to explore the performance of the model constructed in this paper from two aspects: detection accuracy and planning score. The research results show that the model constructed in this paper meets the expected goals.

The Use of Virtual Reality Echocardiography in Medical Education

Virtual reality (VR) is a relatively new technology that allows an individual to experience a virtual world. This new immersive video type may be of particular usefulness in procedure-based healthcare settings. We hypothesized that VR echocardiography was non-inferior to live demonstration. Our aim was to assess the usefulness of a VR echocardiographic approach in teaching echocardiography to pediatric trainees compared to live demonstration. This was a single center, cross-sectional observational design. We used a Garmin VIRB® 360 and a head-mount display to record live echocardiography exams in a pediatric population. An Oculus Go™ was used to view the 360° immersive/VR videos. Trainees responded to a written questionnaire afterwards. Fifteen trainees participated in the study, each of whom had previously seen echocardiography through live demonstration teaching. Eleven respondents had previous hands-on echocardiography experience. All 15 participants confirmed that VR echocardiography is a useful teaching tool with 87% (n = 13) rating it as good or very good on a 5-point Likert scale. When asked to compare VR to live demonstration, 67% (n = 10) rated VR echocardiography as the same or better than live demonstration. One of the participants reported a side effect, namely mild and self-resolving dizziness. VR echocardiography is a safe, inexpensive and practical way for trainees to learn echocardiography. The addition of VR echocardiography to the arsenal of teaching tools may enrich the learning experience for trainees.

Virtual Reality (VR) Applications in Cardiology: A Review

Virtual reality (VR) has applications in cardiology to create enhancement, thereby improving the quality of associated planning, treatment and surgery. The need is to study different applications of this technology in the field of cardiology. We have studied research papers on VR and its applications in cardiology through a detailed bibliometric analysis. The study identified five significant steps for proper implementation of this technology in cardiology. Some challenges are to be undertaken by using this technology, and they can provide some benefits; thus, authors contemplate extensive research and development. This study also identifies 10 major VR technology applications in cardiology and provided a brief description. This innovative technology helps a heart surgeon to perform complex heart surgery effectively. Thus, VR applications have the potential for improving decision-making, which helps save human life. VR plays a significant role in the development of a surgical procedure. This technology undertakes 3D heart model information in full colour, which helps to analyze the overall heart vane, blockage and blood flow. With the help of this digital technology, a surgeon can improve the accuracy of heart surgery, and he can simulate the surgery. A surgeon can undertake surgery in a virtual environment on a virtual patient. The unique purpose of this technology is to practice pre-operatively on the specific circumstance. A cardiologist can also check the proper status of inner and outer heart wall layer. Thus, by using this 3D information, the surgeon can now interact with heart data/information without any physical touch. This technology opens a new opportunity to improve the heart surgery and development in cardiovascular treatment to improve patient outcome.

Virtual reality simulation in robot-assisted surgery: meta-analysis of skill transfer and predictability of skill

BACKGROUND

The value of virtual reality (VR) simulators for robot-assisted surgery (RAS) for skill assessment and training of surgeons has not been established. This systematic review and meta-analysis aimed to identify evidence on transferability of surgical skills acquired on robotic VR simulators to the operating room and the predictive value of robotic VR simulator performance for intraoperative performance.

METHODS

MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science were searched systematically. Risk of bias was assessed using the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale for Education. Correlation coefficients were chosen as effect measure and pooled using the inverse-variance weighting approach. A random-effects model was applied to estimate the summary effect.

RESULTS

A total of 14 131 potential articles were identified; there were eight studies eligible for qualitative and three for quantitative analysis. Three of four studies demonstrated transfer of surgical skills from robotic VR simulators to the operating room measured by time and technical surgical performance. Two of three studies found significant positive correlations between robotic VR simulator performance and intraoperative technical surgical performance; quantitative analysis revealed a positive combined correlation (r = 0.67, 95 per cent c.i. 0.22 to 0.88).

CONCLUSION

Technical surgical skills acquired through robotic VR simulator training can be transferred to the operating room, and operating room performance seems to be predictable by robotic VR simulator performance. VR training can therefore be justified before operating on patients.

Effect of Smartphone Laparoscopy Simulator on Laparoscopic Performance in Medical Students

BACKGROUND

This study aims to investigate if a smartphone laparoscopy simulator, SimuSurg, is effective in improving laparoscopic skills in surgically inexperienced medical students.

METHODS

This is a single-blinded randomized controlled trial featuring 30 preclinical medical students without prior laparoscopic simulation experience. The students were randomly allocated to a control or intervention group (n = 15 each) and 28 students completed the study (n = 14 each). All participants performed three validated exercises in a laparoscopic box trainer and repeated them after 1 week. The intervention group spent the intervening time completing all levels in SimuSurg, whereas the control group refrained from any laparoscopic activity. A prestudy questionnaire was used to collect data on age, sex, handedness, and experience with gaming.

RESULTS

The total score improved significantly between the two testing sessions for the intervention group (n = 14, median change [MC] = 182.00, P = 0.009) but not for the control group (n = 14, MC = 161.50, P = 0.08). Scores for the nondominant hand improved significantly in the intervention group (MC = 66.50, P = 0.008) but not in the control group (MC = 9.00, P = 0.98). There was no improvement in dominant hand scores for either the intervention (MC = 62.00, P = 0.08) or control (MC = 26.00, P = 0.32) groups. Interest in surgery (β = -234.30, P = 0.02) was positively correlated with the baseline total scores; however, age, sex, and experience with video games were not.

CONCLUSIONS

The results suggest that smartphone applications improve laparoscopic skills in medical students, especially for the nondominant hand. These simulators may be a cost-effective and accessible adjunct for laparoscopic training among surgically inexperienced students and clinicians.

Recent Applications of Virtual Reality for the Management of Pain in Burn and Pediatric Patients

PURPOSE OF REVIEW

Virtual reality, via integration of immersive visual and auditory modalities, offers an innovative approach to pain management. The purpose of this review is to investigate the clinical application of virutal reality as an adjunct analgesic to standard of care, particularly in pediatric and burn patients.

RECENT FINDINGS

Although relatively new, virtual reality has been successfully implemented in a wide range of clinical scenarios for educational, diagnostic, and therapeutic purposes. Most recent literature supports the use of this adjunct analgesic in reducing pain intensity for pediatric and burn patients undergoing acute, painful procedures. This summative review demonstrates the efficacy of virtual reality in altering pain perception by decreasing pain and increasing functionality among pediatric and burn patients. However, large, multi-center randomized controlled trials are still warranted to generalize these findings to more diverse patient demographics and medical scenarios.

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5–97.5%, n = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5–100%, n = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5–76%, n = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.

The Learning Curve of Laparoendoscopic Single-Site Surgery in Benign Gynecological Diseases

OBJECTIVE

To analyze and draw the learning curve of laparoendoscopic single-site surgery (LESS) in various benign gynecological diseases, so as to provide a reference for applying this cutting-edge technique.

METHODS

A retrospective analysis of LESS was conducted. Factors influencing the LESS learning process were assessed using Cox's proportional hazards regression. The cumulative sum (CUSUM) value and the learning curve were calculated and visualized based on operation time (OT), blood loss (BL), conventional laparoscopic surgery (CLS), conversion rate (CV), and complications (CP). The CUSUM value was defined as the sum of CUSUM_OT, CUSUM_BL, CUSUM_CV, and CUSUM_CP.

RESULTS

A total of 445 cases, including adnexectomies (n = 147), ovarian cystectomies (n = 175), and myomectomies (n = 123) were analyzed. Multivariate regression analysis indicated that adhesion grade (HR, 1.462; 95% CI, 1.016-1.994; p = .045), surgical type (HR, 1.283; 95% CI, 1.042-1.429; p = .024), and surgeon CLS experience (HR, 1.372; 95% CI, 1.097-2.246; p = .012) were independent factors predicting surgeons' mastery of the LESS technique. Among gynecologists with CLS experience, the cutoff points were 17, 20, and 27 cases for adnexectomy, ovarian cystectomy, and myomectomy, respectively. For those without CLS experience, the corresponding cutoff values were 19, 27, and 35 cases.

CONCLUSION

The learning curve of LESS for benign gynecological diseases indicates a stepwise process, during which the surgeon's CLS experience is the key, especially in ovarian cystectomy and myomectomy. For the training of young gynecologists, CLS should be emphasized in the early stage, and LESS should be introduced gradually.

The Fun Factor: Does Serious Gaming Affect the Volume of Voluntary Laparoscopic Skills Training?

Background

The availability of validated laparoscopic simulators has not resulted in sustainable high-volume training. We investigated whether the validated laparoscopic serious game Underground would increase voluntary training by residents. We hypothesized that by removing intrinsic barriers and extrinsic barriers, residents would spend more time on voluntary training with Underground compared to voluntary training with traditional simulators.

Methods

After 1 year, we compared amount of voluntary time spent on playing Underground to time spent on all other laparoscopic training modalities and to time spent on performing laparoscopic procedures in the OR for all surgical residents. These data were compared to resident’ time spent on laparoscopic activities over the prior year before the introduction of Underground.

Results

From March 2016 until March 2017, 63 residents spent on average 20 min on voluntary serious gaming, 17 min on voluntary simulator training, 2 h and 44 min on mandatory laparoscopic training courses, and 14 h and 49 min on laparoscopic procedures in the OR. Voluntary activities represented 3% of laparoscopic training activities which was similar in the prior year wherein fifty residents spent on average 33 min on voluntary simulator training, 3 h and 28 min on mandatory laparoscopic training courses, and 11 h and 19 min on laparoscopic procedures.

Conclusion

Serious gaming has not increased total voluntary training volume. Underground did not mitigate intrinsic and extrinsic barriers to voluntary training. Mandatory, scheduled training courses remain needed. Serious gaming is flexible and affordable and could be an important part of such training courses.

Bimanual Fundamentals: Validation of a New Curriculum for Virtual Reality Training of Laparoscopic Skills

Background. To determine face and construct validity for the new Bimanual Fundamentals curriculum for the Simendo^® Virtual Reality Laparoscopy Simulator and prove its efficiency as a training and objective assessment tool for surgical resident’s advanced psychomotor skills. Methods. 49 participants were recruited: 17 medical students (novices), 15 residents (intermediates), and 17 medical specialists (experts) in the field of gynecology, general surgery, and urology in 3 tertiary medical centers in the Netherlands. All participants performed the 5 exercises of the curriculum for 3 consecutive times on the simulator. Intermediates and experts filled in a questionnaire afterward, regarding the reality of the simulator and training goals of each exercise. Statistical analysis of performance was performed between novices, intermediates, and experts. Parameters such as task time, collisions/displacements, and path length right and left were compared between groups. Additionally, a total performance score was calculated for each participant. Results. Face validity scores regarding realism and training goals were overall positive (median scores of 4 on a 5-point Likert scale). Participants felt that the curriculum was a useful addition to the previous curricula and the used simulator would fit in their residency programs. Construct validity results showed significant differences on the great majority of measured parameters between groups. The simulator is able to differentiate between performers with different levels of laparoscopic experience. Conclusions. Face and construct validity for the new Bimanual Fundamental curriculum for the Simendo virtual reality simulator could be established. The curriculum is suitable to use in resident’s training programs to improve and maintain advanced psychomotor skills.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

The effect of simulator fidelity on procedure skill training: a literature review

OBJECTIVES

To evaluate the effect of simulator fidelity on procedure skill training through a review of existing studies.

METHODS

MEDLINE, OVID and EMBASE databases were searched between January 1990 and January 2019. Search terms included "simulator fidelity and comparison" and "low fidelity" and "high fidelity" and "comparison" and "simulator". Author classification of low- and high-fidelity was used for non-laparoscopic procedures. Laparoscopic simulators are classified using a proposed schema. All included studies used a randomized methodology with two or more groups and were written in English. Data was abstracted to a standard data sheet and critically appraised from 17 eligible full papers.

RESULTS

Of 17 studies, eight were for laparoscopic and nine for other skill training. Studies employed evaluation methodologies, including subjective and objective measures. The evaluation was conducted once in 13/17 studies and before-after in 4/17. Didactic training only or control groups were used in 5/17 studies, while 10/17 studies included two groups only. Skill acquisition and simulator fidelity were different for the level of training in 1/17 studies. Simulation training was followed by clinical evaluation or a live animal evaluation in 3/17 studies. Low-fidelity training was not inferior to training with a high-fidelity simulator in 15/17 studies.

CONCLUSIONS

Procedure skill after training with low fidelity simulators was not inferior to skill after training with high fidelity simulators in 15/17 studies. Some data suggest that the effectiveness of different fidelity simulators depends on the level of training of participants and requires further study.

The Use of Immersive and Virtual Reality Technologies to Enable Nursing Students to Experience Scenario-Based, Basic Life Support Training-Exploring the Impact on Confidence and Skills

The link between effective basic life support and survival following cardiac arrest is well known. Nurses are often first responders at in-hospital cardiac arrests and receive annual basic life support training to ensure they have the adequate skills, and student nurses are taught this in preparation for their clinical practice. However, it is clear that some nurses still lack confidence and skills to perform basic life support in an emergency situation. This innovative study included 209 participants, used a mixed-methods approach, and examined three environments to compare confidence and skills in basic life support training. The environments were nonimmersive (basic skills room), immersive (immersive room with video technology), and the Octave (mixed reality facility). The skills were measured using a Laerdal training manikin (QCPR manikin), with data recorded on a wireless Laerdal Simpad, and confidence levels before and after training were measured using a questionnaire. The nonimmersive and the immersive rooms were familiar environments, and the students felt more comfortable, relaxed, and, thus, more confident. The Octave offered the higher level of simulation utilizing virtual reality technology. Students felt less comfortable and less confident in the Octave; we assert that this was because the environment was unfamiliar. The study identified that placing students in an unfamiliar environment influences the confidence and skills associated with basic life support; this could be used as a way of preparing student nurses with the necessary emotional resilience to cope in stressful situations.

Systematic Review of Virtual Haptics in Surgical Simulation: A Valid Educational Tool?

BACKGROUND

Virtual reality (VR)-based surgical simulation is an expanding and rapidly advancing modality which aims to serve the increasing demand to acquire surgical skills outside the live operating room. Haptic, or "force-feedback" technology in VR simulation is a rapidly developing field, however the role of haptics in surgical education and its efficacy is unclear.

METHODS

A systematic literature search was carried out until September 2018 in MEDLINE, Embase, and Cochrane Library using the following keywords: (VR OR VR OR simulation OR simulator) AND (Haptic feedback OR Haptics OR Force feedback) AND (Surgery). All randomized controlled studies comparing VR training with and without haptics were included. PRISMA guidelines were adhered to RESULTS: Eight randomized controlled trials that compare VR training with and without haptics were included and 1 survey study with a total of 215 participants, 116 of which received haptic feedback and 99 were assigned to nonhaptic feedback group. Training tasks included basic proficiency based laparoscopic tasks such as object translocation, cutting, camera navigation, and more complex tasks including diathermy, suturing, dissection, knot tying, and operative maneuvers. Six randomized controlled trials demonstrated that haptic enhanced VR simulation is significantly more effective than without haptics for skill training with a reduced learning curve and faster time to proficiency and task completion, particularly in novice learners. Two studies showed no significant differences in task-assessed parameters between the haptics and nonhaptics cohorts, whereas 1 survey study suggested haptics negatively affected training with decreased realism.

CONCLUSION

Haptic feedback has been shown to improve the fidelity, realism and thus the training effect of VR simulators. However, at present haptic simulators are expensive and in a nascent stage and further research as well as cost-benefit analyses of such tools must be considered to determine whether haptics is truly a surgical necessity.