A comparison between randomly alternating imaging, normal laparoscopic imaging, and virtual reality training in laparoscopic psychomotor skill acquisition

Cognitive and physiological evaluation of virtual reality training in nursing

Virtual reality (VR) has increasingly been used in several disciplines, including nursing, a profession in high demand that is now facing a shortage. This study investigated the effectiveness and efficacy of VR hybrid training over traditional training (TR) methods. Sixteen college students were recruited and randomly assigned to get 100% TR or 50% TR and 50% VR (VR50). Participants attended a three-day program with a registered nurse, consisting of lectures and practical lab sessions. Participants' performance, training time, cognitive development, physical development, mental workload, user experience, Students' Satisfaction and Self-Confidence, and team learning were evaluated. The results showed that the VR50 performed as well as, and sometimes even better than the TR group (p-value = 0.043). VR50 group significantly had higher cognitive development and found VR easy to use and attractive (p-value < 0.05). VR-integrated training makes nurses' training more affordable and accessible while providing instant and relevant feedback.

Practitioner Summary: This study assessed employment-integrated virtual training in nursing, particularly peri-care, by comparing the performance, cognitive, physical, and mental workload of traditional and integrated VR training groups. The findings of this study provide significant support for incorporating VR training into educational settings.

Using insights from cognitive science for the teaching of clinical skills: AMEE Guide No. 155

Students have to develop a wide variety of clinical skills, from cannulation to advanced life support, prior to entering clinical practice. An important challenge for health professions' educators is the implementation of strategies for effectively supporting students in their acquisition of different types of clinical skills and also to minimize skill decay over time. Cognitive science provides a unified approach that can inform how to maximize clinical skill acquisition and also minimize skill decay. The Guide discusses the nature of expertise and mastery development, the key insights from cognitive science for clinical skill development and skill retention, how these insights can be practically applied and integrated with current approaches used in clinical skills teaching.

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 in endoscopy: Practical educational strategies to improve learning

In gastrointestinal endoscopy, simulation-based training can help endoscopists acquire new skills and accelerate the learning curve. Simulation creates an ideal environment for trainees, where they can practice specific skills, perform cases at their own pace, and make mistakes with no risk to patients. Educators also benefit from the use of simulators, as they can structure training according to learner needs and focus solely on the trainee. Not all simulation-based training, however, is effective. To maximize benefits from this instructional modality, educators must be conscious of learners' needs, the potential benefits of training, and associated costs. Simulation should be integrated into training in a manner that is grounded in educational theory and empirical data. In this review, we focus on four best practices in simulation-based education: deliberate practice with mastery learning, feedback and debriefing, contextual learning, and innovative educational strategies. For each topic, we provide definitions, supporting evidence, and practical tips for implementation.

Laparoscopic Motor Learning and Workspace Exploration

BACKGROUND

Laparoscopic surgery requires operators to learn novel complex movement patterns. However, our understanding of how best to train surgeons' motor skills is inadequate, and research is needed to determine optimal laparoscopic training regimes. This difficulty is confounded by variables inherent in surgical practice, for example, the increasing prevalence of morbidly obese patients presents additional challenges related to restriction of movement because of abdominal wall resistance and reduced intra-abdominal space. The aim of this study was to assess learning of a surgery-related task in constrained and unconstrained conditions using a novel system linking a commercially available robotic arm with specialised software creating the novel kinematic assessment tool (Omni-KAT).

METHODS

We created an experimental tool that records motor performance by linking a commercially available robotic arm with specialized software that presents visual stimuli and objectively measures movement outcome (kinematics). Participants were given the task of generating aiming movements along a horizontal plane to move a visual cursor on a vertical screen. One group received training that constrained movements to the correct plane, whereas the other group was unconstrained and could explore the entire "action space."

RESULTS

The tool successfully generated the requisite force fields and precisely recorded the aiming movements. Consistent with predictions from structural learning theory, the unconstrained group produced better performance after training as indexed by movement duration (p < 0.05).

CONCLUSION

The data showed improved performance for participants who explored the entire action space, highlighting the importance of learning the full dynamics of laparoscopic instruments. These findings, alongside the development of the Omni-KAT, open up exciting prospects for better understanding of the learning processes behind surgical training and investigate ways in which learning can be optimized.

Night Call Does Not Impair Learning of Laparoscopic Skills

Investigators have looked at the effect of night call on surgical residents but not at learning of laparoscopic skills. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) tests 6 tasks similar to a laparoscopic cholecystectomy. We hypothesized that night call would impair laparoscopic performance and that skills would not improve but rather deteriorate after night call. Seventeen volunteers were tested before and after night call. Data collected included economy of movement, time, and number of errors for each hand/foot. A paired Student t test was used for statistical analysis. On the first 2 tasks, there was an improvement in all parameters post-call, with significance reached in 5 of 18 parameters (P <.05). In the "running of the bowel," 8 of 9 parameters were significantly improved (P < .05). In the final task, 9 of 11 parameters showed a deterioration post-call, but only economy of movement of the foot was significant (P <.05). Most parameters (16) showed improvement rather than deterioration post-call, which is consistent with learning of laparoscopic skills despite lack of sleep from night call.

Varied Practice in Laparoscopy Training: Beneficial Learning Stimulation or Cognitive Overload?

Determining the optimal design for surgical skills training is an ongoing research endeavor. In education literature, varied practice is listed as a positive intervention to improve acquisition of knowledge and motor skills. In the current study we tested the effectiveness of a varied practice intervention during laparoscopy training. Twenty-four trainees (control group) without prior experience received a 3 weeks laparoscopic skills training utilizing four basic and one advanced training task. Twenty-eight trainees (experimental group) received the same training with a random training task schedule, more frequent task switching and inverted viewing conditions on the four basic training tasks, but not the advanced task. Results showed inferior performance of the experimental group on the four basic laparoscopy tasks during training, at the end of training and at a 2 months retention session. We assume the inverted viewing conditions have led to the deterioration of learning in the experimental group because no significant differences were found between groups on the only task that had not been practiced under inverted viewing conditions; the advanced laparoscopic task. Potential moderating effects of inter-task similarity, task complexity, and trainee characteristics are discussed.

Proficiency performance benchmarks for removal of simulated brain tumors using a virtual reality simulator NeuroTouch

OBJECTIVE

Assessment of neurosurgical technical skills involved in the resection of cerebral tumors in operative environments is complex. Educators emphasize the need to develop and use objective and meaningful assessment tools that are reliable and valid for assessing trainees' progress in acquiring surgical skills. The purpose of this study was to develop proficiency performance benchmarks for a newly proposed set of objective measures (metrics) of neurosurgical technical skills performance during simulated brain tumor resection using a new virtual reality simulator (NeuroTouch).

DESIGN

Each participant performed the resection of 18 simulated brain tumors of different complexity using the NeuroTouch platform. Surgical performance was computed using Tier 1 and Tier 2 metrics derived from NeuroTouch simulator data consisting of (1) safety metrics, including (a) volume of surrounding simulated normal brain tissue removed, (b) sum of forces utilized, and (c) maximum force applied during tumor resection; (2) quality of operation metric, which involved the percentage of tumor removed; and (3) efficiency metrics, including (a) instrument total tip path lengths and (b) frequency of pedal activation.

SETTING

All studies were conducted in the Neurosurgical Simulation Research Centre, Montreal Neurological Institute and Hospital, McGill University, Montreal, Canada.

PARTICIPANTS

A total of 33 participants were recruited, including 17 experts (board-certified neurosurgeons) and 16 novices (7 senior and 9 junior neurosurgery residents).

RESULTS

The results demonstrated that "expert" neurosurgeons resected less surrounding simulated normal brain tissue and less tumor tissue than residents. These data are consistent with the concept that "experts" focused more on safety of the surgical procedure compared with novices. By analyzing experts' neurosurgical technical skills performance on these different metrics, we were able to establish benchmarks for goal proficiency performance training of neurosurgery residents.

CONCLUSION

This study furthers our understanding of expert neurosurgical performance during the resection of simulated virtual reality tumors and provides neurosurgical trainees with predefined proficiency performance benchmarks designed to maximize the learning of specific surgical technical skills.

Towards immersive virtual reality (iVR): a route to surgical expertise

Surgery is characterized by complex tasks performed in stressful environments. To enhance patient safety and reduce errors, surgeons must be trained in environments that mimic the actual clinical setting. Rasmussen’s model of human behavior indicates that errors in surgical procedures may be skill-, rule-, or knowledge-based. While skill-based behavior and some rule-based behavior may be taught using box trainers and ex vivo or in vivo animal models, we posit that multimodal immersive virtual reality (iVR) that includes high-fidelity visual as well as other sensory feedback in a seamless fashion provides the only means of achieving true surgical expertise by addressing all three levels of human behavior. While the field of virtual reality is not new, realization of the goals of complete immersion is challenging and has been recognized as a Grand Challenge by the National Academy of Engineering. Recent technological advances in both interface and computational hardware have generated significant enthusiasm in this field. In this paper, we discuss convergence of some of these technologies and possible evolution of the field in the near term.

Randomized controlled trials: a systematic review of laparoscopic surgery and simulation-based training

Introduction:

This systematic review was conducted to analyze the impact and describe simulation-based training and the acquisition of laparoscopic surgery skills during medical school and residency programs.

Methods:

This systematic review focused on the published literature that used randomized controlled trials to examine the effectiveness of simulation-based training to develop laparoscopic surgery skills. Searching PubMed from the inception of the databases to May 1, 2014 and specific hand journal searches identified the studies. This current review of the literature addresses the question of whether laparoscopic simulation translates the acquisition of surgical skills to the operating room (OR).

Results:

This systematic review of simulation-based training and laparoscopic surgery found that specific skills could be translatable to the OR. Twenty-one studies reported learning outcomes measured in five behavioral categories: economy of movement (8 studies); suturing (3 studies); performance time (13 studies); error rates (7 studies), and global rating (7 studies).

Conclusion:

Simulation-based training can lead to demonstrable benefits of surgical skills in the OR environment. This review suggests that simulation-based training is an effective way to teach laparoscopic surgery skills, increase translation of laparoscopic surgery skills to the OR, and increase patient safety; however, more research should be conducted to determine if and how simulation can become apart of surgical curriculum.

Optimal training design for procedural motor skills: a review and application to laparoscopic surgery

This literature review covers the choices to consider in training complex procedural, perceptual and motor skills. In particular, we focus on laparoscopic surgery. An overview is provided of important training factors modulating the acquisition, durability, transfer, and efficiency of trained skills. We summarize empirical studies and their theoretical background on the topic of training complex cognitive and motor skills that are pertinent to proficiency in laparoscopic surgery. The overview pertains to surgical simulation training for laparoscopy, but also to training in other demanding procedural and dexterous tasks, such as aviation, managing complex systems and sports. Evidence-based recommendations are provided for facilitating efficiency in laparoscopic motor skill training such as session spacing, adaptive training, task variability, part-task training, mental imagery and deliberate practice.

An ergonomic analysis of the effects of camera rotation on laparoscopic performance

BACKGROUND

Minimal access surgery is associated with increased risk of complications, particularly early in a surgeon's laparoscopic career. This is mostly due to loss of depth cues, degraded tactile feedback from surgical instrument, and the "fulcrum effect". Degraded and restricted image on the monitor makes camera orientation very important. The objective of this study is to investigate the effects of camera rotation on laparoscopic performance.

METHODS

In two separate studies 100 laparoscopic novices and 7 experienced laparoscopic surgeons ([300 laparoscopic procedures) were asked to perform a simple laparoscopic cutting task and tie intracorporeal square-knots (respectively) under 0, 15, 45, 90, and 180 camera rotation.

RESULTS

In study 1 camera rotation significantly degraded performance of laparoscopic novices (p\0.00001) and also increased their error rate (p\0.00001). In study 2 camera rotation significantly increased the length of time it took surgeons to tie an intracorporeal square-knot (p\0.00001) and the number of errors made (p\0.0001).

CONCLUSIONS

Unintentional camera rotation during surgery should be avoided to eliminate one potential source for errors.

Literature review: instructional design and pedagogy science in healthcare simulation

This article is a review of the literature focused on simulation as an educational intervention in healthcare. The authors examined the literature based on four key levels: (1) the validity and reliability of the simulator, (2) the validity and reliability of the performance evaluation tool, (3) the study design, and (4) the translational impact. The authors found that the majority of research literature in healthcare simulation does not address the validity and reliability of the simulator or the performance evaluation tool. However, there are well-designed research studies that address the translation into clinical settings and have positive patient safety outcomes.

Physical and cognitive effects of virtual reality integrated training

OBJECTIVE

The objective of this study was to evaluate the cognitive and physical impact of virtual reality (VR) integrated training versus traditional training methods in the domain of weld training.

BACKGROUND

Weld training is very important in various industries and represents a complex skill set appropriate for advanced training intervention. As such, there has been a long search for the most successful and most cost-effective method for training new welders.

METHOD

Participants in this study were randomly assigned to one of two separate training courses taught by sanctioned American Welding Society certified welding instructors; the duration of each course was 2 weeks. After completing the training for a specific weld type, participants were given the opportunity to test for the corresponding certification. Participants were evaluated in terms of their cognitive and physical parameters, total training time exposure, and welding certification awards earned. Each of the four weld types taught in this study represented distinct levels of difficulty and required the development of specialized knowledge and skills.

RESULTS

This study demonstrated that participants in the VR integrated training group (VR50) performed as well as, and in some cases, significantly outperformed, the traditional welding (TW) training group.The VR50 group was found to have a 41.6% increase in overall certifications earned compared with the TW group.

CONCLUSION

VR technology is a valuable tool for the production of skilled welders in a shorter time and often with more highly developed skills than their traditionally trained counterparts.

APPLICATION

These findings strongly support the use ofVR integrated training in the welding industry.

Preliminary face and construct validation study of a virtual basic laparoscopic skill trainer

BACKGROUND

The Virtual Basic Laparoscopic Skill Trainer (VBLaST) is a developing virtual-reality-based surgical skill training system that incorporates several of the tasks of the Fundamentals of Laparoscopic Surgery (FLS) training system. This study aimed to evaluate the face and construct validity of the VBLaST system.

MATERIALS AND METHODS

Thirty-nine subjects were voluntarily recruited at the Beth Israel Deaconess Medical Center (Boston, MA) and classified into two groups: experts (PGY 5, fellow and practicing surgeons) and novice (PGY 1-4). They were then asked to perform three FLS tasks, consisting of peg transfer, pattern cutting, and endoloop, on both the VBLaST and FLS systems. The VBLaST performance scores were automatically computed, while the FLS scores were rated by a trained evaluator. Face validity was assessed using a 5-point Likert scale, varying from not realistic/useful (1) to very realistic/useful (5).

RESULTS

Face-validity scores showed that the VBLaST system was significantly realistic in portraying the three FLS tasks (3.95 +/- 0.909), as well as the reality in trocar placement and tool movements (3.67 +/- 0.874). Construct-validity results show that VBLaST was able to differentiate between the expert and novice group (P = 0.015). However, of the two tasks used for evaluating VBLaST, only the peg-transfer task showed a significant difference between the expert and novice groups (P = 0.003). Spearman correlation coefficient analysis between the two scores showed significant correlation for the peg-transfer task (Spearman coefficient 0.364; P = 0.023).

CONCLUSIONS

VBLaST demonstrated significant face and construct validity. A further set of studies, involving improvement to the current VBLaST system, is needed to thoroughly demonstrate face and construct validity for all the tasks.

Simulators, first experiences

It is increasingly being recognized that laparoscopic surgery poses specific strains on the surgical novice. Specific psychomotor skills are required, which cannot easily be acquired by extrapolation from open surgery. Also, limited teaching time in the strict surgical training curricula makes it difficult to acquire such skills. Two surgical simulation platforms, the Advanced Dundee Psychomotor Tester (ADEPT(R)), and the Xitact LS500(R), are objects of study in our hospital for the training and objective assessment of laparoscopic task performance. Multiple validation studies, both at our center and at other institutions, are ongoing. Face-construct and content validity of the two systems under investigation have been established at our skills laboratory. This article highlights the most important findings of our studies using simulative surgical lapraoscopic technologies.

Postural mechatronic assistant for laparoscopic training

In this article we describe a new concept for manipulating a laparoscope during surgery training. The methodology of handling and navigating of the laparoscope suggested depends on the position of the surgeon's body, assisted by a mechatronic system with three degrees of freedom.

Use of a virtual reality, real-time, simulation model for the training of urologists in transurethral resection of the prostate

OBJECTIVE

There is a growing need to develop surgical skills outside the operating theatre. In this study we describe the development of a virtual reality training system for practising transurethral resection of the prostate (TURP).

MATERIAL AND METHODS

A face validity study was performed using a questionnaire sent to 28 experienced urologists to find out the ideal characteristics of a simulated TURP. Based on the comments a simulator was constructed and a content validity study was then performed in which nine experienced urologists tested the simulator and answered a second questionnaire. After corrections to the simulator, a basic construct validity test was performed.

RESULTS

We have developed a computer-based simulator based on the requirements listed by 17 urologists. It consists of a modified resectoscope connected to a haptic device and supported by a frame. The software provides a virtual view of the prostatic lumen and resectoscope tip, a haptic rendering that generates force feedback and a simulation module that computes the information from the haptic device, resectoscope fluid tap and handle and the foot pedals. The software also simulates bleeding, absorption of irrigation fluid and pressure gradients. Variables are measured and presented in a result file after each "operation". Nine experienced urologists performed a content validity study and changes were made accordingly. A basic construct validity test performed by seven inexperienced students showed a significant improvement in performance after they each performed six simulated procedures.

CONCLUSION

We have developed a simulator that may be used to practise TURP and which meets most of the demands raised in a face validity study. A basic construct validity test showed improved performance after repeated practice in the simulated environment.

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.

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.

Hysteroscopic simulator for training and educational purposes

Hysteroscopy is an extensively popular option in evaluating and treating women with infertility. The procedure utilizes an endoscope, inserted through the vagina and cervix to examine the intra-uterine cavity via a monitor. The difficulty of hysteroscopy from the surgeon's perspective is the visual spatial perception of interpreting 3D images on a 2D monitor, and the associated psychomotor skills in overcoming the fulcrum-effect. Despite the widespread use of this procedure, current qualified hysteroscopy surgeons have not been trained the fundamentals through an organized curriculum. The emergence of virtual reality as an educational tool for this procedure, and for other endoscopic procedures, has undoubtedly raised interests. The ultimate objective is for the inclusion of virtual reality training as a mandatory component for gynecological endoscopic training. Part of this process involves the design of a simulator, encompassing the technical difficulties and complications associated with the procedure. The proposed research examines fundamental hysteroscopic factors as well as current training and accreditation norms, and proposes a hysteroscopic simulator design that is suitable for educating and training.

A systematic review of medical skills laboratory training: where to from here?

OBJECTIVES

The aim of this review was to evaluate the effectiveness of medical skills laboratories or simulators. In particular, it aimed to determine if performance in medical skills laboratories is transferable to actual clinical performance and maintained over time.

METHODS

A range of databases was utilised to search for relevant papers published from 1998 to June 2006. Articles were included in the review if they met a number of criteria that included the evaluation of a skills laboratory or simulator for the purpose of procedural skills training, that participants were either undergraduate medical students or postgraduate medical trainees, and that the study used a randomised, controlled trial (RCT) research design in evaluation.

RESULTS

A total of 44 RCTs were identified for inclusion in the review. Overall, 32 (70%) studies reported that simulator training significantly improved procedural skills performance in comparison with standard or no training. Twenty (45%) RCTs assessed the transfer of simulator performance to clinical skills performance; however, 8 of these used animal models, not real patients. Only 2 studies assessed the maintenance of skills post-intervention, both at 4-month follow-up periods.

CONCLUSIONS

Medical skills laboratories do lead to improvement in procedural skills compared with standard or no training at all when assessed by simulator performance and immediately post-training. However, there is a lack of well designed trials addressing the crucial issues of transferability to clinical practice and retention of skills over time. Further research must be carried out to address these matters if medical skills laboratories are to remain an integral component of medical education.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Videotape Mentoring and Surgical Simulation in Laparoscopic Courses

As laparoscopic approaches to core urologic procedures continue to supplant their open counterparts, the demand to train urologists who received inadequate exposure to these techniques during residency has intensified. The acquisition of laparoscopic skills has been aided greatly by the introduction of hand-assisted laparoscopic surgery (HALS). In another training method, participants completed the standard animate and inanimate course training, then entered a mentoring relationship with their instructor, including an observational period and performance of several complex laparoscopic operations with the assistance of the mentor surgeon. However, the time commitment, compensation issues, and need for temporary operating privileges are obstacles to this approach. A number of studies have demonstrated that laparoscopic skills can be measured on a videotrainer and that ability improves with repetitive performance. Senior urologists with minimal initial knowledge may benefit from laparoscopic skills training videotape analysis and critique. Laparoscopic simulators can improve, not only the psychomotor skills required to perform laparoscopy, but operative performance as well. Ultimately, preoperative images and data may be interfaced with robotic simulation software to allow practice of virtual operations with realistic tissue photo-representation prior to performing them on patients. Improvements in laparoscopic surgical simulation and application of these newly acquired skills to a simulated patient will ultimately eliminate the learning curve on actual patients and provide a useful means of establishing competence.

The effect of escalating feedback on the acquisition of psychomotor skills for laparoscopy

BACKGROUND

In the acquisition of new skills that are difficult to master, such as those required for laparoscopy, feedback is a crucial component of the learning experience. Optimally, feedback should accurately reflect the task performance to be improved and be proximal to the training experience. In surgery, however, feedback typically is in vivo. The development of virtual reality training systems currently offers new training options. This study investigated the effect of feedback type and quality on laparoscopic skills acquisition.

METHODS

For this study, 32 laparoscopic novices were prospectively randomized into four training conditions, with 8 in each group. Group 1 (control) had no feedback. Group 2 (buzzer) had audio feedback when the edges were touched. Group 3 (voiced error) had an examiner voicing the word "error" each time the walls were touched. Group 4 (both) received both the audio buzzer and "error" voiced by the examiner All the subjects performed a maze-tracking task with a laparoscopic stylus inserted through a 5-mm port to simulate the fulcrum effect in minimally invasive surgery (MIS). A computer connected to the stylus scored an error each time the edge of the maze was touched, and the subjects were made aware of the error in the aforementioned manner. Ten 2-min trials were performed by the subjects while viewing a monitor. At the conclusion of training, all the subjects completed a 2-min trial of a simple laparoscopic cutting task, with the number of correct and incorrect incisions recorded.

RESULTS

Group 4 (both) made significantly more correct incisions than the other three groups (F = 12.13; df = 3, 28; p < 0.001), and also made significantly fewer errors or incorrect incisions (F = 14.4; p < 0.0001). Group 4 also made three times more correct incisions and 7.4 times fewer incorrect incisions than group 1 (control).

CONCLUSIONS

The type and quality of feedback during psychomotor skill acquisition for MIS have a large effect on the strength of skills generalization to a simple MIS task and should be given serious consideration in curriculum design for surgical training using simulation tasks.

Can skills assessment on a virtual reality trainer predict a surgical trainee’s talent in laparoscopic surgery?

BACKGROUND

A number of studies have investigated several aspects of feasibility and validity of performance assessments with virtual reality surgical simulators. However, the validity of performance assessments is limited by the reliability of such measurements, and some issues of reliability still need to be addressed. This study aimed to evaluate the hypothesis that test subjects show logarithmic performance curves on repetitive trials for a component task of laparoscopic cholecystectomy on a virtual reality simulator, and that interindividual differences in performance after considerable training are significant. According to kinesiologic theory, logarithmic performance curves are expected and an individual's learning capacity for a specific task can be extrapolated, allowing quantification of a person's innate ability to develop task-specific skills.

METHODS

In this study, 20 medical students at the University of Basel Medical School performed five trials of a standardized task on the LS 500 virtual reality simulator for laparoscopic surgery. Task completion time, number of errors, economy of instrument movements, and maximum speed of instrument movements were measured.

RESULTS

The hypothesis was confirmed by the fact that the performance curves for some of the simulator measurements were very close to logarithmic curves, and there were significant interindividual differences in performance at the end of the repetitive trials.

CONCLUSIONS

Assessment of perceptual motor skills and the innate ability of an individual with no prior experience in laparoscopic surgery to develop such skills using the LS 500 VR surgical simulator is feasible and reliable.

Surgical simulation: a systematic review

OBJECTIVE

To evaluate the effectiveness of surgical simulation compared with other methods of surgical training.

SUMMARY BACKGROUND DATA

Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans.

METHODS

Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance.

RESULTS

Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training.

CONCLUSIONS

While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.

Training, assessment and competency in gynaecologic surgery

The trainee gynaecologist requires specific teaching to achieve competency in gynaecological surgery. Basic skills such as knot tying and suturing should be acquired outside the operating theatre. They can be learned on simulations, including bench models, using synthetic materials, life-like models and animal tissue. Video training equipment is useful for the development of basic laparoscopic hand-eye coordination. Intermediate and advanced skills require simulations using more sophisticated bench models, live animals and virtual reality computerised systems. Structured teaching and assessment methods are essential. Surgical skills training models should be reliable and valid, and can be incorporated into an objective structured clinical examination, which could be used to assess individual development and allow progression through a training programme. Simulation training does translate into improved operative performance. Supervised operating experience on patients is crucial to training and should be assessed regularly using a global rating form with constructive feedback to facilitate improvement.

Modelos experimentales en la cirugía laparoscópica urológica

We present the experience of the Minimally Invasive Surgery Centre (MISC) in the development of a modular training model in laparoscopic surgery. The experience analysis includes the description of the training objectives, the learning process of simple and advance laparoscopic urologic techniques, as well as some current and future considerations before applying the laparoscopic techniques. This learning program pretends to optimize the knowledge of the surgeon and the clinical practice of these surgical techniques. The phases of the learning process have been classified in four levels, which include different modules and models and whose application will depend on the experience and surgical skills. This pyramidal training system permits the student to advance step by step through each level depending on her surgical skills. We have presented our experience in twelve courses about laparoscopic urology and four courses of laparoscopic radical prostatectomy, in which more than 300 urologists have assisted. Furthermore, some Spanish Urology Units have been developing special experimental training programs on laparoscopic radical prostatectomy, partial nephrectomy or laparoscopic dismembered pyeloplasty with Anderson-Hynes technique. It has been previously described that laparoscopic modular learning constitutes a very useful concept to avoid problems related to an incomplete and incorrect learning process. Also it seems clear that the laparoscopic training reduces the learning curve in laparoscopic urologic techniques.

Construct validity of the LapSim laparoscopic surgical simulator

BACKGROUND

Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience).

METHODS

Subjects were medical students (MS), residents (RES), and laparoscopic faculty (FAC). Subjects performed 10 repetitions of 6 LapSim tasks. The LapSim measured performance in 6 to 10 parameters per task, and performance was compared between groups. Post hoc t tests were used to make pair-wise comparisons among the 3 groups using the Bonferroni technique. Statistical significance was set at P < .05.

RESULTS

The degree of prior laparoscopic experience was reflected in performance on at least 1 parameter for each task. Several patterns of performance between MS, RES, and FAC were observed.

CONCLUSIONS

The LapSim has performance parameters that reliably differentiate between subjects with varying laparoscopic experience. However, some performance parameters do not differentiate between groups. To accurately measure a trainee's skill level, only parameters that sensitively measure the true level of performance should be used.

Construct and face validity of MIST-VR, Endotower, and CELTS

BACKGROUND

Video trainers may best offer visually realistic laparoscopic simulation, whereas virtual reality (VR) modules may best provide multidimensional objective measures of performance. This study compares the construct and face validity of three different laparoscopic simulators.

METHODS

Subjects were voluntarily enrolled at the Learning Center during the 2004 SAGES annual meeting. Each subject completed two repetitions of a single task on each of three simulators, MIST-VR, Endotower, and CELTS; performance scores were automatically generated and recorded. Scores of individuals with various levels of experience were compared to determine construct validity for each simulator. Experience was defined according to four parameters: (a) PGY level, (b) fellowship training, (c) basic laparoscopic cases, and (d) advanced laparoscopic cases. Subjects rated each simulator regarding six face validity (realism of simulation) parameters using a 10-point Likert scale (10 = best rating) and participant scores were compared to previously established expert scores (proficiency goals for training).

RESULTS

Ninety-one attendees completed the study. Construct validity was demonstrated for all three simulators; significant differences in scores were detected according to one parameter for MIST-VR, two parameters for Endotower, and all four parameters for CELTS. Face validity was rated as good to excellent for all three simulators (7.0 +/- 0.3 for MIST-VR, 7.9 +/- 0.3 for Endotower [p < 0.001 vs MIST-VR], and 8.7 +/- 0.1 for CELTS [p = 0.001 vs MIST-VR, p = 0.01 vs Endotower]); 6%, 0%, and 36% of "expert" participants obtained expert scores on MIST-VR, Endotower, and CELTS, respectively.

CONCLUSIONS

All three simulators demonstrated significant construct and reasonable face validity. Although virtual reality holds great promise to expand the scope of laparoscopic simulation, current interfaces may limit their utility for assessment. Computer-enhanced video trainers may offer an improved interface while incorporating useful multidimensional metrics. Further work is needed to establish standards for appropriate skills assessment methods and performance levels using simulators.

The laparoscopic performance of novice surgical trainees: testing for acquisition, loss, and reacquisition of psychomotor skills

BACKGROUND

It has been suggested that virtual reality (VR) might be useful for the selection of surgical trainees and the measurement of technical performance during preoperative training and retraining. This study was designed to determine whether it is possible to define and measure the acquisition, loss, and reacquisition of psychomotor skills in novice surgical trainees.

METHODS

Novice surgical trainees (NSTs n = 10, junior surgical registrars with little or no prior experience with laparoscopic surgery) were tested and retested after 1 month using the Minimally Invasive Surgical Trainer-Virtual Reality. Two tasks were used: the simple task [stretch diathermy (SD)] and the more complex task [manipulation diathermy (MD)]. The score was derived from the time taken to complete the task and the number of errors that occurred. Acquisition is the difference between the first and last score of the first training session, loss is the difference in score that occurs between the last score of the first training session and the first score of the second training session, and reacquisition is the difference in the first and last scores of the second training session. A performance criterion level was defined for each task by testing a group of experienced laparoscopic surgeons (n = 10). Groups were compared using the nonparametric Wilcoxon signed rank test, with p < 0.05 considered to be significant.

RESULTS

Acquisition of skill was found for five of 10 NSTs with the SD task and 10/10 for the MD task. As a group the NSTs achieved the criterion level from the outset with the SD task and exceeded it by the eighth attempt for the MD task. The best score was achieved with fewer attempts during the second training session for the SD but not the MD task. The defined parameters are expressed as mean percentage score +/- SD for the 10 NSTs and for each task. There was a 36% (+/- 26) acquisition for the SD task compared with 50% (+/- 4) for the MD task (Wilcoxon p = 0.241). There was a 23% (+/- 19) loss for the SD task compared with 81% (+/- 16) for the MD task (p < 0.005). There was a 20% (+/- 10) reacquisition for the SD task compared with 54% (+/- 7) for the MD task (p < 0.005). The mean scores were greater for the more complex task (MD), which was more useful in discriminating between the individual trainees and the two training sessions.

CONCLUSIONS

It is possible to use VR to define the acquisition, loss, and reacquisition of psychomotor skills in individual NSTs and to compare them with a predefined performance criterion level. This study defines parameters that will be useful in repeated training sessions of NSTs in the preoperative phase of training and during retraining.

Correlation between Perceptual, Visuo-spatial, and Psychomotor Aptitude to Duration of Training Required to Reach Performance Goals on the MIST-VR Surgical Simulator

Given the dynamic nature of modern surgical education, determining factors that may improve the efficiency of laparoscopic training is warranted. The objective of this study was to analyze whether perceptual, visuo-spatial, or psychomotor aptitude are related to the amount of training required to reach specific performance-based goals on a virtual reality surgical simulator. Sixteen MS4 medical students participated in an elective skills course intended to train laparoscopic skills. All were tested for perceptual, visuo-spatial, and psychomotor aptitude using previously validated psychological tests. Training involved as many instructor-guided 1-hour sessions as needed to reach performance goals on a custom designed MIST-VR manipulation-diathermy task (Mentice AB, Gothenberg, Sweden). Thirteen subjects reached performance goals by the end of the course. Two were excluded from analysis due to previous experience with the MIST-VR (total n = 11). Perceptual ability (r = -0.76, P = 0.007) and psychomotor skills (r = 0.62, P = 0.04) significantly correlated with the number of trials required. Visuo-spatial ability did not significantly correlate with training duration. The number of trials required to train subjects to performance goals on the MIST-VR manipulation diathermy task is significantly related to perceptual and psychomotor aptitude.

Analysis of errors in laparoscopic surgical procedures

BACKGROUND

The determination of laparoscopic surgeon ability is essential to training error avoidance. The present study describes a practical method of surgical error analysis.

METHODS

After review of practice videotapes of the excisional phase of laparoscopic cholecystectomy, consensus on the identification of eight errors was achieved. Interrater agreement at the end of this phase was 84-96%. Fourteen study videotapes of gallbladder excision were then observed independently by expert reviewers blinded to surgical team identity. Procedures were assessed using a scoring matrix of 1-min segments with each error reported each minute.

RESULTS

Interrater agreement was 84-100% for all error categories.

CONCLUSIONS

The present study demonstrates that excellent interrater agreement of procedural errors can be achieved by carefully defining and training recognition of targeted events. Extension of this simple and reliable analysis tool to other procedures should be feasible to define behaviors leading to adverse clinical outcomes.

Discriminative validity of the Minimally Invasive Surgical Trainer in Virtual Reality (MIST-VR) using criteria levels based on expert performance

BACKGROUND

Increasing constraints on the time and resources needed to train surgeons have led to a new emphasis on finding innovative ways to teach surgical skills outside the operating room. Virtual reality training has been proposed as a method to both instruct surgical students and evaluate the psychomotor components of minimally invasive surgery ex vivo.

METHODS

The performance of 100 laparoscopic novices was compared to that of 12 experienced (>50 minimally invasive procedures) and 12 inexperienced (<10 minimally invasive procedures) laparoscopic surgeons. The values of the experienced surgeons' performance were used as benchmark comparators (or criterion measures). Each subject completed six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) three times. The outcome measures were time to complete the task, number of errors, economy of instrument movement, and economy of diathermy.

RESULTS

After three trials, the mean performance of the medical students approached that of the experienced surgeons. However, 7-27% of the scores of the students fell more than two SD below the mean scores of the experienced surgeons (the criterion level).

CONCLUSIONS

The MIST-VR system is capable of evaluating the psychomotor skills necessary in laparoscopic surgery and discriminating between experts and novices. Furthermore, although some novices improved their skills quickly, a subset had difficulty acquiring the psychomotor skills. The MIST-VR may be useful in identifying that subset of novices.

The intercollegiate Basic Surgical Skills Course

OBJECTIVE

This study was undertaken to establish residents' progress in minimal access surgery (MAS) after attending the Intercollegiate Basic Surgical Skills Course (BSSC) by means of the Xitact LS500 laparoscopy simulator assessment program.

METHODS

Twenty-five surgical residents attended the BSSC in Leiden and Eindhoven, The Netherlands. Before and after the course, participants performed three "runs" on the Xitact LS500, featuring a standardized laparoscopic cholecystectomy clip-and-cut task. A control group of 25 interns not attending the course also performed two sessions of three runs. Parameters of interest were "score" and "time for completion of task".

RESULTS

No significant differences were found within the resident group for the parameters "time" and "score" when comparing outcomes pre- and post-BSSC. No significant differences were found comparing time and score between residents and interns on each of the six runs, except for time in run 2. Over six runs, both residents and interns became significantly faster.

CONCLUSIONS

The Xitact LS500 cholecystectomy simulator did not detect significant improvement in MAS performance among a group of surgical residents attending the BSSC.

Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures

BACKGROUND

Minimally invasive surgery (MIS) has introduced a new and unique set of psychomotor skills for a surgeon to acquire and master. Although assessment technologies have been proposed, precise and objective psychomotor skills assessment of surgeons performing laparoscopic procedures has not been detailed.

STUDY DESIGN

Two hundred ten surgeons attending the 2001 annual meeting of the American College of Surgeons in New Orleans who reported having completed more than 50 laparoscopic procedures participated. Subjects were required to complete one box-trainer laparoscopic cutting task and a similar virtual reality task. These tasks were specifically designed to test only psychomotor and not cognitive skills. Both tasks were completed twice. Performance of tasks was assessed and analyzed. Demographic and laparoscopic experience data were also collected.

RESULTS

Complete data were available on 195 surgeons. In this group, surgeons performed the box-trainer task better with their dominant hand (p < 0.0001) and there was a strong and statistically significant correlation between trials (r = 0.47 - 0.64, p < 0.0001). After transforming raw data to z-scores (mean = 0 and SD = 1) it was shown that between 2% and 12% of surgeons performed more than two standard deviations from the mean. Some surgeons' performance was 20 standard deviations from the mean. Minimally Invasive Surgical Trainer Virtual Reality metrics demonstrated high measurement consistency as assessed by coefficient alpha (alpha = 0.849).

CONCLUSIONS

Objective assessment of laparoscopic psychomotor skills is now possible. Surgeons who had performed more than 50 laparoscopic procedures showed considerable variability in their performance on a simple laparoscopic and virtual reality task. Approximately 10% of surgeons tested performed the task significantly worse than the group's average performance. Studies such as this may form the methodology for establishing criteria levels and performance objectives in objective assessment of the technical skills component of determining surgical competence.

Learning curves and impact of previous operative experience on performance on a virtual reality simulator to test laparoscopic surgical skills

BACKGROUND

The study was carried out to analyze the learning rate for laparoscopic skills on a virtual reality training system and to establish whether the simulator was able to differentiate between surgeons with different laparoscopic experience.

METHODS

Forty-one surgeons were divided into three groups according to their experience in laparoscopic surgery: masters (group 1, performed more than 100 cholecystectomies), intermediates (group 2, between 15 and 80 cholecystectomies), and beginners (group 3, fewer than 10 cholecystectomies) were included in the study. The participants were tested on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) 10 consecutive times within a 1-month period. Assessment of laparoscopic skills included time, errors, and economy of hand movement, measured by the simulator.

RESULTS

The learning curves regarding time reached plateau after the second repetition for group 1, the fifth repetition for group 2, and the seventh repetition for group 3 (Friedman's tests P <0.05). Experienced surgeons did not improve their error or economy of movement scores (Friedman's tests, P >0.2) indicating the absence of a learning curve for these parameters. Group 2 error scores reached plateau after the first repetition, and group 3 after the fifth repetition. Group 2 improved their economy of movement score up to the third repetition and group 3 up to the sixth repetition (Friedman's tests, P <0.05). Experienced surgeons (group 1) demonstrated best performance parameters, followed by group 2 and group 3 (Mann-Whitney test P <0.05).

CONCLUSIONS

Different learning curves existed for surgeons with different laparoscopic background. The familiarization rate on the simulator was proportional to the operative experience of the surgeons. Experienced surgeons demonstrated best laparoscopic performance on the simulator, followed by those with intermediate experience and the beginners. These differences indicate that the scoring system of MIST-VR is sensitive and specific to measuring skills relevant for laparoscopic surgery.