Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy

Training and assessment for colorectal surgery and appendicectomy- a systematic review

AIM

There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach.

METHOD

A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported.

RESULTS

Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery.

CONCLUSION

This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

A Bi-national needs assessment to identify and prioritise procedures in paediatric surgery for simulation-based training

BACKGROUND

Simulation-based education (SBE) has led to significant changes in healthcare education. However, SBE has often been based on available resources and local expertise rather than a systematic approach to curriculum development. The aim of this study was to perform a bi-national needs assessment to identify and prioritise procedures in a paediatric surgery curriculum that can be supported using SBE.

METHOD

A modified 3-round Delphi technique was used to gather consensus from education leaders and trainees in paediatric surgery in Australia and Aotearoa New Zealand (ANZ). Round 1 identified all procedures a newly specialised paediatric surgeon should be able to perform. In Round 2, each procedure was explored for the need for SBE using the Copenhagen Academy for Medical Education and Simulation (CAMES) Needs-Assessment Formula (NAF). This pre-prioritised list from Round 2 was sent back to participants for final exclusion and ranking in Round 3. Results 88 participants were identified and invited. From 174 procedures identified in Round 1, 71 procedures were grouped and categorised for Round 2 using the CAMES NAF. In Round 3, 17 procedures were eliminated resulting in 54 procedures. Appendicectomy, inguinal herniotomy, and central venous access were the highest rank procedures after prioritisation in Round 3. There was a strong correlation (r = 0.99) between the NAF score and the prioritised ranking, as well as between consultants and trainees (r = 0.92 in Round 2 and 0.98 in Round 3).

CONCLUSION

The prioritised list represents a consensus document decided upon by education leaders and stakeholders in paediatric surgery. These procedures should be an integral part of the SBE of paediatric surgeons in the region.

LEVEL OF EVIDENCE

Level V.

Standard Setting in Simulation-Based Training of Surgical Procedures: A Systematic Review

OBJECTIVE

This systematic review aims to examine the use of standard-setting methods in the context of simulation-based training of surgical procedures.

SUMMARY OF BACKGROUND

Simulation-based training is increasingly used in surgical education. However, it is important to determine which level of competency trainees must reach during simulation-based training before operating on patients. Therefore, pass/fail standards must be established using systematic, transparent, and valid methods.

METHODS

Systematic literature search was done in four databases (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library). Original studies investigating simulation-based assessment of surgical procedures with application of a standard setting were included. Quality of evidence was appraised using GRADE.

RESULTS

Of 24,299 studies identified by searches, 232 studies met the inclusion criteria. Publications using already established standard settings were excluded (N = 70), resulting in 162 original studies included in the final analyses. Most studies described how the standard setting was determined (N = 147, 91%) and most used the mean or median performance score of experienced surgeons (n = 65, 40%) for standard setting. We found considerable differences across most of the studies regarding study design, set-up, and expert level classification. The studies were appraised as having low and moderate evidence.

CONCLUSION

Surgical education is shifting towards competency-based education, and simulation-based training is increasingly used for acquiring skills and assessment. Most studies consider and describe how standard settings are established using more or less structured methods but for current and future educational programs, a critical approach is needed so that the learners receive a fair, valid and reliable assessment.

Efficacy of a virtual reality-based basic and clinical fused curriculum for clinical education on the lumbar intervertebral disc

OBJECTIVE

Today, minimally invasive procedures have become mainstream surgical procedures. Percutaneous endoscopic transforaminal discectomy for lumbar disc herniation (LDH) requires profound knowledge of the laparoscopic lumbar anatomy. Immersive virtual reality (VR) provides three-dimensional patient-specific models to help in the process of preclinical surgical preparation. In this study, the authors investigated the efficacy of VR application in LDH for training orthopedic residents and postgraduates.

METHODS

VR images of the lumbar anatomy were created with immersive VR and mAnatomy software. The study was conducted among 60 residents and postgraduates. A questionnaire was developed to assess the effect of and satisfaction with this VR-based basic and clinical fused curriculum. The teaching effect was also evaluated through a postlecture test, and the results of the prelecture surgical examination were taken as baselines.

RESULTS

All participants in the VR group agreed that VR-based education is practical, attractive, and easy to operate, compared to traditional teaching, and promotes better understanding of the anatomical structures involved in LDH. Learners in the VR group achieved higher scores on an anatomical and clinical fusion test than learners in the traditional group (84.67 ± 14.56 vs 76.00 ± 16.10, p < 0.05).

CONCLUSIONS

An immersive VR-based basic and clinical fused curriculum can increase residents' and postgraduates' interest and support them in mastering the structural changes and complicated symptoms of LDH. However, a simplified operational process and more realistic haptics of the VR system are necessary for further surgical preparation and application.

Development and clinical implementation of a structured, simulation-based training programme in laparoscopic appendectomy: description, validation and evaluation

Background

Laparoscopic appendectomy is a common procedure in general surgery but is likely underused in structured and real-life teaching. This study describes the development, validation and evaluation of implementing a structured training programme for laparoscopic appendectomy.

Study design

A structured curriculum and simulation-based programme for trainees and trainers was developed. All general surgery trainees and trainers were involved in laparoscopic appendectomies. All trainees and trainers underwent the structured preprocedure training programme before real-life surgery evaluation. A standardised form evaluated eight technical steps (skills) of the procedure as well as an overall assessment, and nine elements of communication (feedback), and was used for bilateral evaluation by each trainee and trainer. A consecutive, observational cohort over a 12-month period was used to gauge real-life implementation.

Results

During 277 eligible real-life appendectomies, structured evaluation was performed in 173 (62%) laparoscopic appendectomies, for which 165 forms were completed by 19 trainees. Construct validity was found satisfactory. Inter-rater reliability demonstrated good correlation between trainee and trainer. The trainees’ and trainers’ stepwise and overall assessments of technical skills had an overall good reliability (intraclass correlation coefficient of 0.88). The vast majority (92.2%) of the trainees either agreed or strongly agreed that the training met their expectations.

Conclusion

Structured training for general surgery residents can be implemented for laparoscopic appendectomy. Skills assessment by trainees and trainers indicated reliable self-assessment. Overall, the trainees were satisfied with the training, including the feedback from the trainers.

Advances and innovations in total hip arthroplasty

Total hip arthroplasty (THA) has been quoted as one of the most successful and cost-effective procedures in Orthopaedics. The last decade has seen an exponential rise in the number of THAs performed globally and a sharp increase in the percentage of young patients hoping to improve their quality of life and return to physically demanding activities. Hence, it is imperative to review the various applications of technology in total hip arthroplasty for improving outcomes. The development of state-of-the-art robotic technology has enabled more reproducible and accurate acetabular positioning, while long-term data are needed to assess its cost-effectiveness. This opinion piece aims to outline and present the advances and innovations in total hip arthroplasty, from virtual reality and three-dimensional printing to patient-specific instrumentation and dual mobility bearings. This illustrates and reflects the debate that will be at the centre of hip surgery for the next decade.

Needs Assessment for a VR-Based Adult Nursing Simulation Training Program for Korean Nursing Students: A Qualitative Study Using Focus Group Interviews

Virtual reality programs are being actively utilized in various education fields, but not many have been developed/used in nursing. This study aimed to explore the essential components and improvements needed in an adult nursing VR-based simulation training program for nursing students through focus group interviews (FGIs). This was a qualitative study. Fourteen nursing students from three cities in Korea who had experienced clinical practice and simulation training participated. They were divided into three FGIs. Data were collected from February–March 2020. We analyzed the data from the FGIs using Colaizzi’s phenomenological methodology. In total, 40 themes emerged, divided into 13 theme clusters and the following four categories. When developing an adult nursing VR-based simulation training program, the development should focus on addressing the limitations of conventional clinical practice, and these should be analyzed; it should also reflect students’ needs, including the following: provide an array of scenarios/skills to be trained; difficulty-specific learning scenarios; immediate feedback (e.g., those in computerized games); simulate emergency situations; simulate clinical cases that are difficult to experience in clinical practice; and allow for the training of patient–nurse communication skills.

Current status of simulation-based training in pediatric surgery: A systematic review

BACKGROUND

Simulation based training enables pediatric surgical trainees to attain proficiency in surgical skills. This study aims to identify the currently available simulators for pediatric surgery, assess their validation and strength of evidence supporting each model.

METHODS

Both Medline and EMBASE were searched for English language articles either describing or validating simulation models for pediatric surgery. A level of evidence (LoE) followed by a level of recommendation (LoR) was assigned to each validation study and simulator, based on a modified Oxford Centre for Evidence-Based Medicine classification for educational studies.

RESULTS

Forty-nine articles were identified describing 44 training models and courses. Of these articles, 44 were validation studies. Face validity was evaluated by 20 studies, 28 for content, 24 demonstrated construct validity and 1 showed predictive validity. Of the validated models, 3 were given an LoR of 2, 21 an LoR of 3 and 12 an LoR of 4. None reached the highest LoR.

CONCLUSIONS

There are a growing number of simulators specific to pediatric surgery. However, these simulators have limited LoE and LoR in current studies. The lack of NoTSS training is also apparent. We advocate more randomized trials to validate these models, and attempts to determine predictive validity.

TYPE OF STUDY

Original / systematic review.

LEVEL OF EVIDENCE

1.

Emotional Intelligence Predicts Accurate Self-Assessment of Surgical Quality: A Pilot Study

BACKGROUND

Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA).

MATERIALS AND METHODS

Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures.

RESULTS

Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031).

CONCLUSIONS

Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

Cognitive load and performance in immersive virtual reality versus conventional virtual reality simulation training of laparoscopic surgery: a randomized trial

BACKGROUND

Virtual reality simulators combined with head-mounted displays enable highly immersive virtual reality (VR) for surgical skills training, potentially bridging the gap between the simulation environment and real-life operating room conditions. However, the increased complexity of the learning situation in immersive VR could potentially induce high cognitive load thereby inhibiting performance and learning. This study aims to compare cognitive load and performance in immersive VR and conventional VR simulation training.

METHODS

A randomized controlled trial of residents (n = 31) performing laparoscopic salpingectomies with an ectopic pregnancy in either immersive VR or conventional VR simulation. Cognitive load was estimated by secondary-task reaction time at baseline, and during nonstressor and stressor phases of the procedure. Simulator metrics were used to evaluate performance.

RESULTS

Cognitive load was increased by 66% and 58% during immersive VR and conventional VR simulation, respectively (p < 0.001), compared to baseline. A light stressor induced a further increase in cognitive load by 15.2% and a severe stressor by 43.1% in the immersive VR group compared to 23% (severe stressor) in the conventional VR group. Immersive VR also caused a significantly worse performance on most simulator metrics.

CONCLUSION

Immersive VR simulation training induces a higher cognitive load and results in a poorer performance than conventional VR simulation training in laparoscopy. High extraneous load and element interactivity in the immersive VR are suggested as mechanisms explaining this finding. However, immersive VR offers some potential advantages over conventional VR such as more real-life conditions but we only recommend introducing immersive VR in surgical skills training after initial training in conventional VR.

Validation of a virtual reality laparoscopic appendicectomy simulator: a novel process using cognitive task analysis

BACKGROUND

Virtual reality (VR) simulation is a vital component of surgical training with demonstrated improvements in surgical quality and clinical outcome.

AIMS

To validate the LAP Mentor (Simbionix™) laparoscopic appendicectomy (LA) VR simulator with inclusion of a novel tool, Cognitive Task Analysis (CTA).

METHODS

Thirty-two novices and nine experienced surgeons performed two simulated LAs. An expert-consensus questionnaire guided face validity assessment. Content validity was assessed using CTA-derived questions encompassing eight operative steps and four decision points. Construct validity was evaluated using dexterity metrics, masked assessment of surgical quality using the OSATS global rating scale, and mental workload from two validated tools: the NASA-TLX and SMEQ. Ten novices performed eight further LAs for learning curve assessment.

RESULTS

Face validity was demonstrated across all domains. Considering content validity, the essential technical and non-technical steps were evident. The experienced group performed the procedure quicker (median time 361 vs. 538 s, P = 0.0039) with fewer total movements (426 vs. 641, P < 0.0001) and shorter idle time (131 vs. 199 s, P = 0.0006). This correlated with higher OSATS scores (median 33.5 vs. 22.2, P < 0.0001) and lower mental demand (NASA-TLX: 9.0 vs. 13.75, P = 0.012; SMEQ: 60 vs. 80, P = 0.0025), indicating construct validity. Learning curve data showed statistically significant improvements after the 7th session for procedure time, total movements and idle time, which correlated with reduction in mental demand.

CONCLUSIONS

The LAP Mentor demonstrates face, content and construct validity for LA; thus, it can be used as an effective tool in surgical training. Task repetition leads to achievement of expert benchmarks.