The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials

Acceptance and use of extended reality in surgical training: an umbrella review

BACKGROUND

Extended reality (XR) technologies which include virtual, augmented, and mixed reality have significant potential in surgical training, because they can help to eliminate the limitations of traditional methods. This umbrella review aimed to investigate factors that influence the acceptance and use of XR in surgical training using the unified theory of acceptance and use of technology (UTAUT) model.

METHODS

An umbrella review was conducted in 2024 by searching various databases until the end of 2023. Studies were selected based on the predefined eligibility criteria and analyzed using the components of the UTAUT model. The quality and risk of bias of the selected studies were assessed, and the findings were reported descriptively.

RESULTS

A total of 44 articles were included in this study. In most studies, XR technologies were used for surgical training of orthopedics, neurology, and laparoscopy. Based on the UTAUT model, the findings indicated that XR technologies improved surgical skills and procedural accuracy while simultaneously reducing risks and operating room time (performance expectancy). In terms of effort expectancy, user-friendly systems were accessible for the trainees with various levels of expertise. From a social influence standpoint, XR technologies enhanced learning by providing positive feedback from experienced surgeons during surgical training. In addition, facilitating conditions emphasized the importance of resource availability and addressing technical and financial limitations to maximize the effectiveness of XR technologies in surgical training.

CONCLUSIONS

XR technologies significantly improve surgical training by increasing skills and procedural accuracy. Although adoption is facilitated by designing user-friendly interfaces and positive social influences, financial and resource challenges must be overcome, too. The successful integration of XR into surgical training necessitates careful curriculum design and resource allocation. Future research should focus on overcoming these barriers, so that XR can fully realize its potential in surgical training.

Optimizing laparoscopic and robotic skills through simulation in participants with limited or no prior experience: a systematic review and meta-analysis

BACKGROUND

Simulation is an innovative tool for developing complex skills required for surgical training. The objective of this study was to determine the advancement of laparoscopic and robotic skills through simulation in participants with limited or no previous experience.

METHODS

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. We conducted searches using MEDLINE (PubMed), Web of Science, Google Scholar, and Cochrane Library. Variables analyzed were study characteristics, participant demographics, and characteristics of the learning program. Our main measures were effectiveness, surgical time, and errors. These were reported using standardized mean difference (SMD) with 95% CI (P < .05). Secondary measures included skill transfer and learning curve.

RESULTS

A total of 17 RCTs were included and comprised 619 participants: 354 participants (57%) were in the simulation group and 265 (43%) in the control group. Results indicated that laparoscopic simulation effectively enhanced surgical skills (SMD, 0.59 [0.18-1]; P = .004) and was significantly associated with shorter surgical duration (SMD, -1.08 [-1.57 to -0.59]; P < .0001) and a fewer errors made (SMD, -1.91 [-3.13 to -0.70]; P = .002). In the robotic simulation, there was no difference in effectiveness (SMD, 0.17 [-0.19 to 0.52]; P = .36) or surgical time (SMD, 0.27 [-0.86 to 1.39]; P = .64). Furthermore, skills were found to be transferable from simulation to a real-life operating room (P < .05).

CONCLUSION

Simulation is an effective tool for optimizing laparoscopic skills, even in participants with limited or no previous experience. This approach not only contributes to the reduction of surgical time and errors but also facilitates the transfer of skills to the surgical environment. In contrast, robotic simulation fails to maximize skill development, requiring previous experience in laparoscopy to achieve optimal levels of effectiveness.

Training the gynecologic oncologists of the future - challenges and opportunities

Several recent advances in gynecologic cancer care have improved patient outcomes. These include national screening and vaccination programs for cervical cancer as well as neoadjuvant chemotherapy for ovarian cancer. Conversely, these advances have cumulatively reduced surgical opportunities for training creating a need to supplement existing training strategies with evidence-based adjuncts. Technologies such as virtual reality and augmented reality, if properly evaluated and validated, have transformative potential to support training. Given the changing landscape of surgical training in gynecologic oncology, we were keen to summarize the evidence underpinning current training in gynecologic oncology.In this review, we undertook a literature search of Medline, Google, Google Scholar, Embase and Scopus to gather evidence on the current state of training in gynecologic oncology and to highlight existing evidence on the best methods to teach surgical skills. Drawing from the experiences of other surgical specialties we examined the use of training adjuncts such as cadaveric dissection, animation and 3D models as well as simulation training in surgical skills acquisition. Specifically, we looked at the use of training adjuncts in gynecologic oncology training as well as the evidence behind simulation training modalities such as low fidelity box trainers, virtual and augmented reality simulation in laparoscopic training. Finally, we provided context by looking at how training curriculums varied internationally.Whereas some evidence to the reliability and validity of simulation training exists in other surgical specialties, our literature review did not find such evidence in gynecologic oncology. It is important that well conducted trials are used to ascertain the utility of simulation training modalities before integrating them into training curricula.

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 comparative study in learning curves of laparoscopic lateral suspension vs. laparoscopic sacrocolpopexy: preliminary results

Background

Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves of different techniques in laparoscopic pelvic floor surgery.

Objective

The aim of this study was to compare the learning curve of two operative techniques, laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC).

Material and methods

We conducted a prospective study to assess the learning curve of LLS and LSC by implementing a structured urogynecologic surgical training program with the use of pelvic trainers for our urogynecology fellow. The fellow was an experienced urogynecologic surgeon, but was laparoscopic suturing and dissection naive at the beginning of the study. She was required to assist in 20 laparoscopic urogynecologic surgeries and undertake laparoscopic suturing and knot tying training with mesh positioning on a laparoscopic trainer for 4 h/week during the trial period. After the completion of this structured training program, the fellow performed LLS and LSC under the supervision of an experienced subspecialist as the primary surgeon. Linear regression analysis was used to compare the data of LLS and LSC learning curves. Subjective pre- and post-operative evaluation of pelvic organ prolapse (POP) and pelvic floor disorders was undertaken preoperatively and 12 months postoperatively using the PFDI-20-Quality of Life validated questionnaire. Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist. Objective cure was defined as Pelvic Organ Prolapse-Qualification (POP-Q) stage

Results

The mean operative times of laparoscopic sacrocolpopexy and lateral suspension were 168.26 and 160.33 min, respectively. According to linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than for laparoscopic sacrocolpopexy (OPTime 134.69 min). In both groups, there was a significant reduction in bothersome POP symptoms (p ≤ 0.005). Bladder injuries in two cases and lumbar pain in one case were recorded during the study. Overall objective success at 12 months was 90.7% for LSC and 89.1% for LLS.

Conclusion

Laparoscopic lateral suspension could be an alternative to laparoscopic sacrocolpopexy in the treatment of POP with its good objective and subjective outcomes. Lateral suspension has a shorter learning curve, and it is technically less demanding than LSC. Procedure-dedicated training can accelerate the move from a novice to a master laparoscopic surgeon.

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Key Words

• laparoscopic surgery
• lateral suspension
• learning curve
• prolapse
• sacropexy

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MESH Headings Collapse

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Affiliation(s)

Ewelina Malanowska-Jarema Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Yana Osnytska Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Andrzej Starczewski Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Matteo Balzarro Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
Emanuele Rubilotta Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy

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Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis

Objective

An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work.

Results

Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes.

Conclusion

There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

The Beginner Laparoscopists Trends in the Learning Process of Laparoscopy for Adnexal Gynecological Pathologies-The Experience of Our Center

BACKGROUND

Laparoscopy for benign ovarian pathology is the appropriate surgical approach and it has many well-known advantages. Minimal invasive gynecological surgery increases the quality of life of the patient. The learning process of laparoscopy is difficult and requires many interventions to acquire manual skills. The objectives of the study were to assess the learning process of laparoscopy for adnexal pathology surgery performed by beginner laparoscopists.

MATERIALS AND METHODS

This study included three gynecological surgeons who were beginners in laparoscopy and who were named A, B, and C. We collected information about patients, diagnosis, surgical technique, and complications.

RESULTS

We have analyzed the data from 159 patients. The most frequent primary diagnosis was functional ovarian cyst, and the laparoscopic cystectomy was performed in 49.1% of interventions. The need to convert a laparoscopy into laparotomy was necessary in 1.3% of patients. There were no cases of reintervention, blood transfusion, or ureteral lesions. The duration of the surgical intervention varied statistically significantly according to patient's BMI and to the surgeon. After 20 laparoscopic interventions, a significant improvement was found in the time needed to perform ovarian cystectomy (operators A and B) and salpingectomy (operator C).

CONCLUSIONS

The process of learning laparoscopy is laborious and difficult. We found a significant decrease in operating time after a twenty laparoscopic interventions.

Endometriosis Imaging: Enter the Metaverse of Possibilities

While laparoscopy has classically been defined as the gold standard for diagnosis of endometriosis, there is now a strong recommendation for the use of advanced imaging in diagnosing the disease. In addition to playing a crucial role in the diagnosis of endometriosis, advanced imaging is also essential for assisting gynaecologic surgeons in planning the surgical management of complex cases of deep endometriosis. This case demonstrates a metaverse of high-level imaging modalities, including advanced ultrasound and magnetic resonance (MRI), which were further enhanced with medical virtual reality, and used for assessment of a patient seen in an outpatient tertiary care gynaecology clinic.

Shared Learning Utilizing Digital Methods in Surgery to Enhance Transparency in Surgical Innovation: Protocol for a Scoping Review

BACKGROUND

Surgical innovation can lead to important improvements in patient outcomes. Currently, information and knowledge about novel procedures and devices are disseminated informally and in an unstandardized way (eg, through social media). This can lead to ineffective and inefficient knowledge sharing among surgeons, which can result in the harmful repetition of mistakes and delay in the uptake of promising innovation. Improvements are needed in the way that learning in surgical innovation is shared through the development of novel, real-time methods, informed by a contemporary and comprehensive investigation of existing methods.

OBJECTIVE

The aim of this scoping review is to explore the application of existing digital methods for training/education and feedback to surgeons in the context of performing invasive surgical procedures. This work will (1) summarize existing methods for shared learning in surgery and how they are characterized and operationalized, (2) examine the impact of their application, and (3) explore their benefits and barriers to implementation. The findings of this scoping review will inform the development of novel, real-time methods to optimize shared learning in surgical innovation.

METHODS

This study will adhere to the recommended guidelines for conducting scoping reviews. A total of 6 different searches will be conducted within multiple sources (2 electronic databases, journals, social media, gray literature, commercial websites, and snowball searches) to comprehensively identify relevant articles and data. Searches will be limited to articles published in the English language within the last 5 years. Wherever possible, a 2-stage study selection process will be followed whereby the eligibility of articles will be assessed through the title, abstract, and full-text screening independently by 2 reviewers. Inclusion criteria will be articles providing data on (1) fully qualified theater staff involved in performing invasive procedures, (2) one or more methods for shared learning (ie, digital means for training/education and feedback), and (3) qualitative or quantitative evaluations of this method. Data will be extracted (10% double data extraction by an independent reviewer) into a piloted proforma and analyzed using descriptive statistics, narrative summaries, and principles of thematic analysis.

RESULTS

The study commenced in October 2021 and is planned to be completed in 2023. To date, systematic searches were applied to 2 electronic databases (MEDLINE and Web of Science) and returned a total of 10,093 records. The results of this scoping review will be published as open access in a peer-reviewed journal.

CONCLUSIONS

This scoping review of methods for shared learning in surgery is, to our knowledge, the most comprehensive and up-to-date investigation that maps current information on this topic. Ultimately, efficient and effective sharing of information and knowledge of novel procedures and devices has the potential to optimize the evaluation of early-phase surgical research and reduce harmful innovation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37544.

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.

A Comprehensive Assessment of Human Factors in Cyber Security Compliance toward Enhancing the Security Practice of Healthcare Staff in Paperless Hospitals

Recent reports indicate that over 85% of data breaches are still caused by a human element, of which healthcare is one of the organizations that cyber criminals target. As healthcare IT infrastructure is characterized by a human element, this study comprehensively examined the effect of psycho-socio-cultural and work factors on security behavior in a typical hospital. A quantitative approach was adopted where we collected responses from 212 healthcare staff through an online questionnaire survey. A broad range of constructs was selected from psychological, social, cultural perception, and work factors based on earlier review work. These were related with some security practices to assess the information security (IS) knowledge, attitude and behavior gaps among healthcare staff in a comprehensive way. The study revealed that work emergency (WE) has a positive correlation with IS conscious care behavior (ISCCB) risk. Conscientiousness also had a positive correlation with ISCCB risk, but agreeableness was negatively correlated with information security knowledge (ISK) risk and information security attitude (ISA) risk. Based on these findings, intrinsic and extrinsic motivation methods combined with cutting-edge technologies can be explored to discourage IS risks behaviors while enhancing conscious care security practice.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries.

DATA SOURCES

PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included.

METHODS

Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals.

RESULTS

Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures.

CONCLUSION

Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

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.

We live in a virtual world: Training the trainee using an integrated visual reality simulator curriculum

Background

Gynaecology trainees struggle to obtain adequate procedural experience. Training programs integrating virtual reality simulators (VRS) have been suggested as a solution.

Aims

The study aimed to assess if a VRS training program (LapSim^®, Surgical Sciences, Göteborg, 2017) improved live operating performance at six months for novice and experienced trainees. Additional outcomes included the association between LapSim^® logged time and live operating performance at six months, LapSim^® scores and live operating performance at zero and sixmonths and the difference in benefit for novice and experienced gynaecology trainees.

Methods

A prospective intervention study was conducted. Novice and experienced trainees were enrolled, and comparisons made at zero‐ and six‐month time points. The intervention groups were provided with a laparoscopic gynaecology curriculum incorporating VRS. Controls underwent routine training only. Assessment of live operating performance was conducted after six months training.

Results

Thirty‐five trainees participated, and 25 had access to the VRS curriculum (17 novice and eight experienced trainees). Access to the VRS curriculum and time spent training on the LapSim^® made no difference to live operating ability for either intervention group (P > 0.05). The median (interquartile range) hours of VRS usage were 7.9 (4.5–10.8) and 6.0 (4.0–6.8) for novice and experienced trainees respectively. The intervention group provided positive feedback on the utility of VRS in their laparoscopic skill development.

Conclusion

Optimal utilisation of VRS in Australian training paradigms remains incompletely understood. Further research is required to establish the most effective integration of VRS into training models to ensure uptake and transferability to the operating theatre.

Virtual reality simulation does not correlate with overall trainee robot-assisted laparoscopic hysterectomy performance

STUDY OBJECTIVE

While both simulator practice and intraoperative performance serve to inform surgical trainee training, the skill transfer from simulation to the intraoperative setting remains unclear. This study evaluates the correlation between trainee performance on virtual reality (VR) simulation and (1) overall intraoperative performance during robotic-assisted laparoscopic hysterectomy (RALH) procedures, and (2) suturing performance during vaginal cuff closure portion of the case.

DESIGN

Retrospective subgroup analysis of randomized controlled trial SETTING: Academic hospital PATIENTS: Patients with RALH (n=29) INTERVENTIONS: Gynecological trainees (n=21) performed simulation tasks using the da Vinci Skills Simulator on the day of surgery, prior to performing RALH. Attending surgeons assessed participants' intraoperative performance using Global Evaluative Assessment of Robotic Skills (GEARS). Performance of the vaginal cuff closure step was subsequently assessed using GEARS scoring of anonymized videos. Spearman's correlation was used to quantify the relationship between simulation and intraoperative performances.

MEASUREMENTS AND MAIN RESULTS

Trainees achieved a median intraoperative GEARS score of 18.5/30 (IQR:17-22) and a median total simulator score of 84.4/100 (IQR:78.1-87.5). More advanced residents exhibited worse overall simulator performance (median score 86.6/100 compared to 78.8/100, p=0.03) and similar intraoperative GEARS scores during overall RALH and vaginal cuff closure compared to less experienced trainees. Total simulation performance score was negatively correlated with GEARS Bimanual Dexterity (rho=-0.46, p=0.02) and Force Sensitivity subscores (rho=-0.39, p=0.05). There was no correlation between total GEARS intraoperative vaginal cuff closure scores and overall simulation performances; however, total Tubes simulation score was correlated with higher GEARS Force Sensitivity subscore (rho=0.73, p=0.048).

CONCLUSIONS

In this study, there was limited correlation between simulation score metrics and trainees' overall intraoperative performance. Furthermore, we identified that GEARS scores could not distinguish between similar trainee skill levels. These findings underscore the need to develop intraoperative assessment tools that can better discriminate different but similar skill levels.

Robotic lobectomy: how to teach thoracic residents

Robotic thoracic surgery emerged at the beginning of the 21st century and keep presenting the continuous development of its robotic systems, tools, and associated techniques. Strong clinical results including safety and oncological outcomes have fostered the dissemination of the robotic platform all over the world. However, there are still some safety concerns, especially regarding more elaborated procedures as lung resections, during the learning curve. In consequence, training programs for surgeons and surgery residents have been proposed to put into operation a strong and complete curriculum for robotic surgery and increase safety during the learning process. Also, the implementation of the training program makes the process complete and efficient. Lung lobectomies are complex procedures especially because of pulmonary arteries and pulmonary veins dissection, which demands quite accurate skills. Consequently, it is believed that specific training of thoracic surgery residents in robotic lobectomy is capital. The ideal curriculum must include technical content and broad psychomotor training using virtual reality models and also physical and animal models. Valid evaluation methods can be used from the first skill training to daily clinical practice. At the beginning as a console surgeon, the resident must initiate gradually with small procedures and progress to more complex surgeries before performing the whole lobectomy.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review

Background

Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents’ unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children.

Objective

The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research.

Methods

PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies.

Results

Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality.

Conclusions

Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents’ interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760

A review of participant recruitment transparency for sound validation of hip surgery simulators: a novel umbrella approach

Malposition of implants is associated with complications, higher wear and increased revision rates in total hip replacement (THR) along with surgeon inexperience. Training THR residents to reach expert proficiency is affected by the high cost and resource limitations of traditional training techniques. Research in extended reality (XR) technologies can overcome such barriers. These offer a platform for learning, objective skill-monitoring and, potentially, for automated certification. Prior to their incorporation into curricula however, thorough validation must be undertaken. As validity is heavily dependent on the participants recruited, there is a need to review, scrutinise and define recruitment criteria in the absence of pre-defined standards, for sound simulator validation. A systematic review on PubMed and IEEE databases was conducted. Training simulator validation research in fracture, arthroscopy and arthroplasty relating to the hip was included. 46 validation studies were reviewed. It was observed that there was no uniformity in reporting or recruitment criteria, rendering cross-comparison challenging. This work developed Umbrella categories to help prioritise recruitment, and has formulated a detailed template of fields and guidelines for reporting criteria so that, in future, research may come to a consensus as to recruitment criteria for a hip "expert" or "novice".

The use of virtual reality simulation among nursing students and registered nurses: A systematic review

BACKGROUND

Due to technological advancements and the current generation being more tech-savvy, the use of virtual worlds in nursing education and clinical practice is increasingly popular. We performed a systematic review on randomised controlled trials and quasi-experimental studies to examine the current evidence on the use of virtual worlds as a teaching tool and to ascertain the outcomes measured.

DESIGN

Systematic review of randomised controlled trials and quasi-experimental studies.

DATA SOURCES

Six electronic databases (PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Web of Science, and ProQuest) were searched by title and abstract from each database's date of inception to December 2019.

REVIEW METHODS

The Joanna Briggs Institute's Critical Appraisal Tool was used to conduct critical appraisal of the selected articles.

RESULTS

Eighteen studies were included in the narrative summary. Studies were mostly conducted in developed countries and focused on nursing students. Advantages of virtual worlds include higher time-cost-effectiveness as compared to mannequin-based simulations and face-to-face lectures. Two major disadvantages were technological issues and the lack of realism.

CONCLUSIONS

Among the three learning outcomes (skills-based, cognitive, and affective), virtual worlds are the most effective in improving cognitive outcomes such as theoretical knowledge. This suggests that virtual worlds may be used as an alternative or complementary method to teach theoretical knowledge in nursing education.

Procedural virtual reality simulation training for robotic surgery: a randomised controlled trial

Background

Virtual reality (VR) training is widely used for surgical training, supported by comprehensive, high-quality validation. Technological advances have enabled the development of procedural-based VR training. This study assesses the effectiveness of procedural VR compared to basic skills VR in minimally invasive surgery.

Methods

26 novice participants were randomised to either procedural VR (n = 13) or basic VR simulation (n = 13). Both cohorts completed a structured training programme. Simulator metric data were used to plot learning curves. All participants then performed parts of a robotic radical prostatectomy (RARP) on a fresh frozen cadaver. Performances were compared against a cohort of 9 control participants without any training experience. Performances were video recorded and assessed blindly using GEARS post hoc.

Results

Learning curve analysis demonstrated improvements in technical skill for both training modalities although procedural training was associated with greater training effects.

Any VR training resulted in significantly higher GEARS scores than no training (GEARS score 11.3 ± 0.58 vs. 8.8 ± 2.9, p = 0.002). Procedural VR training was found to be more effective than both basic VR training and no training (GEARS 11.9 ± 2.9 vs. 10.7 ± 2.8 vs. 8.8 ± 1.4, respectively, p = 0.03).

Conclusions

This trial has shown that a structured programme of procedural VR simulation is effective for robotic training with technical skills successfully transferred to a clinical task in cadavers. Further work to evaluate the role of procedural-based VR for more advanced surgical skills training is required.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08197-w) contains supplementary material, which is available to authorized users.

Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial

OBJECTIVE

To demonstrate the noninferiority of the fundamentals of robotic surgery (FRS) skills curriculum over current training paradigms and identify an ideal training platform.

SUMMARY BACKGROUND DATA

There is currently no validated, uniformly accepted curriculum for training in robotic surgery skills.

METHODS

Single-blinded parallel-group randomized trial at 12 international American College of Surgeons (ACS) Accredited Education Institutes (AEI). Thirty-three robotic surgery experts and 123 inexperienced surgical trainees were enrolled between April 2015 and November 2016. Benchmarks (proficiency levels) on the 7 FRS Dome tasks were established based on expert performance. Participants were then randomly assigned to 4 training groups: Dome (n = 29), dV-Trainer (n = 30), and DVSS (n = 32) that trained to benchmarks and control (n = 32) that trained using locally available robotic skills curricula. The primary outcome was participant performance after training based on task errors and duration on 5 basic robotic tasks (knot tying, continuous suturing, cutting, dissection, and vessel coagulation) using an avian tissue model (transfer-test). Secondary outcomes included cognitive test scores, GEARS ratings, and robot familiarity checklist scores.

RESULTS

All groups demonstrated significant performance improvement after skills training (P < 0.01). Participating residents and fellows performed tasks faster (DOME and DVSS groups) and with fewer errors than controls (DOME group; P < 0.01). Inter-rater reliability was high for the checklist scores (0.82-0.97) but moderate for GEARS ratings (0.40-0.67).

CONCLUSIONS

We provide evidence of effectiveness for the FRS curriculum by demonstrating better performance of those trained following FRS compared with controls on a transfer test. We therefore argue for its implementation across training programs before surgeons apply these skills clinically.

Design and validation of a cross-specialty simulation-based training course in basic robotic surgical skills

BACKGROUND

The aim of this study was to design and validate a cross-specialty basic robotic surgical skills training program on the RobotiX Mentor virtual reality simulator.

METHODS

A Delphi panel reached consensus on six modules to include in the training program. Validity evidence was collected according to Messick's framework with three performances in each simulator module by 11 experienced robotic surgeons and 11 residents without robotic surgical experience.

RESULTS

For five of the six modules, a compound metrics-based score could significantly discriminate between the performances of novices and experienced robotic surgeons. Pass/fail levels were established, resulting in very few novices passing in their first attempt.

CONCLUSIONS

This validated course can be used for structured simulation-based basic robotic surgical skills training within a mastery learning framework where the individual trainee can practice each module until they achieve proficiency and can continue training on other modalities and more specific to their specialty.

The impact of surgical simulation on patient outcomes: a systematic review and meta-analysis

The use of simulation in surgical training is ever growing. Evidence suggests such training may have beneficial clinically relevant effects. The objective of this research is to investigate the effects of surgical simulation training on clinically relevant patient outcomes by evaluating randomized controlled trials (RCT). PubMed was searched using PRISMA guidelines: "surgery" [All Fields] AND "simulation" [All Fields] AND "patient outcome" [All Fields]. Of 119 papers identified, 100 were excluded for various reasons. Meta-analyses were conducted using the inverse-variance random-effects method. Nineteen papers were reviewed using the CASP RCT Checklist. Sixteen studies looked at surgical training, two studies assessed patient-specific simulator practice, and one paper focused on warming-up on a simulator before performing surgery. Median study population size was 22 (range 3-73). Most articles reported outcome measures such as post-intervention Global Rating Scale (GRS) score and/or operative time. On average, the intervention group scored 0.42 (95% confidence interval 0.12 to 0.71, P = 0.005) points higher on a standardized GRS scale of 1-10. On average, the intervention group was 44% (1% to 87%, P = 0.04) faster than the control group. Four papers assessed the impact of simulation training on patient outcomes, with only one finding a significant effect. We found a significant effect of simulation training on operative performance as assessed by GRS, albeit a small one, as well as a significant reduction to operative time. However, there is to date scant evidence from RCTs to suggest a significant effect of surgical simulation training on patient outcomes.

Virtual reality simulation to enhance laparoscopic salpingectomy skills

BACKGROUND

To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning.

METHODS

A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series.

RESULTS

26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased.

CONCLUSIONS

The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

Augmented and Virtual Reality Evolution and Future Tendency

Augmented reality and virtual reality technologies are increasing in popularity. Augmented reality has thrived to date mainly on mobile applications, with games like Pokémon Go or the new Google Maps utility as some of its ambassadors. On the other hand, virtual reality has been popularized mainly thanks to the videogame industry and cheaper devices. However, what was initially a failure in the industrial field is resurfacing in recent years thanks to the technological improvements in devices and processing hardware. In this work, an in-depth study of the different fields in which augmented and virtual reality have been used has been carried out. This study focuses on conducting a thorough scoping review focused on these new technologies, where the evolution of each of them during the last years in the most important categories and in the countries most involved in these technologies will be analyzed. Finally, we will analyze the future trend of these technologies and the areas in which it is necessary to investigate to further integrate these technologies into society.

Effect of structural training on surgical outcomes of residents' first operative laparoscopy: a randomized controlled trial

BACKGROUND

Gynecological surgery and resident education have changed during recent decades, thus impacting surgical training. Training on simulators must begin before operating on patients. The objective of this study was to evaluate the effect of a simple curriculum on the surgical outcome of the participants' first operative laparoscopy.

METHODS

This randomized prospective interventional study was carried out in Helsinki University Hospital and Hyvinkää Hospital. We recruited twenty junior residents in Obstetrics and Gynecology, of which half formed a control group and the rest completed the intervention with a theoretical and a practical part. The participants' first laparoscopic salpingectomy was assessed from video recordings by using Objective Structured Assessment of Technical Skills (OSATS) forms and the Numeric Rating Scale (NRS). The surgical outcome and assessed scores were compared between the groups.

RESULTS

We found no differences in operative time, blood loss, or complications, nor in OSATS or NRS scores. In the intervention group, participants with the weakest performances in the simulator, seemed to benefit from the training program more than the participants with the best performances (skill level elevation 29.2-31.6% vs. 21.1-23.3%, respectively). The participants with the best performances in the simulator were scored among the best in the recorded operations as well.

CONCLUSION

In this study, we found no difference in the surgical outcome between the groups. However, the participants with low starting levels in the simulator could elevate their skill levels more, though they did not reach the skill level of those with a high starting level. Consequently, we found elevation in skills levels in the simulator tasks, but not in the surgical outcome. Likely, our simple training program with a fixed number of repetitions was insufficient to reach a plateau in the learning curve, and thus the training program in such a curriculum should be proficiency based.

A SWOT Analysis of the Field of Virtual Reality for Firefighter Training

Virtual reality (VR) research has gone through rapid advances and the technology has established itself as a valuable training tool in many domains. While research in the field of emergency response, and more specifically in the field of firefighting, is still catching up, the future potential of VR technology for training is promising. This paper uses the SWOT framework to analyse the strengths, weaknesses, opportunities, and threats immersive VR technology faces in the field of firefighter training. While using VR for training is cost-effective, safe to use and provides the ability to prepare trainees with a large variety of high fidelity training environments, the lack in specialization of the applications for the fire-service sector and issues with technology acceptance and limitations need to be addressed. Looking to current research, there are promising findings that might be directly transferable, creating affective, and multi-sensory experiences for more effective mental and physical training of firefighters in the future. More research is needed to establish methods of skills transfer from VR to real life scenarios and to evaluate the potential risk of frequent training in engaging and physiologically stimulating virtual environments.

Evaluation of Urology Residency Training and Perceived Resident Abilities in the United States

OBJECTIVE

To identify differences and potential deficiencies in urology residency training programs in the United States as they are perceived by residents/recent graduates and program directors.

MATERIALS AND METHODS

A 45-question and 38-question survey was sent to chief residents/recent graduates and program directors, respectively, at all 120 US urology programs regarding prior medical education, urologic training curricula, and perceived surgical proficiency, among other topics.

RESULTS

Survey response rate was 58% and 52% for residents and program directors, respectively. Responses regarding program characteristics (e.g., salary, vacation) and research training were similar between program directors and residents. However, their responses regarding skills training and subspecialty training (e.g., robotics and pediatrics) differed substantially. Program directors reported the availability of advanced skills trainers (robot-88%, laparoscopic-86%), whereas fewer residents felt they were available (robot 54% and laparoscopic 72%). The same discrepancies persisted with questions about subspecialty exposure (e.g., program directors reported 48% renal transplant experience vs. 13% reported by residents). Most residents felt comfortable performing essential urology procedures (e.g., cystoscopy/ureteroscopy, open nephrectomy). In contrast, the majority expressed a lack of confidence in performing unsupervised advanced minimally invasive procedures (e.g., laparoscopic and robotic partial nephrectomy, endopyelotomy). Among the responding residents, 72% pursued fellowship training; nearly two-thirds of these residents chose to enter fellowship in order to overcome perceived training deficiencies.

CONCLUSIONS

Program directors and residents have differing perceptions regarding the education and resources associated with US urology residency training programs. US graduates of urology residency programs express a perceived lack of confidence in several procedures that are commonly encountered in a general urologic practice.

Development and face validation of a virtual camera navigation task trainer

BACKGROUND

The fundamentals of laparoscopic surgery (FLS) trainer box, which is now established as a standard for evaluating minimally invasive surgical skills, consists of five tasks: peg transfer, pattern cutting, ligation, intra- and extracorporeal suturing. Virtual simulators of these tasks have been developed and validated as part of the Virtual Basic Laparoscopic Skill Trainer (VBLaST) (Arikatla et al. in Int J Med Robot Comput Assist Surg 10:344-355, 2014; Zhang et al. in Surg Endosc 27(10):3603-3615, 2013; Sankaranarayanan et al. in J Laparoendosc Adv Surg Tech 20(2):153-157, 2010; Qi et al. J Biomed Inform 75:48-62, 2017). The virtual task trainers have many advantages including automatic real-time objective scoring, reduced costs, and eliminating human proctors. In this paper, we extend VBLaST by adding two camera navigation system tasks: (a) pattern matching and (b) path tracing.

METHODS

A comprehensive camera navigation simulator with two virtual tasks, simplified and cheaper hardware interface (compared to the prior version of VBLaST), graphical user interface, and automated metrics has been designed and developed. Face validity of the system is tested with medical students and residents from the University at Buffalo's medical school.

RESULTS

The subjects rated the simulator highly in all aspects including its usefulness in training to center the target and to teach sizing skills. The quality and usefulness of the force feedback scored the lowest at 2.62.

Development of a structured virtual reality curriculum for laparoscopic appendicectomy

BACKGROUND

Laparoscopic appendicectomy (LA) is a common surgical emergency procedure mainly performed by trainees. The aim was to develop a step-wise structured virtual reality (VR) curriculum for LA to allow junior surgeons to hone their skills in a safe and controlled environment.

METHODS

A prospective randomized study was designed using a high-fidelity VR simulator. Thirty-five novices and 25 experts participated in the assessment and their performances were compared to assess construct validity. Learning curve analysis was performed.

RESULTS

Five of the psychomotor tasks and all appendicectomy tasks showed construct validity. Learning was demonstrated in the majority of construct-valid tasks. A novel goal-directed VR curriculum for LA was constructed.

CONCLUSIONS

A step-wise structured VR curriculum for LA is proposed with a framework which includes computer generated metrics and supports deliberate practice, spacing intervals, human instruction/feedback and assessment. Future study should test the feasibility of its implementation and transferability of acquired skill.

Use of Commercial Off-The-Shelf Devices for the Detection of Manual Gestures in Surgery: Systematic Literature Review

Background

The increasingly pervasive presence of technology in the operating room raises the need to study the interaction between the surgeon and computer system. A new generation of tools known as commercial off-the-shelf (COTS) devices enabling touchless gesture–based human-computer interaction is currently being explored as a solution in surgical environments.

Objective

The aim of this systematic literature review was to provide an account of the state of the art of COTS devices in the detection of manual gestures in surgery and to identify their use as a simulation tool for motor skills teaching in minimally invasive surgery (MIS).

Methods

For this systematic literature review, a search was conducted in PubMed, Excerpta Medica dataBASE, ScienceDirect, Espacenet, OpenGrey, and the Institute of Electrical and Electronics Engineers databases. Articles published between January 2000 and December 2017 on the use of COTS devices for gesture detection in surgical environments and in simulation for surgical skills learning in MIS were evaluated and selected.

Results

A total of 3180 studies were identified, 86 of which met the search selection criteria. Microsoft Kinect (Microsoft Corp) and the Leap Motion Controller (Leap Motion Inc) were the most widely used COTS devices. The most common intervention was image manipulation in surgical and interventional radiology environments, followed by interaction with virtual reality environments for educational or interventional purposes. The possibility of using this technology to develop portable low-cost simulators for skills learning in MIS was also examined. As most of the articles identified in this systematic review were proof-of-concept or prototype user testing and feasibility testing studies, we concluded that the field was still in the exploratory phase in areas requiring touchless manipulation within environments and settings that must adhere to asepsis and antisepsis protocols, such as angiography suites and operating rooms.

Conclusions

COTS devices applied to hand and instrument gesture–based interfaces in the field of simulation for skills learning and training in MIS could open up a promising field to achieve ubiquitous training and presurgical warm up.

Operator experience affects the risk of obstetric anal sphincter injury in vacuum extraction deliveries

INTRODUCTION

Delivery by vacuum extraction is a major risk factor for obstetric anal sphincter injury. The aim of this study was to assess risk factors for obstetric anal sphincter injury in vacuum extraction in nulliparous women, specifically operator-related factors. A secondary aim was to assess other complications of vacuum extraction that are dependent on operator experience.

MATERIAL AND METHODS

A historical cohort study of nulliparous women with a live single fetus ≥34 weeks, delivered by vacuum extraction at a teaching hospital in Sweden in 1 year (2013), using data from medical records. Risk of obstetric anal sphincter injury was assessed for obstetricians (reference), gynecologists, and residents, and adjusted for maternal, fetal, procedure-related, and operator-related covariates using unconditional logistic regression. Results are presented as prevalence and crude and adjusted odds ratio (aOR) with 95% CI.

RESULTS

In total, 323 nulliparous women delivered by vacuum extraction were included. Obstetric anal sphincter injury occurred in 57 (17.6%) women. Fifteen (11.5%) obstetric anal sphincter injuries occurred in vacuum extractions performed by obstetricians, 10 (13.5%) by gynecologists (aOR 1.84, 95% CI 0.72-4.70), and 32 (26.9%) by residents (aOR 5.13, 95% CI 2.20-11.95). Maternal height ≤155 cm (aOR 4.63, 95% CI 1.35-15.9) and conversion to forceps (aOR 19.4, 95% CI 1.50-252) increased the risk of obstetric anal sphincter injury. Operator gender, night shift work, or being a frequent operator did not affect the risk of obstetric anal sphincter injury. Postpartum hemorrhage and fetal complications did not differ between operator categories.

CONCLUSIONS

The adjusted risk of obstetric anal sphincter injury in nulliparous women was five times higher in vacuum extractions performed by residents compared with those performed by obstetricians. Vacuum extractions performed by gynecologists did not carry an increased risk of obstetric anal sphincter injury. Experience in years of training, rather than frequency of the procedure, seemed to have the highest impact on reducing obstetric anal sphincter injury in vacuum extractions, which indicates a need for increased training and supervision.

Comparison of Effectiveness of Two Teaching Methods on Acquisition of Skills in Preclinical Fixed Prosthodontics

The aim of this study was to evaluate the effects of dental faculty-student interactions, virtual assessment software, and associated rubrics on student performance by assessing tooth preparations generated during the students' final practical exam. The study, conducted in 2017 and 2018, compared teeth prepared for preclinical fixed prosthodontics competency exams by two subsequent classes of second-year dental students trained using different methods. Class A was trained for nine months prior to the exam using feedback via student-faculty interactions and conventional rubrics. Class B was trained for five and half months prior to the exam via contemporary rubrics that incorporated feedback from both faculty and virtual assessment software. Two blinded, independent, and calibrated faculty members randomly evaluated the tooth preparations and graded them as excellent, standard, or standard not met for occlusal reduction, axial/lingual reduction, contour/long axis/axial wall height, finish line location, finish line quality, and finish of the preparation. The interrater agreement was slight to fair (0.01 < Kappa < 0.4) for evaluation of preparations. The teaching method did not have a significant impact (p>0.05) on student performance for the assessed criteria. These results suggest that, with the use of virtual assessment software, a course director may be able to shorten a course and obtain the same results as a nine-month course.

High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students

BACKGROUND

Simulation has become integral to the training of both undergraduate medical students and medical professionals. Due to the increasing degree of realism and range of features, the latest mannequins are referred to as high-fidelity simulators. Whether increased realism leads to a general improvement in trainees' outcomes is currently controversial and there are few data on the effects of these simulators on participants' personal confidence and self-assessment.

METHODS

One-hundred-and-thirty-five fourth-year medical students were randomly allocated to participate in either a high- or a low-fidelity simulated Advanced Life Support training session. Theoretical knowledge and self-assessment pre- and post-tests were completed. Students' performance in simulated scenarios was recorded and rated by experts.

RESULTS

Participants in both groups showed a significant improvement in theoretical knowledge in the post-test as compared to the pre-test, without significant intergroup differences. Performance, as assessed by video analysis, was comparable between groups, but, unexpectedly, the low-fidelity group had significantly better results in several sub-items. Irrespective of the findings, participants of the high-fidelity group considered themselves to be advantaged, solely based on their group allocation, compared with those in the low-fidelity group, at both pre- and post-self-assessments. Self-rated confidence regarding their individual performance was also significantly overrated.

CONCLUSION

The use of high-fidelity simulation led to equal or even worse performance and growth in knowledge as compared to low-fidelity simulation, while also inducing undesirable effects such as overconfidence. Hence, in this study, it was not beneficial compared to low-fidelity, but rather proved to be an adverse learning tool.

Educational training in laparoscopic gynecological surgery based on ethanol-glycerol-lysoformin-preserved body donors

PURPOSE

Educational training of laparoscopic skills performed on body donors is considered the gold standard prior to surgery in living patients. Appropriate, safe, and feasible fixation of body donors, reflecting true-to-life conditions of tissues, is an essential prerequisite for training workshops.

MATERIALS AND METHODS

Here we describe and evaluate a modified ethanol-glycerol-lysoformin-based fixation technique. Body donors were fixed by perfusion (70% ethanol, 30% glycerol, 0.3% lysoformin; ca. 20l) via femoral artery and stored in a humid atmosphere (1% thymol) at 4°C. Technical equipment included a mobile operating table, endoscopy system with gas insufflation, suction/irrigation pump, standard and electrosurgical instruments. The tissue properties of ethanol-glycerol-lysoformin-fixed body donors and their suitability for laparoscopic surgery were tested and compared to the in vivo situation.

RESULTS

Modified ethanol-glycerol-lysoformin fixation was a simple, cost-efficient and hazard-free procedure, resulting in near-to-life tissue conditions regarding consistency and flexibility, with moderate discoloration and greater viscosity of organs. Key laparoscopic procedures (trocar handling, pneumoperitoneum, blunt/sharp dissection, partial/total removal of organs, bi- or monopolar electrosurgery, suturing techniques) could be performed without difficulty. Multiple reuse of body donors was feasible over one year. Compared to the in vivo situation, the investigation of body donors required a greater degree of gas insufflation and more energy for electrosurgery.

CONCLUSIONS

Modified ethanol-glycerol-lysoformin fixation applied to body donors permitted laparoscopic surgery in a realistic and practical manner. Due to its logistic advantages, this technique provides appropriate conditions to train laparoscopic skills and implement novel minimally invasive approaches.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure

BACKGROUND

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum.

METHODS

Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method.

RESULTS

The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives).

CONCLUSION

Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

An Information-Theoretic Approach to the Cost-benefit Analysis of Visualization in Virtual Environments

Visualization and virtual environments (VEs) have been two interconnected parallel strands in visual computing for decades. Some VEs have been purposely developed for visualization applications, while many visualization applications are exemplary showcases in general-purpose VEs. Because of the development and operation costs of VEs, the majority of visualization applications in practice have yet to benefit from the capacity of VEs. In this paper, we examine this status quo from an information-theoretic perspective. Our objectives are to conduct cost-benefit analysis on typical VE systems (including augmented and mixed reality, theater-based systems, and large powerwalls), to explain why some visualization applications benefit more from VEs than others, and to sketch out pathways for the future development of visualization applications in VEs. We support our theoretical propositions and analysis using theories and discoveries in the literature of cognitive sciences and the practical evidence reported in the literatures of visualization and VEs.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Translational Relevance

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

Development of an assessment strategy in preclinical fixed prosthodontics course using virtual assessment software-Part 2

The purpose of this study was to evaluate interrater agreement between faculty and virtual assessments of preparations for complete coverage restorations in preclinical fixed prosthodontics. Teeth prepared during preclinical fixed prosthodontics practical exams at the University at Buffalo School of Dental Medicine were used in this study. Teeth were prepared for fabrication of complete cast, metal ceramic, and all ceramic crowns. The specimens were digitized using an intraoral scanner. Then, they were virtually superimposed on the corresponding standard preparations using Compare software. The software was used to quantify comparison percentages, average finish line widths, and average axial wall heights. Two calibrated faculty members assessed preparations for occlusal/incisal reduction, finish line location, axial wall height, and finish line width using traditional assessment forms. Cohen's kappa coefficient was used to measure interrater agreement between faculty and virtual assessments. Kappa interrater agreement scores ranged between 0.83 and 0.88 for virtually assessed comparison percentages and sums of faculty-assessed occlusal/incisal reduction and finish line location. Kappa interrater agreement score ranges were 0.64-0.94 and 0.74-0.89 for comparisons of virtual and faculty assessments for axial wall height and finish line width, respectively. Virtual assessments are similar to faculty assessments for occlusal/incisal reduction, finish line location, axial wall height, and finish line width in fixed prosthodontics and can be used as equivalent evaluations of student performance for these criteria.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

Laparoscopic assistance by operating room nurses: Results of a virtual-reality study

BACKGROUND

Laparoscopic assistance is often entrusted to a less experienced resident, medical student, or operating room nurse. Data regarding laparoscopic training for operating room nurses are not available.

OBJECTIVES

The aim of the study was to analyse the initial performance level and learning curves of operating room nurses in basic laparoscopic surgery compared with medical students and surgical residents to determine their ability to assist with this type of procedure.

DESIGN

The study was designed to compare the initial virtual reality performance level and learning curves of user groups to analyse competence in laparoscopic assistance.

PARTICIPANTS

The study subjects were operating room nurses, medical students, and first year residents.

METHODS

Participants performed three validated tasks (camera navigation, peg transfer, fine dissection) on a virtual reality laparoscopic simulator three times in 3 consecutive days. Laparoscopic experts were enrolled as a control group. Participants filled out questionnaires before and after the course.

RESULTS

Nurses and students were comparable in their initial performance (p>0.05). Residents performed better in camera navigation than students and nurses and reached the expert level for this task. Residents, students, and nurses had comparable bimanual skills throughout the study; while, experts performed significantly better in bimanual manoeuvres at all times (p<0.05).

CONCLUSION

The included user groups had comparable skills for bimanual tasks. Residents with limited experience reached the expert level in camera navigation. With training, nurses, students, and first year residents are equally capable of assisting in basic laparoscopic procedures.

Simulation-based camera navigation training in laparoscopy-a randomized trial

BACKGROUND

Inexperienced operating assistants are often tasked with the important role of handling camera navigation during laparoscopic surgery. Incorrect handling can lead to poor visualization, increased operating time, and frustration for the operating surgeon-all of which can compromise patient safety. The objectives of this trial were to examine how to train laparoscopic camera navigation and to explore the transfer of skills to the operating room.

MATERIALS AND METHODS

A randomized, single-center superiority trial with three groups: The first group practiced simulation-based camera navigation tasks (camera group), the second group practiced performing a simulation-based cholecystectomy (procedure group), and the third group received no training (control group). Participants were surgical novices without prior laparoscopic experience. The primary outcome was assessment of camera navigation skills during a laparoscopic cholecystectomy. The secondary outcome was technical skills after training, using a previously developed model for testing camera navigational skills. The exploratory outcome measured participants' motivation toward the task as an operating assistant.

RESULTS

Thirty-six participants were randomized. No significant difference was found in the primary outcome between the three groups (p = 0.279). The secondary outcome showed no significant difference between the interventions groups, total time 167 s (95% CI, 118-217) and 194 s (95% CI, 152-236) for the camera group and the procedure group, respectively (p = 0.369). Both interventions groups were significantly faster than the control group, 307 s (95% CI, 202-412), p = 0.018 and p = 0.045, respectively. On the exploratory outcome, the control group for two dimensions, interest/enjoyment (p = 0.030) and perceived choice (p = 0.033), had a higher score.

CONCLUSIONS

Simulation-based training improves the technical skills required for camera navigation, regardless of practicing camera navigation or the procedure itself. Transfer to the clinical setting could, however, not be demonstrated. The control group demonstrated higher interest/enjoyment and perceived choice than the camera group.