Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures

Background: The objective assessment of the psychomotor skills of surgeons is now a priority; however, this is a difficult task because of measurement difficulties associated with the assessment of surgery in vivo. In this study, virtual reality (VR) was used to overcome these problems. Methods: Twelve experienced (>50 minimal-access procedures), 12 inexperienced laparoscopic surgeons (<10 minimal-access procedures), and 12 laparoscopic novices participated in the study. Each subject completed 10 trials on the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). Results: Experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, with less error, more economy in the movement of instruments and the use of diathermy, and with greater consistency in performance. The standardized coefficient alpha for performance measures ranged from a = 0.89 to 0.98, showing high internal measurement consistency. Test–retest reliability ranged from r = 0.96 to r = 0.5. Conclusion: VR is a useful tool for evaluating the psychomotor skills needed to perform laparoscopic surgery.     

Objective Psychomotor Skills Assessment of Experienced, Junior, and Novice Laparoscopists with Virtual Reality

Objective assessment of psychomotor skills in surgery is now a priority; however, this assessment is difficult to achieve because of measurement difficulties associated with the reliability and validity of assessing surgical skills in vivo and in the laboratory. In this study virtual reality (VR) was used to overcome these problems in the objective psychomotor assessment of senior, junior, and novice laparoscopists. Twelve experienced laparoscopic surgeons (performed >50 Minimal Access Surgery (MAS) procedures), 12 inexperienced laparoscopic surgeons (<10 MAS procedures), and 12 laparoscopic novices (no MAS procedures) participated in the study. Each subject completed all six tasks of the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). In comparison to the other groups, experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, had a lower error rate, were more economic in their movement of surgical instruments and in the use of diathermy. As a group they also showed greater consistency in their performance. MIST VR distinguished between the three groups of laparoscopists. VR provides a useful objective assessment tool for evaluating psychomotor skills for laparoscopic surgery.     

Randomized clinical trial of virtual reality simulation for laparoscopic skills training

BACKGROUND: This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. METHODS: Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. RESULTS: No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores. CONCLUSION: Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.     

Learning rate for laparoscopic surgical skills on MIST VR, a virtual reality simulator: quality of human-computer interface

Acquiring laparoscopic surgical skills involves initial learning of cognitive and motor skills followed by refinement of those skills. The successful use of a virtual reality simulator depends on the quality of the interface for the human-computer interaction and this can be determined by the initial learning rate. MIST VR, a part-task virtual reality laparoscopic simulator, provides objective assessment of psychomotor skills and can generate an overall score for performance, based upon errors made and time taken for six different tasks. This study analysed the rate of early task/instrument/computer familiarization on consecutive scores achieved by surgically experienced and naive individuals. Eleven surgeons, 18 medical students and seven non-medical personnel were tested on the simulator up to ten consecutive times, within a 2-week period. Performance data from every task and repetition were analysed to obtain individual scores of task performance. The calculation of overall score penalized errors far more heavily than total time taken, with high scores indicating poor performance. The surgeon-computer interface generated a rapid and significant early familiarization curve up to the third session on the simulator, with significant reductions in both time taken and total contact errors made. These results suggest that MIST VR represents a high quality interface. Surgeons scored consistently and significantly better than other subjects on all tasks. For surgically naive individuals, it was possible to predict the level of laparoscopic skills performance that would be attained after overcoming initial simulator learning curve, by studying their initial score. Overall scores reflected surgical experience and suggest that the simulator is measuring surgically relevant parameters. MIST VR provides a validated and much needed method for objective assessment of laparoscopic skills, for a variety of surgical disciplines.     

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

Background: Increasing constraints on the time and resources needed to train surgeons have led to a new emphasis on finding innovative ways to teach surgical skills outside the operating room. Virtual reality training has been proposed as a method to both instruct surgical students and evaluate the psychomotor components of minimally invasive surgery ex vivo. Methods: The performance of 100 laparoscopic novices was compared to that of 12 experienced (>50 minimally invasive procedures) and 12 inexperienced (<10 minimally invasive procedures) laparoscopic surgeons. The values of the experienced surgeons performance were used as benchmark comparators (or criterion measures). Each subject completed six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR) three times. The outcome measures were time to complete the task, number of errors, economy of instrument movement, and economy of diathermy. Results: After three trials, the mean performance of the medical students approached that of the experienced surgeons. However, 7–27% of the scores of the students fell more than two SD below the mean scores of the experienced surgeons (the criterion level). Conclusions: The MIST-VR system is capable of evaluating the psychomotor skills necessary in laparoscopic surgery and discriminating between experts and novices. Furthermore, although some novices improved their skills quickly, a subset had difficulty acquiring the psychomotor skills. The MIST-VR may be useful in identifying that subset of novices.     

Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR) learning center study

Background The Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR) has been well validated as a training device for laparoscopic skills. It has been demonstrated that training to a level of proficiency on the simulator significantly improves operating room performance of laparoscopic cholecystectomy. The purpose of this project was to obtain a national standard of proficiency using the MIST-VR based on the performance of experienced laparoscopic surgeons. Methods Surgeons attending the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 2004 Annual Scientific Meeting who had performed more than 100 laparoscopic procedures volunteered to participate. All the subjects completed a demographic questionnaire assessing laparoscopic and MIST-VR experience in the learning center of the SAGES 2004 meeting. Each subject performed two consecutive trials of the MIST-VR Core Skills 1 program at the medium setting. Each trial involved six basic tasks of increasing difficulty: acquire place (AP), transfer place (TP), traversal (TV), withdrawal insert (WI), diathermy task (DT), and manipulate diathermy (MD). Trial 1 was considered a “warm-up,” and trial 2 functioned as the test trial proper. Subject performance was scored for time, errors, and economy of instrument movement for each task, and a cumulative total score was calculated. Results Trial 2 data are expressed as mean time in seconds in Table 2. Conclusion Proficiency levels for laparoscopic skills have now been established on a national scale by experienced laparoscopic surgeons using the MIST-VR simulator. Residency programs, training centers, and practicing surgeons can now use these data as guidelines for performance criterion during MIST-VR skills training.     

The Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) objectifying subjective psychomotor test performance

Background

This study was undertaken to establish the value of the Advanced Dundee Psychomotor Tester (ADEPT) as an objective real-time scoring system, correcting for subjective assessor opinion on endoscopic task performance. The main research questions were as follows:

⊙ Are surgeons good estimators of their own performance on ADEPT?

⊙ Do surgeons perceive ADEPT to be a valid instrument for measuring laparoscopic skills?

⊙ Does performance on ADEPT reflect innate psychomotor ability?

Methods

Each of 45 surgeons completed two runs on ADEPT. The runs comprised five standardized tasks. A posttest visual analog scaled (VAS) questionnaire measuring attitude toward skills testing in general, validation, and performance on ADEPT was used. Subjective responses were compared with objective scores generated through performance on ADEPT.

Results

Surgeons emphasize the importance of using a variety of training methods for surgical residents during their residency, including laparoscopic virtual reality simulators. Monitoring of residents’ endoscopic progress seemed to be a key issue. Surgeons themselves underestimate their individual performance on ADEPT (mean subjective score of 6.1 vs mean objective score of 6.6). Self-reported performance on ADEPT is unreliable because confidence intervals between the VAS score and the ADEPT score overlap. Surgeons disagree on the validity of ADEPT. The mean score for validity was 5.8, ranging from 0 to 10 with almost equal distribution over the scale. Innate ability established as surgeons’ scores express is high concordance between test run and true run, with 72.7% of the participants’ true run score within one distance from the test run.

Conclusions

Surgeons cannot correctly predict their standardized individual test result on ADEPT. Performance on ADEPT reflects innate psychomotor ability along with improvement over runs. Surgeons are ambivalent in assessing the validity of ADEPT, irrespective of personal performance.     

Virtual Reality Simulation Training can Improve Inexperienced Surgeons'' Endovascular Skills

PURPOSE: The aim of this study was to evaluate virtual reality (VR) simulation for endovascular training of surgeons inexperienced in this technique. METHODS: Twenty consultant vascular surgeons were divided into those who had performed >50 endovascular procedures (e.g. aortic and carotid stent) as primary operator (n=8), and those having performed <10 procedures (n=12). To test for endovascular skill rather than procedural knowledge, all subjects performed a renal artery balloon angioplasty and stent procedure. The simulator uses real tools with active force feedback, and provides a realistic image of the virtual patient. Surgeons with endovascular skills performed two repetitions and those without completed six repetitions of the same task. The simulator recorded time taken for the procedure, the amount of contrast fluid used and total fluoroscopy time. RESULTS: Initially, surgeons with endovascular skills were significantly faster (median 571.5 vs. 900.0 s, p=0.039) and used less contrast fluid (19.1 vs. 42.9 ml, p=0.047) than inexperienced operators, though differences for fluoroscopy time were not significant (273 vs. 441 s, p=0.305). Over the six sessions, the inexperienced group made significant improvements in performance for time taken (p=0.007) and contrast fluid usage (p=0.021), achieving similar scores at the end of the training program to the experienced group. CONCLUSIONS: Surgeons with minimal endovascular experience can improve their time taken and contrast usage during short-phase training on a VR endovascular task. VR simulation may be useful for the early part of the learning curve for surgeons who wish to expand their endovascular interests.     

Assessment of individual hand performance in box trainers compared to virtual reality trainers

Training residents in laparoscopic skills is ideally initiated in an inanimate laboratory with both box trainers and virtual reality trainers. Virtual reality trainers have the ability to score individual hand performance although they are expensive. Here we compared the ability to assess dominant and nondominant hand performance in box trainers with virtual reality trainers. Medical students without laparoscopic experience were utilized in this study (n = 16). Each student performed tasks on the LTS 2000, an inanimate box trainer (placing pegs with both hands and transferring pegs from one hand to another), as well as a task on the MIST-VR, a virtual reality trainer (grasping a virtual object and placing it in a virtual receptable with alternating hands). A surgeon scored students for the inanimate box trainer exercises (time and errors) while the MIST-VR scored students (time, economy of movements, and errors for each hand). Statistical analysis included Pearson correlations. Errors and time for the one-handed tasks on the box trainer did not correlate with errors, time, or economy measured for each hand by the MIST-VR (r = 0.01 to 0.30; P = NS). Total errors on the virtual reality trainer did correlate with errors on transferring pege (r = 0.61; P < 0.05). Economy and time of both dominant and nondominant hand from the MIST-VR correlated with time of transferring pegs in the box trainer (r = 0.53 to 0.77; P < 0.05). While individual hand assessment by the box trainer during 2-handed tasks was related to assessment by the virtual reality trainer, individual hand assessment during 1-handed tasks did not correlate with the virtual reality trainer. Virtual reality trainers, such as the MIST-VR, allow assessment of individual hand skills which may lead to improved laparoscopic skill acquisition. It is difficult to assess individual hand performance with box trainers alone.     

Virtual reality and computer-enhanced training devices equally improve laparoscopic surgical skill in novices

BACKGROUND: The study aim was to compare the effectiveness of virtual reality and computer-enhanced videoscopic training devices for training novice surgeons in complex laparoscopic skills. METHODS: Third-year medical students received instruction on laparoscopic intracorporeal suturing and knot tying and then underwent a pretraining assessment of the task using a live porcine model. Students were then randomized to objectives-based training on either the virtual reality (n=8) or computer-enhanced (n=8) training devices for 4 weeks, after which the assessment was repeated. RESULTS: Posttraining performance had improved compared with pretraining performance in both task completion rate (94% versus 18%; P<0.001*) and time [181+/-58 (SD) versus 292+/-24*]. Performance of the 2 groups was comparable before and after training. Of the subjects, 88% thought that haptic cues were important in simulators. Both groups agreed that their respective training systems were effective teaching tools, but computer-enhanced device trainees were more likely to rate their training as representative of reality (P<0.01). CONCLUSIONS: Training on virtual reality and computer-enhanced devices had equivalent effects on skills improvement in novices. Despite the perception that haptic feedback is important in laparoscopic simulation training, its absence in the virtual reality device did not impede acquisition of skill.     

Construct validation of the ProMIS simulator using a novel laparoscopic suturing task

Background The use of simulation for minimally invasive surgery (MIS) skills training has many advantages over current traditional methods. One advantage of simulation is that it enables an objective assessment of technical performance. The purpose of this study was to determine whether the ProMIS augmented reality simulator could objectively distinguish between levels of performance skills on a complex laparoscopic suturing task. Methods Ten subjects — five laparoscopic experts and five laparoscopic novices — were assessed for baseline perceptual, visio-spatial, and psychomotor abilities using validated tests. After three trials of a novel laparoscopic suturing task were performed on the simulator, measures for time, smoothness of movement, and path distance were analyzed for each trial. Accuracy and errors were evaluated separately by two blinded reviewers to an interrater reliability of >0.8. Comparisons of mean performance measures were made between the two groups using a Mann-Whitney U test. Internal consistency of ProMIS measures was assessed with coefficient α. Results The psychomotor performance of the experts was superior at baseline assessment (p < 0.001). On the laparoscopic suturing task, the experts performed significantly better than the novices across all three trials (p < 0.001). They performed the tasks between three and four times faster (p < 0.0001), had three times shorter instrument path length (p < 0.0001), and had four times greater smoothness of instrument movement (p < 0.009). Experts also showed greater consistency in their performance, as demonstrated by SDs across all measures, which were four times smaller than the novice group. Observed internal consistency of ProMIS measures was high (α = 0.95, p < 0.00001). Conclusions Preliminary results of construct validation efforts of the ProMIS simulator show that it can distinguish between experts and novices and has promising psychometric properties. The attractive feature of ProMIS is that a wide variety of MIS tasks can be used to train and assess technical skills.     

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

OBJECTIVES: To evaluate virtual reality as a laparoscopic training device in helping surgeons to automate to the "fulcrum effect" by comparing it to time-matched training programs using randomly alternating images (ie, y-axis inverted and normal laparoscopic) and normal laparoscopic viewing conditions. METHODS: Twenty-four participants (16 females and 8 males), were randomly assigned to minimally invasive surgery virtual reality (MIST VR), randomly alternating (between y-axis inverted and normal laparoscopic images), and normal laparoscopic imaging condition. Participants were requested to perform a 2-minute laparoscopic cutting task before and after training. RESULTS: In the test trial participants who trained on the MIST VR performed significantly better than those in the normal laparoscopic and randomly alternating imaging conditions. CONCLUSION: The results show that virtual reality training may provide faster skill acquisition with particular reference to automation of the fulcrum effect. MIST VR provides a new way of training laparoscopic psychomotor surgical skills.     

Assessment of construct validity of a virtual reality laparoscopy simulator

BACKGROUND: The aim of this study was to assess whether virtual reality (VR) can discriminate between the skills of novices and intermediate-level laparoscopic surgical trainees (construct validity), and whether the simulator assessment correlates with an expert's evaluation of performance. METHODS: Three hundred and seven (307) participants of the 19th-22nd Davos International Gastrointestinal Surgery Workshops performed the clip-and-cut task on the Xitact LS 500 VR simulator (Xitact S.A., Morges, Switzerland). According to their previous experience in laparoscopic surgery, participants were assigned to the basic course (BC) or the intermediate course (IC). Objective performance parameters recorded by the simulator were compared to the standardized assessment by the course instructors during laparoscopic pelvitrainer and conventional surgery exercises. RESULTS: IC participants performed significantly better on the VR simulator than BC participants for the task completion time as well as the economy of movement of the right instrument, not the left instrument. Participants with maximum scores in the pelvitrainer cholecystectomy task performed the VR trial significantly faster, compared to those who scored less. In the conventional surgery task, a significant difference between those who scored the maximum and those who scored less was found not only for task completion time, but also for economy of movement of the right instrument. CONCLUSIONS: VR simulation provides a valid assessment of psychomotor skills and some basic aspects of spatial skills in laparoscopic surgery. Furthermore, VR allows discrimination between trainees with different levels of experience in laparoscopic surgery establishing construct validity for the Xitact LS 500 clip-and-cut task. Virtual reality may become the gold standard to assess and monitor surgical skills in laparoscopic surgery.     

Laparoscopic skills training and assessment

BACKGROUND: The introduction of laparoscopic techniques to general surgery was associated with many unnecessary complications, which led to the development of skills laboratories to train novice laparoscopic surgeons. This article reviews the tools currently available for training and assessment in laparoscopic surgery. METHODS: Medline searches were performed to identify articles with combinations of the following key words: laparoscopy, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers. RESULTS: Current training involves the use of box trainers with either innate models or animal tissues; it lacks objective assessment of skill acquisition. Virtual reality simulators have the ability to teach laparoscopic psychomotor skills, and objective assessment is now possible using dexterity-based and video analysis systems. CONCLUSION: The tools are now available for the development of a structured, competency-based, laparoscopic surgical training programme.     

Limitations of haptic feedback devices on construct validity of the LapSim® virtual reality simulator

Background

Surgeons performing laparoscopy need a high degree of psychomotor skills, which can be trained and assessed on virtual reality (VR) simulators. VR simulators simulate the surgical environment and assess psychomotor skills according to predefined parameters. This study aimed to validate a proficiency-based training setup that consisted of two tasks with predefined threshold values and handles with haptic feedback on the LapSim^® VR simulator. The two tasks have been found to have construct validity in previous studies using handles without haptic feedback.

Methods

The participants were divided into three groups: novices (0–50 laparoscopic procedures), intermediates (51–300 laparoscopic procedures), and experts (more than 300 procedures). It was assumed that psychomotor skills increase with experience. All participants conducted the tasks lifting and grasping and fine dissection 20 times each. Validity of the training setup was investigated by comparing the number of times each participant passed a predefined threshold level for a set of 19 parameters.

Results

Construct validity was established for one parameter; “misses on right side” on the lifting and grasping task, whereas the other 18 parameters did not show construct validity.

Conclusion

The setup employed in this study failed to establish construct validity for more than one parameter. This indicates that the simulation of haptic feedback influences the training performance on laparoscopic simulators and is an important part of validating a training setup. A haptic device should generate haptic sensations in a realistic manner, without introducing frictional forces that are not inherent to laparoscopy.     

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training(box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon's performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.     

The Impact of Self-Belief on Laparoscopic Performance of Novices and Experienced Surgeons

BACKGROUND: In many professions, nontechnical aspects such as motivation or coping with stress are known to influence performance, success, and outcome. These qualities are assessed and trained in novices for quality and safety reasons. This study explored the impact of self-belief of surgeons on laparoscopic performance using a virtual reality simulator (LapSim((R))). METHODS: Eighteen inexperienced surgical residents (with less than ten laparoscopic procedures performed) and 22 advanced residents (with more than 50 laparoscopic procedures performed) filled out a ten-item questionnaire used for the assessment of the individual sense of general self-efficacy (GSE). Afterward the participants were asked to perform three defined tasks on the LapSim, each at two different levels of difficulty. The tasks consisted of coordination, dissection, and application of clips. To assess laparoscopic performance, the total time to complete the tasks, economy of motion, and damage parameters were analyzed and correlated with the GSE score by means of Bravis-Pearson correlation analysis. RESULTS: In novices, high GSE scores correlated with more errors and poor economy of motion, while in advanced residents, laparoscopic performance was independent of the level of assessed self-efficacy. CONCLUSION: In a small sample, high self-belief does not predict success. In novices it negatively correlates with laparoscopic skills, while in advanced residents it is independent of laparoscopic performance. Thus, training aspects seem to be of greater importance for laparoscopic skills. Nevertheless, nontechnical aspects like self-belief, motivation, stress-coping strategies, judgment, decision-making, and leadership should be included in the surgical curriculum.     

Objective assessment of laparoscopic skills using a virtual reality stimulator

Background Virtual reality simulation has a great potential as a training and assessment tool of laparoscopic skills. The study was carried out to investigate whether the LapSim system (Surgical Science Ltd., Gothenburg, Sweden) was able to differentiate between subjects with different laparoscopic experience and thus to demonstrate its construct validity. Methods Subjects 24 were divided into two groups: experienced (performed > 100 laparoscopic procedures, n = 10) and beginners (performed <10 laparoscopic procedures, n = 14). Assessment of laparoscopic skills was based on parameters measured by the computer system. Results Experienced surgeons performed consistently better than the residents. Significant differences in the parameters time and economy of motion existed between the two groups in seven of seven tasks. Regarding error parameters, differences existed in most but not all tasks. Conclusion LapSim was able to differentiate between subjects with different laparoscopic experience. This indicates that the system measures skills relevant for laparoscopic surgery and can be used in training programs as a valid assessment tool.     

A prospective randomized study to test the transfer of basic psychomotor skills from virtual reality to physical reality in a comparable training setting

OBJECTIVE: To test whether basic skills acquired on a virtual endoscopic surgery simulator are transferable from virtual reality to physical reality in a comparable training setting. SUMMARY BACKGROUND DATA: For surgical training in laparoscopic surgery, new training methods have to be developed that allow surgeons to first practice in a simulated setting before operating on real patients. A virtual endoscopic surgery trainer (VEST) has been developed within the framework of a joint project. Because of principal limitations of simulation techniques, it is essential to know whether training with this simulator is comparable to conventional training. METHODS: Devices used were the VEST system and a conventional video trainer (CVT). Two basic training tasks were constructed identically (a) as virtual tasks and (b) as mechanical models for the CVT. Test persons were divided into 2 groups each consisting of 12 novices and 4 experts. Each group carried out a defined training program over the course of 4 consecutive days on the VEST or the CVT, respectively. To test the transfer of skills, the groups switched devices on the 5th day. The main parameter was task completion time. RESULTS: The novices in both groups showed similar learning curves. The mean task completion times decreased significantly over the 4 training days of the study. The task completion times for the control task on Day 5 were significantly lower than on Days 1 and 2. The experts' task completion times were much lower than those of the novices. CONCLUSIONS: This study showed that training with a computer simulator, just as with the CVT, resulted in a reproducible training effect. The control task showed that skills learned in virtual reality are transferable to the physical reality of a CVT. The fact that the experts showed little improvement demonstrates that the simulation trains surgeons in basic laparoscopic skills learned in years of practice.     

A surgical virtual reality simulator distinguishes between expert gynecologic laparoscopic surgeons and perinatologists

Background:Concern regarding the quality of surgical training in obstetrics and gynecology residency programs is focusing attention on competency based education. Because open surgical skills cannot necessarily be translated into laparoscopic skills and with minimally invasive surgery becoming standard in operative gynecology, the discrepancy in training between obstetrics and gynecology will widen. Training on surgical simulators with virtual reality may improve surgical skills. However, before incorporation into training programs for gynecology residents the validity of such instruments needs to first be established. We sought to prove the construct validity of a virtual reality laparoscopic simulator, the SurgicalSim^TM, by showing its ability to distinguish between surgeons with different laparoscopic experience.Methods:Eleven gynecologic surgeons (experts) and 11 perinatologists (controls) completed 3 tasks on the simulator, and 10 performance parameters were compared.Results:The experts performed faster, more efficiently, and with fewer errors, proving the construct validity of the SurgicalSim.Conclusions:Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skill levels. Hence, these simulators could be integrated into gynecology resident endoscopic training and utilized for objective assessment. Second, the skills required for competency in obstetrics cannot necessarily be utilized for better performance in laparoscopic gynecology.