Training opportunities and the role of virtual reality simulation in acquisition of basic laparoscopic skills

BACKGROUND: Within the past decade, there has been increasing interest in simulation-based devices for training and assessment of technical skills, especially for minimally invasive techniques such as laparoscopy. The aim of this study was to investigate the perceptions of senior and junior surgeons to virtual reality simulation within the context of current training opportunities for basic laparoscopic procedures. METHODS: A postal questionnaire was sent to 245 consultants and their corresponding specialist registrar (SpR), detailing laparoscopic surgical practice and their knowledge and use of virtual reality (VR) surgical simulators. RESULTS: One hundred ninety-one (78%) consultants and 103(42%) SpRs returned questionnaires; 16%(10/61) of junior SpRs (year 1-4) had performed more than 50 laparoscopic cholecystectomies to date compared with 76% (32/42) of senior SpRs (year 5-6) (P < 0.001); 90% (55/61) of junior SpRs and 67% (28/42) of senior SpRs were keen to augment their training with VR (P = 0.007); 81% (238/294) of all surgeons agreed that VR has a useful role in the laparoscopic surgical training curriculum. CONCLUSIONS: There is a lack of experience in index laparoscopic cases of junior SpRs, and laparoscopic VR simulation is recognized as a useful mode of practice to acquire technical skills. This should encourage surgical program directors to drive the integration of simulation-based training into the surgical curriculum.     

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

Background  Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation. Methods  A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education. Results  The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. Conclusions  In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.     

Virtual reality training improves operating room performance: results of a randomized,double-blinded study

OBJECTIVE: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. SUMMARY BACKGROUND DATA: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. METHODS: Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). RESULTS: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P <.007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P <.04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case; P <.008, Mann-Whitney test). CONCLUSIONS: The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.     

Minimally invasive training in urologic oncology

Use of minimally invasive surgical (MIS) techniques continues to expand in the field of urologic oncology; however, proficiency in these techniques is subject to a learning curve. Current training paradigms have incorporated MIS, but in a non-standardized fashion. Residency work-hour restrictions and ethical concerns may influence efforts to deliver adequate training during a defined residency period. Post-residency fellowships or mini-courses may help urologists gain proficiency in these skills, but are time-consuming and may not provide adequate exposure. Surgical simulation with dry labs and augmentation with virtual reality are important adjuncts to operative training for MIS. The urologic oncologist must be familiar with open and MIS techniques to effectively treat cancer in the least morbid way possible and adapt to the ever-changing field of MIS with dynamic training paradigms.     

Endovascular skills training and assessment

OBJECTIVE: Evolving endovascular therapies have transformed the management of vascular disease. At the same time, the increasing use of non-invasive vascular imaging techniques has reduced the opportunities to gain the required basic wire and catheter handling skills by performing diagnostic catheterizations. This article reviews the evidence for alternative tools currently available for endovascular skills training and assessment. METHODS: A literature search was performed on PubMed using combinations of the following keywords; endovascular, skills, training, simulation, assessment and learning curve. Additional articles were retrieved from the reference lists of identified papers as well as discussion with experts in the arena of medical education. RESULTS: Available alternatives to training on patients include synthetic models, anesthetized animals, human cadavers and virtual reality (VR) simulation. VR simulation is a useful tool enabling objective demonstration of improved skills performance both in simulated performance and in subsequent in-vivo performance. Assessment modalities reviewed include time action analysis, error analysis, global rating scales, procedure specific checklists and VR simulators. Assessment in training has been widely validated using VR simulation. Rating scales and checklists are presently the only assessment modalities that have demonstrated utility outside the training lab. CONCLUSION: The tools required for a structured proficiency based endovascular training curriculum are already available. Organization of training programs needs to evolve to make full use of modern simulation capability for technical and non-technical skills training.     

Establishing a curriculum for the acquisition of laparoscopic psychomotor skills in the virtual reality environment

BackgroundThe unique psychomotor skills required in laparoscopy result in reduced patient safety during the early part of the learning curve. Evidence suggests that these may be safely acquired in the virtual reality (VR) environment. Several VR simulators are available, each preloaded with several psychomotor skills tasks that provide users with computer-generated performance metrics. This review aimed to evaluate the usefulness of specific psychomotor skills tasks and metrics, and how trainers might build an effective training curriculum.MethodsWe performed a comprehensive literature search.ResultsThe vast majority of VR psychomotor skills tasks show construct validity for one or more metrics. These are commonly for time and motion parameters. Regarding training schedules, distributed practice is preferred over massed practice. However, a degree of supervision may be needed to counter the limitations of VR training.ConclusionsIn the future, standardized proficiency scores should facilitate local institutions in establishing VR laparoscopic psychomotor skills curricula.     

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.     

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery

OBJECTIVE: The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group. SUMMARY BACKGROUND DATA: Simulator-based training has been shown to improve technical performance during real laparoscopic procedures, although research to date has not proven the persistence of this effect over subsequent cases. MATERIAL AND METHODS: Twenty novice surgeons underwent baseline laparoscopic skills testing followed by a 1-day didactic training session. Control subjects (n = 10) performed 5 cadaveric porcine LCs each; VR-trained subjects (n = 10) completed a VR training curriculum followed by 3 porcine LCs each. A further 10 experienced laparoscopic surgeons (>100 LCs) performed 2 porcine LCs each to define benchmark levels. Technical skill assessment was by motion analysis and video-based global rating scores (out of 35). RESULTS: There were no intergroup differences in baseline skill. The first LC revealed significant differences between control and VR groups for time (median 4590 seconds vs. 2165 seconds, P = 0.038), path length (169.2 meters vs. 86.8 meters, P = 0.009), number of movements (2446 vs. 1029, P = 0.009), and video scores (17 vs. 25, P = 0.001). The VR group, although not a control, achieved video and dexterity scores equivalent to expert levels of performance. CONCLUSIONS: A proficiency based VR training curriculum shortens the learning curve on real laparoscopic procedures when compared with traditional training methods. This may be a more cost- and time-effective approach, and supports the need for simulator-based practice to be integrated into surgical training programs.     

Cognitive skills training in digital era: A paradigm shift in surgical education using the TaTME model

Surgical competence is a complex, multifactorial process, requiring ample time and training. Optimal training is based on acquiring knowledge and psychomotor and cognitive skills. Practicing surgical skills is one of the most crucial tasks for both the novice surgeon learning new procedures and surgeons already in practice learning new techniques. Focus is placed on teaching traditional technical skills, but the importance of cognitive skills cannot be underestimated. Cognitive skills allow recognizing environmental cues to improve technical performance including situational awareness, mental readiness, risk assessment, anticipating problems, decision-making, adaptation, and flexibility, and may also accelerate the trainee's understanding of a procedure, formalize the steps being practiced, and reduce the overall training time to become technically proficient. The introduction and implementation of the transanal total mesorectal excision (TaTME) into practice may be the best demonstration of this new model of teaching and training, including pre-training, course attendance, and post-course guidance on technical and cognitive skills. To date, the TaTME framework has been the ideal model for structured training to ensure safe implementation. Further development of metrics to grade successful learning and assessment of long term outcomes with the new pathway will confirm the success of this training model.     

Simulation training in video-assisted urologic surgery

The current system of surgical education is facing many challenges in terms of time ef.ciency, costs, and patient safety. Training using simulation is an emerging area, mostly based on the experience of other high-risk professions like aviation. The goal of simulation-based training in surgery is to develop not only technical but team skills. This learning environment is stress-free and safe, allows standardization and tailoring of training, and also objectively evaluate performances. The development of simulation training is straightforward in endourology, since these procedures are video-assisted and the low degree of freedom of the instruments is easily replicated. On the other hand, these interventions necessitate a long learning curve, training in the operative room is especially costly and risky. Many models are already in use or under development in all fields of video-assisted urologic surgery: ureteroscopy, percutaneous surgery, transurethral resection of the prostate, and laparoscopy. Although bench models are essential, simulation increasingly benefits from the achievements and development of computer technology. Still in its infancy, virtual reality simulation will certainly belong to tomorrow’s teaching tools.     

Need for simulation in laparoscopic colorectal surgery training

The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.     

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.     

Contemporary virtual reality laparoscopy simulators: quicksand or solid grounds for assessing surgical trainees?

Background

A demand for safe, efficient laparoscopic training tools has prompted the introduction of virtual reality (VR) laparoscopic simulators, which might be used for performance assessment. The purpose of this review is to determine the value of VR metrics in laparoscopic skills assessment.

Data sources

An exhaustive search of the MEDLINE and EMBASE databases was performed to identify publications concerning construct, concurrent and predictive validation of VR simulators. Of 643 publications found, 42 were included in this review. Studies into all 3 types of validation showed a large heterogeneity in study design. Although concurrence of VR metrics with box trainer metrics, mental aptitude tests, and in vivo surgical performance was generally weak, several metrics demonstrated construct validity in selected simulators.

Conclusions

Using the right simulator, tasks, and metrics, trainees' and experts' laparoscopic skills can reliably be compared. However, VR simulators cannot yet predict levels of real life surgical skills.     

Accomplishments and challenges of surgical simulation

For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.     

Face validation of the Simbionix LAP Mentor virtual reality training module and its applicability in the surgical curriculum

BACKGROUND: The goal of our study was to determine expert and referent face validity of the LAP Mentor, the first procedural virtual reality (VR) laparoscopy trainer. METHODS: In The Netherlands 49 surgeons and surgical trainees were given a hands-on introduction to the Simbionix LAP Mentor training module. Subsequently, a standardized five-point Likert-scale questionnaire was administered. Respondents who had performed over 50 laparoscopic procedures were classified as "experts." The others constituted the "referent" group, representing nonexperts such as surgical trainees. RESULTS: Of the experts, 90.5% (n = 21) judge themselves to be average or above-average laparoscopic surgeons, while 88.5% of referents (n = 28) feel themselves to be less-than-average laparoscopic surgeons (p = 0.000). There is agreement between both groups on all items concerning the simulator's performance and application. Respondents feel strongly about the necessity for training on basic skills before operating on patients and unanimously agree on the importance of procedural training. A large number (87.8%) of respondents expect the LAP Mentor to enhance a trainee's laparoscopic capability, 83.7% expect a shorter laparoscopic learning curve, and 67.3% even predict reduced complication rates in laparoscopic cholecystectomies among novice surgeons. The preferred stage for implementing the VR training module is during the surgeon's residency, and 59.2% of respondents feel the surgical curriculum is incomplete without VR training. CONCLUSION: Both potential surgical trainees and trainers stress the need for VR training in the surgical curriculum. Both groups believe the LAP Mentor to be a realistic VR module, with a powerful potential for training and monitoring basic laparoscopic skills as well as full laparoscopic procedures. Simulator training is perceived to be both informative and entertaining, and enthusiasm among future trainers and trainees is to be expected. Further validation of the system is required to determine whether the performance results agree with these favorable expectations.     

A virtual reality module for intravenous catheter placement

BACKGROUND: Virtual reality (VR) is a potential tool for technical skills training. We tested the validity and instructional effectiveness of a prototype VR module for learning intravenous (i.v.) catheter placement. METHODS: First-year medical students (n = 37), third-year medical students (n = 14), and surgical residents (n = 9) attempted two pretest i.v.s into each other, used the VR module for 12 minutes, and subsequently attempted two posttest i.v.s. Success or failure were recorded for each attempt. For each successful attempt, time and global rating of i.v. insertion were also recorded. RESULTS: The pretest success rate was significantly different between groups (chi square = 28.71, P <0.01). VR success rate was not significantly different between groups (F(2,57) = 1.47, ns). Although there was improvement in all groups during VR training (F(2,114) = 44.16, P <0.01), this did not result in improvement in posttest performance. CONCLUSIONS: Significant differences between groups were observed in performance of i.v. insertion in physical reality. However, no significant difference was observed in performance in VR. Thus, performance in VR demonstrated neither construct nor concurrent validity. While performance improved in VR, transfer of skill from VR to physical reality was not observed. Additional development and testing of VR as a training tool is warranted before its widespread use can be recommended.     

Orthopaedic education in the era of surgical simulation: Still at the crawling stage

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulationbased curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.     

Do Soft Skills Predict Surgical Performance?

Background

Virtual reality (VR) training in minimal invasive surgery (MIS) is feasible in surgical residency and beneficial for the performance of MIS by surgical trainees. Research on stress-coping of surgical trainees indicates the additional impact of soft skills on VR performance in the surgical curriculum. The aim of this study was to evaluate the impact of structured VR training and soft skills on VR performance of trainees.

Method

The study was designed as a single-center randomized controlled trial. Fifty first-year surgical residents with limited experience in MIS (??camera navigation?? in laparoscopic cholecystectomy only) were randomized for either 3?months of VR training or no training. Basic VR performance and defined soft skills (self-efficacy, stress-coping, and motivation) were assessed prior to randomization using basic modules of the VR simulator LapSim^? and standardized psychological questionnaires. Three months after randomization VR performance was reassessed. Outcome measurement was based on the results derived from the most complex of the basic VR modules (??diathermy cutting??) as the primary end point. A correlation analysis of the VR end-point performance and the psychological scores was done in both groups.

Results

Structured VR training enhanced VR performance of surgical trainees. An additional correlation to high motivational states (P?P?P?>?0.05).

Conclusion

Low self-efficacy and negative stress-coping strategies seem to predict poor VR performance. However, structured training along with high motivational states is likely to balance out this impairment.     

Documenting a learning curve and test-retest reliability of two tasks on a virtual reality training simulator in laparoscopic surgery

BACKGROUND: Virtual reality simulators are a component of the armamentarium for training surgical residents. No one knows exactly how to incorporate virtual reality simulators into a curriculum. The purpose of this study was to document and show the learning curve and test-retest reliability of 2 tasks on a virtual reality-training simulator (LapSim; Surgical Science, G?teborg, Sweden) in laparoscopic surgery. METHODS: Twenty-nine medical students participated in 8 iterations of 7 virtual reality tasks ("camera navigation" (CN), "instrument navigation," "coordination," "grasping," "lifting and grasping" (LG), "cutting," and "clip applying") Learning curves for each outcome variable of the CN and LG tasks were generated. Using ANOVA, we evaluated the differences between each score from attempt number 7 to attempt number 8 to document test-retest reliability. RESULTS: A plateau in the learning curve occurred within 8 sessions for CN misses, CN tissue damage, CN maximum damage, and LG maximum damage. Over the course of 8 sessions, a plateau in the learning curve was nearly reached for CN time, CN drift, CN path, CN angular path, and LG left and right path. The following variables had a downward trend to the mean learning curve over 8 sessions, but they did not reach a plateau: LG time, LG left and right miss, LG left and right angular path, and LG tissue damage. CONCLUSION: Using the LapSim virtual reality simulator, we documented a learning curve and test-retest reliability for each outcome variable for CN and LG for rank novices. The modeling of the general learning curve is useful in designing training program. These results may be important in developing standards for technical evaluation in a surgical training curriculum.