The effects of video games on laparoscopic simulator skills

Background

Recently, there has been a growth in studies supporting the hypothesis that video games have positive effects on basic laparoscopic skills. This review discusses all studies directly related to these effects.

Data Sources

A search in the PubMed and EMBASE databases was performed using synonymous terms for video games and laparoscopy. All available articles concerning video games and their effects on skills on any laparoscopic simulator (box trainer, virtual reality, and animal models) were selected.

Conclusions

Video game experience has been related to higher baseline laparoscopic skills in different studies. There is currently, however, no standardized method to assess video game experience, making it difficult to compare these studies. Several controlled experiments have, nevertheless, shown that video games cannot only be used to improve laparoscopic basic skills in surgical novices, but are also used as a temporary warming-up before laparoscopic surgery.     

Comparison of Nintendo Wii and PlayStation2 for Enhancing Laparoscopic Skills

Background and Objective:

The increase in laparoscopic surgery has led to a growing need to train residents in this skill. Virtual reality simulators and box trainers have been used as educational tools outside of the operating room, but both approaches have advantages and disadvantages. Video games have been an area of interest in the search for other modalities to train residents. Experience with the traditional single controller unit video games have been correlated with better surgical skill acquisition. In 2006, Nintendo introduced the Wii, a novel gaming modality that mimics movements in laparoscopy better than traditional games do. Our objective was to compare the Nintendo Wii and PlayStation2 for enhancing laparoscopy skills.

Methods:

The study included stratified randomization of 23 less experienced (<12 laparoscopy cases per year) and 19 more experienced (>12 per year) physicians, residents, and medical students to 30 min of Wii versus PlayStation2 in a university-affiliated hospital Department of Obstetrics and Gynecology. Pre- and posttest bead transfer and suturing scores were obtained.

Results:

Baseline characteristics were similar for both video game groups. Participants assigned to Wii and PlayStation2 both demonstrated significant improvement in bead transfer. Neither Wii nor PlayStation2 participants improved in suturing scores. The Wii group improved more in bead transfer scores when compared to the PlayStation2 group (60 points vs. 40 points, respectively), but this difference was not statistically significant.

Conclusions:

Both Wii and PlayStation2 significantly improved laparoscopic skills in bead transfer. These video games may be inexpensive alternatives to laparoscopy training simulators.     

Beyond task time: automated measurement augments fundamentals of laparoscopic skills methodology

Background

Laparoscopic psychomotor skills are challenging to learn and objectively evaluate. The Fundamentals of Laparoscopic Skills (FLS) program provides a popular, inexpensive, widely-studied, and reported method for evaluating basic laparoscopic skills. With an emphasis on training safety before efficiency, we present data that explore the metrics in the FLS curriculum.

Materials and methods

A multi-institutional (n = 3) cross-sectional study enrolled subjects (n = 98) of all laparoscopic skill levels to perform FLS tasks in an instrumented box trainer. Recorded task videos were postevaluated by faculty reviewers (n = 2) blinded to subject identity using a modified Objective Structured Assessment of Technical Skills (OSATS) protocol. FLS scores were computed for each completed task and compared with demographically established skill levels (training level and number of procedures), video review scoring, and objective performance metrics including path length, economy of motion, and peak grasping force.

Results

Three criteria used to determine expert skill, training and experience level, blinded review of performance by faculty via OSATS, and FLS scores, disagree in establishing concurrent validity for determining “true experts” in FLS tasks. FLS-scoring exhibited near-perfect correlation with task time for all three tasks (Pearson r = 0.99, 1.00, 1.00 with P <0.00000001). FLS error penalties had negligible effect on FLS scores. Peak grasping force did not correlate with task time or FLS scores.

Conclusions

FLS technical skills scores presented negligible benefit beyond the measurement of task time. FLS scoring is weighted more toward speed than precision and may not significantly address poor tissue handling skills, especially regarding excessive grasping force. Categories of experience or training level may not form a suitable basis for establishing proficiency thresholds or for construct validity studies for technical skills.     

The effect of video game "warm-up" on performance of laparoscopic surgery tasks

Background:

Performing laparoscopic procedures requires special training and has been documented as a significant source of surgical errors. “Warming up” before performing a task has been shown to enhance performance. This study investigates whether surgeons benefit from “warming up” using select video games immediately before performing laparoscopic partial tasks and clinical tasks.

Methods:

This study included 303 surgeons (249 men and 54 women). Participants were split into a control (n=180) and an experimental group (n=123). The experimental group played 3 previously validated video games for 6 minutes before task sessions. The Cobra Rope partial task and suturing exercises were performed immediately after the warm-up sessions.

Results:

Surgeons who played video games prior to the Cobra Rope drill were significantly faster on their first attempt and across all 10 trials. The experimental and control groups were significantly different in their total suturing scores (t=2.28, df=288, P<.05). The overall Top Gun score showed that the experimental group performed marginally better overall.

Conclusion:

This study demonstrates that subjects completing “warming-up” sessions with select video games prior to performing laparoscopic partial and clinical tasks (intracorporeal suturing) were faster and had fewer errors than participants not engaging in “warm-up.” More study is needed to determine whether this translates into superior procedural execution in the clinical setting.     

Utilidad de un sistema de seguimiento óptico de instrumental en cirugía laparoscópica para evaluación de destrezas motoras

Introduction

The objective of this study is to assess the usefulness of an evaluation system of surgical skills based on motion analysis of laparoscopic instruments.

Method

This system consists of a physical laparoscopic simulator and a tracking and assessment system of technical skills in laparoscopy. Six surgeons with intermediate experience (between 1 and 50 laparoscopic surgeries) and 5 experienced surgeons (more than 50 laparoscopic surgeries) took part in this study. All participants were right-handed. The subjects performed 3 repetitions of a cutting task on synthetic tissue with the right hand, dissection of a gastric serous layer, and a suturing task in the dissection previously done. Objective metrics such as time, path length, speed of movements, acceleration and motion smoothness were analyzed for the instruments of each hand.

Results

In the cutting task, experienced surgeons show less acceleration (P=.014) and a smoother motion (P=.023) using the scissors. Regarding the dissection activity, experienced surgeons need less time (P=.006) and less length with both instruments (P=.006 for dissector and P=.01 for scissors). In the suturing task, experienced surgeons require less time (P=.037) and distance travelled (P=.041) by the dissector.

Conclusions

This study shows the usefulness of the evaluation system for the cutting, dissecting, and suturing tasks. It represents a significant step in the development of advanced systems for training and assessment of surgical skills in laparoscopic surgery.     

Motion analysis in the pediatric laparoscopic surgery (PLS) simulator: validation and potential use in teaching and assessing surgical skills

Background

Construct validity for the pediatric laparoscopic surgery (PLS) simulator has been established through a scoring system based on time and precision. We describe the development and initial validation of motion analysis to teach and assess skills related to pediatric minimal access surgery (MAS).

Methods

Participants were asked to perform a standardized intracorporeal suturing task. They were classified as novices, intermediates, and experts. Motion in the four degrees of freedom available during traditional MAS (PITCH, YAW, ROLL and SURGE) was assessed using range, velocity, and acceleration.

Results

Analysis of motion allowed discrimination between the 75 participants according to level of expertise. The most discriminating motion parameter was the acceleration in performing the ROLL (pronation/supination) with values of 30 ± 27 for novices, 15 ± 5 for intermediates, and 3.7 ± 3 for experts (p < 0.001).

Conclusions

Tracking and analyzing the motion of instruments within the PLS simulator allow discrimination between novices, intermediates, and experts, thus establishing construct validity. Further development may establish motion analysis as a useful “real time” modality to teach and assess MAS skills.     

Development of a knowledge,skills, and attitudes framework for training in laparoscopic cholecystectomy

Background

The implementation of duty-hour restrictions and a heightened awareness of patient safety has changed resident education and training. A new focus has been placed on high-yield training programs and simulation training has naturally grown to fill this need.

Methods

This article discusses the development of a training framework, knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. Five residents were recruited for a pilot study of the curriculum.

Results

A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. The curriculum consisted of classroom and virtual reality simulation training and was completed in 3.1 to 4.8 hours.

Conclusions

The current curricula that have been developed for surgical education cover the breadth of a surgical residency well. This curriculum went beyond these curricula and developed a structured framework for surgical training, a method that can be applied to any procedure.     

Reliable assessment of general surgeons' non-technical skills based on video-recordings of patient simulated scenarios

Background

Nontechnical skills are essential for safe and efficient surgery. The aim of this study was to evaluate the reliability of an assessment tool for surgeons' nontechnical skills, Non-Technical Skills for Surgeons dk (NOTSSdk), and the effect of rater training.

Methods

A 1-day course was conducted for 15 general surgeons in which they rated surgeons' nontechnical skills in 9 video recordings of scenarios simulating real intraoperative situations. Data were gathered from 2 sessions separated by a 4-hour training session.

Results

Interrater reliability was high for both pretraining ratings (Cronbach's α = .97) and posttraining ratings (Cronbach's α = .98). There was no statistically significant development in assessment skills. The D study showed that 2 untrained raters or 1 trained rater was needed to obtain generalizability coefficients >.80.

Conclusions

The high pretraining interrater reliability indicates that videos were easy to rate and Non-Technical Skills for Surgeons dk easy to use. This implies that Non-Technical Skills for Surgeons dk (NOTSSdk) could be an important tool in surgical training, potentially improving safety and quality for surgical patients.     

Validation of a new box trainer-related tracking device: the TrEndo

Background

There is an increasing demand for structured objective ex vivo training and assessment of laparoscopic psychomotor skills prior to implementation of these skills in practice. The aim of this study was to establish the internal validity of the TrEndo, a motion-tracking device, for implementation on a laparoscopic box trainer.

Methods

Face validity and content validity were addressed through a structured questionnaire. To assess construct validity, participants were divided into an expert group and a novice group and performed two basic laparoscopic tasks. The TrEndo recorded five motion analysis parameters (MAPs) and time.

Results

Participants demonstrated a high regard for face and content validity. All recorded MAPs differed significantly between experts and novices after performing a square knot. Overall, the TrEndo correctly assigned group membership in 84.7 and 95.7% of cases based on two laparoscopic tasks.

Conclusion

Face, content, and construct validities of the TrEndo were established. The TrEndo holds real potential as a (home) training device.     

Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills

Background

Virtual reality (VR) laparoscopic simulators have been around for more than 10 years and have proven to be cost- and time-effective in laparoscopic skills training. However, most simulators are, in our experience, considered less interesting by residents and are often poorly accessible. Consequently, these devices are rarely used in actual training. In an effort to make a low-cost and more attractive simulator, a custom-made Nintendo Wii game was developed. This game could ultimately be used to train the same basic skills as VR laparoscopic simulators ought to. Before such a video game can be implemented into a surgical training program, it has to be validated according to international standards.

Methods

The main goal of this study was to test construct and concurrent validity of the controls of a prototype of the game. In this study, the basic laparoscopic skills of experts (surgeons, urologists, and gynecologists, n = 15) were compared to those of complete novices (internists, n = 15) using the Wii Laparoscopy (construct validity). Scores were also compared to the Fundamentals of Laparoscopy (FLS) Peg Transfer test, an already established assessment method for measuring basic laparoscopic skills (concurrent validity).

Results

Results showed that experts were 111 % faster (P = 0.001) on the Wii Laparoscopy task than novices. Also, scores of the FLS Peg Transfer test and the Wii Laparoscopy showed a significant, high correlation (r = 0.812, P < 0.001).

Conclusions

The prototype setup of the Wii Laparoscopy possesses solid construct and concurrent validity.     

Update on training models in endourology: a qualitative systematic review of the literature between January 1980 and April 2008

Context

Interest in the use of simulators in urological skills training is on the increase. To ensure effective implementation of training models, an overview of the nature and validity of the available models is of the essence.

Objective

To obtain an overview of training models and their validity by performing a qualitative systematic review of the literature.

Evidence acquisition

Studies were identified through searches of PubMed, the Cochrane Library, and Web of Science between January 1980 and April 2008 using two search strategies: “urology and (training or simulat* or model)” and combinations of these terms with “prostate,” “kidney,” “bladder,” or “ureter.” Studies were included if they (1) described one or more training models, and/or (2) examined the validity of training models. Studies in undergraduate education and of training models for physical examination were excluded. Validation studies were scored according to Kirkpatrick and Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence.

Evidence synthesis

Forty-five articles (out of the initial list of 4753 retrieved articles, 0.9%) were included, describing 30 types of training models and 54 validation studies. The largest number of models has been described for ureterorenoscopy (nine types). Only three randomised controlled trials (RCTs), receiving a 1b OCEBM level of evidence score, were found. Studies investigating the impact of simulator training on performance in patients (criterion B validity) were scarce. The number of participants in experimental studies ranged from 7 to 136.

Conclusions

Due to growing interest in training models in urology, it is increasingly urgent to determine which of these models are most valuable for postgraduate training. Because the validation studies published so far are few in number, have low evidence levels, and are composed of only a few RCTs, it is important that more randomised controlled validation studies including larger numbers of participants are performed.     

Intracorporal suturing—driving license necessary?

Background

Intracorporeal suturing and knot tying (ICKT) in minimal invasive surgery (MIS) represents a key skill for advanced procedures. Different methods exist for measuring knot quality and performance, but the heterogeneity of these methods makes direct comparisons difficult. The aim of this study is to compare the quality of a laparoscopic knot to one that is performed open.

Methods

To compare open and laparoscopic knot-tying methods we used a surgeon's square knot. For laparoscopic knot tying we used a Pelvitrainer. The 32 participants were divided among 4 groups of different skill levels. Group 1 consisted of 6 senior physicians. Group 2 was made up of 10 first to fourth year interns. Groups 3 and 4 contained 16 medical students who had never performed either laparoscopic procedures or open sutures before. Group 3 participants received a 1-hour hands-on training in suturing, whereas group 4 participants received no prior training. Total time, knot quality, suture placement accuracy, and performance defined the parameters for assessment in this study.

Results

All participants, irrespective of education level were inferior in ICKT compared to open suturing. Only Group 1 showed no significant difference in knot quality and accuracy between the open and laparoscopic suture performance.

Conclusion

It is well documented that psychomotor skills need to be developed before more advanced skills can be put into practice. Training centres for minimally invasive surgery should be an integral part of surgical education. The variables in our study are meaningful and easy to implement. They can be used to measure personal progress and as objective parameters in the development of laparoscopic trainee education.     

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

Background

Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score).

Methods

Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score.

Results

Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method.

Conclusions

The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.     

Influence of medical students' past experiences and innate dexterity on suturing performance

Background

Medical students often site their ability to excel at technical tasks as justification for choosing surgery as a career path. We sought to investigate how medical students' dexterity skills and past experiences correlated with suturing performance.

Methods

Sixty-four 3rd-year medical students were surveyed about previous experiences that involved manual dexterity. Technical skills were then measured using a validated test of manual dexterity and subcuticular closure of a pig's foot incision. Spearman's rank correlation coefficients determined correlation between variables.

Results

Previous experiences, self-assessment of dexterity, prior suturing, and current interest in surgery did not significantly correlate with manual dexterity or suturing skill scores. Innate manual dexterity score was the only significant correlating factor to suture skill score (Spearman's rank correlation coefficient = .336; P = .007).

Conclusions

Innate manual dexterity skills are predictive of initial surgical suturing performance regardless of past student experiences. Interventions aimed at improving early surgical technique should be optimally focused on dexterity training.     

A comparison of the endoscopic and laparoscopic view of the gastroesophageal junction in the use of transoral fundoplication

Background

Endoscopic fundoplication requires accurate evaluation of the gastroesophageal junction (GJ) to determine if hiatal hernia repair is necessary before fundoplication. We compared the endoscopic and laparoscopic evaluations of the GJ.

Methods

A total of 53 patients with gastroesophageal reflux disease underwent a laparoscopic repair of a hiatal defect before endoscopic fundoplication. The video of the preoperative endoscopic evaluation was compared with the laparoscopic video (n = 44). Nine patients were excluded because both endoscopic and laparoscopic videos were not available. A 2-tailed paired t test was used to assess the difference between the 2 study groups.

Results

The greatest transverse dimension of the hiatus assessed endoscopically was 3.30 cm ± 1.00 vs 3.88 cm ± 1.03 assessed laparoscopically, P < .001. In 22.8%, the average endoscopic Hill grade was lower than the estimated Hill grade when viewed laparoscopically. In 11.1% (range, 6% to 15%) of cases, the endoscopic view indicated a hiatal hernia repair was unnecessary when the matching laparoscopic view indicated hiatal repair would be needed.

Conclusions

Endoscopic evaluation of the GJ may underestimate the radial size of the hiatal defect.     

Construct,content and face validity of the camera handling trainer (CHT): a new E-BLUS training task for 30° laparoscope navigation skills

Purpose

Assessing construct, face and content validity of the camera handling trainer (CHT), a novel low-fidelity training device for 30° laparoscope navigation skills.

Methods

We developed a custom-designed box trainer with clinically based graphic targets. A total of 117 participants, stratified according to their previous experience (novice, competent, expert), took part to a CHT session and subsequently were asked to fill out a survey to assess the impact of the CHT on their 30° laparoscope navigation skills. Sixty of them were also studied for task performance during a 1-h session, with multiple time measurements.

Results

All participants, regardless of the previous experience, significantly improved their performance after the CHT session. Regarding construct validity, the mean task performance on the last measurement for novice group was found to be comparable to the mean first attempt of both competent (p = 0.12) and expert (p = 0.24) participants. All participants agreed that “the CHT is a valid training tool” and that “the CHT should be part of the regular dry laboratory training sessions”, assessing both face and content validity. Limitations include the need for assessment of predictive validity.

Conclusions

The CHT is a valid training tool for 30° laparoscope navigation and thus should be considered as one of the fundamental exercises during basic laparoscopic hands-on training sessions for urologists.

     

Construct Validity of an Inanimate Training Model for Laparoscopic Appendectomy

Background and Objective:

The use of training models in laparoscopic surgery allows the surgical team to practice procedures in a safe environment. The aim of this study was to determine the capability of an inanimate laparoscopic appendectomy model to discriminate between different levels of surgical experience (construct validity).

Methods:

The performance of 3 groups with different levels of expertise in laparoscopic surgery—experts (Group A), intermediates (Group B), and novices (Group C)—was evaluated. The groups were instructed of the task to perform in the model using a video tutorial. Procedures were recorded in a digital format for later analysis using the Global Operative Assessment of Laparoscopic Skills (GOALS) score; procedure time was registered. The data were analyzed using the analysis of variance test.

Results:

Twelve subjects were evaluated, 4 in each group, using the GOALS score and time required to finish the task. Higher scores were observed in the expert group, followed by the intermediate and novice groups, with statistically significant difference. Regarding procedure time, a significant difference was also found between the groups, with the experts having the shorter time. The proposed model is able to discriminate among individuals with different levels of expertise, indicating that the abilities that the model evaluates are relevant in the surgeon''s performance.

Conclusions:

Construct validity for the inanimate full-task laparoscopic appendectomy training model was demonstrated. Therefore, it is a useful tool in the development and evaluation of the resident in training.     

Comparison of Laparoscopy Training Using the Box Trainer Versus the Virtual Trainer

Background and Objectives:

To evaluate whether training on a virtual reality laparoscopic simulator improves the performance on a laparoscopic box trainer.

Methods:

Twenty-six subjects were trained using a box trainer, and 17 participants were trained using a virtual simulator. Participants in the experimental group completed 1 session of 5 exercises on the box trainer, 4 sessions on the virtual simulator, and a final session on the box trainer. Participants in the control group completed 6 sessions of 5 exercises on the box trainer alone. Exercises were monitored and scored for time and accuracy. Participants completed a self-evaluation survey after each session and a user satisfaction questionnaire at the end of the training.

Results:

No significant difference existed between the 2 groups in improvement of accuracy. Pegboard time (P=0.0110) and pattern cutting time (P=0.0229) were the only exercise parameters that improved significantly more in the control group compared with the experimental group. The experimental group developed more interest in a surgical field as a result of their experience than the control group did (70.6% vs 53.8%, respectively).

Conclusion:

The virtual simulator is a reasonable alternative to the box trainer for laparoscopic skills training.     

Laparoscopic Suturing Skills Acquisition: A Comparison Between Laparoscopy-Exposed and Laparoscopy-Naive Surgeons

Background:

Laparoscopic suturing is a difficult skill to master but can be acquired with extensive training outside the operating room. This study was done with the primary aim of assessing whether prior exposure to laparoscopic surgery helped trainees in acquiring laparoscopic suturing skills more quickly than trainees with no prior exposure to laparoscopic surgery.

Materials and Methods:

Twenty laparoscopy-exposed and 20 laparoscopy-naïve surgeons performed 5 laparoscopic gastrojejunostomies each on a phantom porcine model. The performance was evaluated for operation time, overall anastomotic score (calculated by adding scores of anastomotic leak, size of the anastomosis, suture placement, and mucosal approximation), and the level of difficulty. The performance at the beginning of training (baseline) was compared to the performance at the end of training.

Results:

All participants showed statistically significant improvement in operation time, overall anastomotic score, and difficulty level. Laparoscopy-exposed surgeons had a significantly better operation time than laparoscopy-naïve surgeons at the beginning of training; however, the difference became insignificant by the end of training. The difference in overall anastomotic score was not significant between laparoscopy-exposed and naïve-surgeons. Laparoscopy-exposed surgeons showed significant improvements in anastomotic leak rate and size of the anastomosis, whereas laparoscopy naïve surgeons showed improvements in all the parameters, although these were not significant statistically.

Conclusion:

Training improves the laparoscopic suturing skills of laparoscopy-exposed as well as laparoscopy-naïve surgeons. Prior experience in laparoscopic surgery does not seem to influence the acquisition of laparoscopic suturing skills as laparoscopic-naïve surgeons manage to catch up with the skills of the laparoscopy-exposed surgeons.     

Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos

Introduction

Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning.

Objective

We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation.

Material and methods

Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12 h in animal models, and 4 h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work.

Results

Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was > 10 cases/month in 19%, and < 5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach.

Conclusions

Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.