New dimensions in surgical training: immersive virtual reality laparoscopic simulation exhilarates surgical staff

Introduction

Virtual reality (VR) and head mount displays (HMDs) have been advanced for multimedia and information technologies but have scarcely been used in surgical training. Motion sickness and individual psychological changes have been associated with VR. The goal was to observe first experiences and performance scores using a new combined highly immersive virtual reality (IVR) laparoscopy setup.

Methods

During the study, 10 members of the surgical department performed three tasks (fine dissection, peg transfer, and cholecystectomy) on a VR simulator. We then combined a VR HMD with the VR laparoscopic simulator and displayed the simulation on a 360° video of a laparoscopic operation to create an IVR laparoscopic simulation. The tasks were then repeated. Validated questionnaires on immersion and motion sickness were used for the study.

Results

Participants’ times for fine dissection were significantly longer during the IVR session (regular: 86.51 s [62.57 s; 119.62 s] vs. IVR: 112.35 s [82.08 s; 179.40 s]; p?=?0.022). The cholecystectomy task had higher error rates during IVR. Motion sickness did not occur at any time for any participant. Participants experienced a high level of exhilaration, rarely thought about others in the room, and had a high impression of presence in the generated IVR world.

Conclusion

This is the first clinical and technical feasibility study using the full IVR laparoscopy setup combined with the latest laparoscopic simulator in a 360° surrounding. Participants were exhilarated by the high level of immersion. The setup enables a completely new generation of surgical training.

     

Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation

Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a “desk-top” endoscopic physical simulator. Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). There was significant correlation between the participant’s skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.     

Telementoring versus on-site mentoring in virtual reality-based surgical training

BACKGROUND: Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training. METHODS: In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured. RESULTS: Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p < 0.05) for most tasks (grasping, cutting, suturing). No significant difference was achieved for clip-applying. CONCLUSIONS: Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.     

重视腹腔镜下动物组织模拟训练在腹腔镜培训中的作用

目的 探讨腹腔镜下动物组织模拟训练在外科学研究生腹腔镜技能培训中的作用.方法 2010年11月10日至2010年12月31日期间于中山大学各附属医院招收外科学研究生共48人,举办培训班3期,每期培训16人,每期培训12d,平均每人每天训练4h.培训内容包括腹腔镜基础理论学习、模拟操作训练、腹腔镜下动物组织(猪大肠)操作训练、手术观摩学习、模拟动物训练.在三期培训过程中对体外模拟箱操作训练和腹腔镜下动物组织(猪大肠)操作训练进行不同时间的分配,最后考核在腹腔镜下缝合与打结用时,用以比较在不同培训方法下培训效果之间的差异.结果 三期不同临床经验的研究生在接受培训后,完成拾豆、拆套橡皮筋及穿鞋带等操作的培训后用时比培训前用时明显减少,差异有统计学意义(P＜0.05).在不同的培训时间分配下,腹腔镜下猪大肠操作训练时间较多的第2期、第3期学员在培训后动物实验中腹腔镜下缝合与打结用时较分配时间少的第1期学员明显减少,差异有统计学意义(P＜0.05),而第2期与第3期相比无显著差异.结论 重视腹腔镜下动物组织模拟操作训练可提高腹腔镜培训的效果,值得推广.     

腹腔镜基础技能模拟训练的量化研究

目的比较医学生和外科低年资住院医师在腹腔镜基础技能模拟训练中的差异,为腹腔镜基础技能训练提供客观的数据。 方法通过比较医学生和低年资医师在传递、精确定位、剪切、打结及缝合打结项目中的操作时间和失误情况得分的差异,建立各自的学习曲线。 结果经过10次训练后,A、B组参与者在传递、精确定位、剪切、打结及缝合打结5个项目的得分分别是(89.81±2.07) vs(93.91±3.46)、(89.00±6.39) vs(91.21±6.69)、(84.35±5.94) vs(86.69±6.46)、(93.88±3.01) vs(93.51±2.65)、(87.34±3.22)vs (92.09±4.10)。A、B组参与者的精确定位、剪切、打结的训练结果之间无差异(P >0.05),而传递和缝合打结的训练结果之间存在统计学差异(P<0.05)。A、B组参与者在同一训练项目中第1次与第10次的训练结果之间存在差异(P<0.05)。A、B组参与者在传递、打结和缝合打结项目中呈反曲线发展,而在精确定位和剪切两个项目中呈线性发展。 结论通过训练,A、B组参与者的腹腔镜基础技能均获得显著提高,重复性的训练可以使A组在精确定位、剪切、打结的训练中达到B组的水平,A、B组参与者在传递、打结和缝合打结项目中已达到平台期,而在精确定位和剪切两个项目中仍处于增长期。     

A model for longitudinal mentoring and telementoring of laparoscopic colon surgery

Objective  To demonstrate the feasibility of longitudinal mentoring and telementoring of community surgeons in laparoscopic colon surgery. Methods  A mentoring protocol was established between a university centre and surgeons at a community hospital 60 km away. The community surgeons (CS) attended a course on laparoscopic colon surgery before observing surgery at the mentoring institution. Patients were identified from the CS practice and referred for formal consultation with the mentor. The mentor worked with the same two CS on every case in their local hospital. Procedure outcomes were recorded using Canadian Advanced Endoscopic Surgery Registry (CAESaR) practice audit software. The mentoring endpoint was 20 cases based on American Society of Colon and Rectal Surgeons (ASCRS)/Society of Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines. Results  From March 2006 to August 2007, 40 patients underwent elective colon surgery by the CS, 20 of whom were referred and accepted for laparoscopic mentoring. After nine cases the MS did not scrub. Beginning with case 15, procedures were telementored except for a subtotal colectomy for which the MS assisted. Patients selected for mentoring (7 female, 13 male) compared with open cases (8 female, 12 male) were younger (60 ± 13 years versus 72 ± 17 years, p = 0.013), less likely to have cancer (50% versus 70%, p = 0.33)) and tended to require less complex resections. There were no conversions. Mentored cases took longer (150 ± 43 min versus 108 ± 40 min, p = 0.003) but resulted in shorter hospital stay (median 2.5 versus 7.0 days, p < 0.001). Median number of lymph nodes were equivalent in cancer resections (13 versus 12, p = 0.465) There were no technical difficulties with telementoring. Data will be recorded for a further 1 year to assess adoption rate and outcomes. Conclusions  This project demonstrates the feasibility of longitudinal mentoring and telementoring of laparoscopic colon surgery for cancer. This program may serve as a model for safe technology transfer to the community. This paper was an oral presentation on April 11, 2008 at SAGES, Philadelphia, PA. An erratum to this article can be found at     

Virtual-reality-based laparoscopic surgical training: the role of simulation fidelity in haptic feedback.

Although there have been significant advances in the development of virtual-reality-based surgical simulations, there remain fundamental questions concerning the fidelity required for effective surgical training. A dual-station experimental platform was built for the purpose of investigating these fidelity requirements. Analogous laparoscopic surgical tasks were implemented on a virtual station and a real station, with the virtual station modeling the real environment with various degrees of fidelity. After measuring the subjects' initial performance on the real station, different groups of subjects were trained on the virtual station under a variety of conditions and finally tested on the real station. Experiments involved bimanual pushing and cutting tasks on a nonlinear elastic object. The results showed that force feedback results in significantly improved training transfer as compared to training without force feedback. The training effectiveness of a linear approximation model was approximately the same as that of a more accurate nonlinear model.     

Endoscopic endonasal transsphenoidal surgery: a mentoring surgical model

Background: We report the experience of endoscopic endonasal transsphenoidal surgery (EETS) for resection of pituitary region tumours at Wellington, the central regional referral centre for neurosurgery in New Zealand, and discuss the collaborative mentoring surgical model that enhanced the learning experience. Method: Between January 2007 and June 2009, a total of 47 operations on 46 patients were performed and reviewed retrospectively. All patients had perioperative clinical assessment, hormonal profile and magnetic resonance imaging studies for residual/recurrent disease. The collaborative model utilized two neurosurgeons with experience in the microsurgical resection of pituitary tumours: an endoscopic skull base fellowship trained rhinologist and an endoscopic skull base rhinologist with more experience who visited twice a year from Adelaide, Australia. Results: The pathology results included: 30 non‐functioning pituitary adenomas, 10 secreting pituitary adenomas, 3 meningiomas, 1 chordoma, 1 anterior skull base adenocarcinoma and 1 clival prostate metastasis. Complete tumour resection was intended and achieved in 38 cases. All 10 patients with secreting adenomas achieved improvement of hormonal profile. Nineteen out of 27 cases demonstrated improvement of vision. Perioperative complications included one epistaxis, three cerebrospinal fluid fistulae, one delayed chronic subdural haematoma and one persistent diabetes insipidus. Conclusion: Our results highlight the value of a collaborative mentoring surgical model for a single centre adopting the endoscopic transsphenoidal technique and demonstrate that excellent EETS outcomes can be achieved in a smaller endoscopic skull base unit in Australasia during the learning phase.     

Animate advanced laparoscopic courses improve resident operative performance

BACKGROUND: The use of animate training laboratories have been touted as an important part of a surgical resident's training. This study determines if there was any benefit in resident performance and whether that benefit persisted. METHODS: Twelve senior surgical residents attended a course in advanced laparoscopy with didactic and laboratory components. The residents' skills were tested by having them perform a laparoscopic fundoplication before, immediately after, and 6 months after the course. The procedure was videotaped, and divided into stages that were timed and scored by a single, masked observer. RESULTS: Overall performance score was 35.7 +/- 2.5 for the pretest, improving to 16.5 +/- 1.2 (P <0.05) immediately after the course, and 23.7 +/- 5.1 (P <0.05) at 6 months. Significant improvements were seen with trocar insertion, crural closure, division of short gastric arteries, and fundoplication. CONCLUSIONS: The data presented demonstrate significant and persistent improvement in laparoscopic operative skills as a result of focused laboratory skill training.     

Hand assisted laparoscopic training for postgraduate urologists: the role of mentoring

PURPOSE: Hand assisted laparoscopy (HAL) has recently been accepted as a safe alternative for nephrectomy. HAL courses have been offered at several institutions to train novice laparoscopic surgeons in this minimally invasive surgical procedure. Mentoring by a course instructor or an experienced laparoscopist provides assistance to surgeons with their initial operation. However, to our knowledge the impact of mentoring on the clinical practice of HAL is not known. Therefore, we evaluated the clinical practice patterns of urologists following a postgraduate HAL course, comparing course graduates who underwent subsequent mentoring with those who were not mentored. MATERIALS AND METHODS: A total of 71 urologists attended a postgraduate training course in HAL at our institution between March 2002 and October 2002. Graduates were given the opportunity for one of the instructors to travel to their home institution and mentor them during their initial case(s). Followup surveys were mailed to the graduates in March 2003 to evaluate their practice patterns. Responses from returned surveys were entered into a dedicated database and data analysis was performed. RESULTS: Of the 71 surveys mailed 56 were returned (79%). The majority of respondents (91%) described themselves as community based general urologists. Respondents were categorized into 1 of 2 groups, namely group 1-those who had mentoring by a course instructor (23.2%) or another experienced laparoscopist (30.4%) and group 2-those who were not mentored (46.4%). The majority of group 1 respondents (93%) reported that they were still performing laparoscopic procedures at 6 months of followup. However, only 44% of the surgeons in group 2 were performing laparoscopy at 6 months. The majority of surgeons in group 1 (72%) reported that their laparoscopic experience had been sufficient to maintain their expertise compared to only 42% in group 2. CONCLUSIONS: Mentoring provides a useful adjunct to postgraduate urological training and the integration of laparoscopic techniques into the community based practice of urology.     

Videotape feedback in teaching laryngoscopy

Purpose  To evaluate if videotape feedback provides educational insights for students learning laryngoscopy that they would not otherwise perceive. Methods  Twenty-six medical students were videotaped while performing laryngoscopy for oral intubation. Before and after reviewing their performance on the videotape, they answered a standardized questionnaire assessing the adequacy of positioning, head movement during laryngoscopy, degrees of neck flexion and head extension, time elapsed, and whether the laryngoscope contacted the upper lip or teeth. After the review, they were asked if being videotaped was distracting, whether it provided new instructional insights and, if so, which was most important. Results  Only 4% of students felt that initial head and neck positioning was suboptimal and this increased to 38% after videotape review (P = 0.029). The perceived inadequacy of positioning seemed related to initial overestimation of head extension (34.0 ± 15°) compared with that seen on videotape (21.5 ± 13.5°, P = 0.003). The estimated duration of laryngoscopy was underestimated (55 ± 32 sec vs. 75 ± 29 sec, P= .024) before videotape review. Although 26.9% (7/26) of students admitted feeling distracted by the video camera, all felt the expenence had educational value. Conclusion  Videotape feedback changed students’ perception of how they performed laryngoscopy. In particular, head extension was overestimated and duration of laryngoscopy underestimated.

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Résumé Objectif  évaluer si le feed-back par vidéocassette procure aux étudiants en apprentissage de la laryngoscopie une perception de l’intubation qu’ils ne pourraient obtenir autrement. Méthodes  Vingt-six étudiants en médecine ont été filmés sur vidéocassette pendant une laryngoscopie pour intubation orale. Avant et après avoir assisté à leur prestation sous vidéocassette, ils ont répondu à un questionnaire standard sur la validité de la position, les mouvements de la tête pendant la laryngoscopie, le degré de flexion du cou et d’extension de la tête, le temps écoulé et si le laryngoscope faisait contact avec la lèvre supérieure ou les dents. Après avoir visionné la cassette, on leur a demandé si le fait d’être filmé les avait dérangés, si cette méthode favorisait, oui ou non, l’approche pédagogique à l’intubation et, le cas échéant, qu’estce qui pour eux était le plus important. Résultats  Avant la représentation de la vidéocassette, seulement 4% des étudiants pensaient que la position de la tête et du cou était inadéquate ; cette proportion passait à 38% après la représentation (P=0,029). La perception qu’ils avaient d’une erreur de position semblait en rapport avec une évaluation initiale exagérée de l’extension céphalique (34,0± 15°) comparativement à ce qu’ils voyaient sur la cassette (21, 5± 13, 5° P=0.003). La durée de la laryngoscopie était sous-estimée (55±32 sec vs 75±29, P=0, 024) avant la représentation de la vidéocassette. Bien que 26.9% (7/26) des étudiants aient admis avoir été distraits par la camera, tous pensaient que l’expérience avait une valeur pédagogique. Conclusion  Le feed-back sur vidéocassette a changé la perception qu’avaient les étudiants de leur performance en laryngoscopie. Lextension de la tête et la durée de la laryngoscopie ont été particulièrement sousestimées.

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Presented at the 1996 Canadian Anaesthetists’ Society annual meeting, Montréal, Québec.     

Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses

BACKGROUND: Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. METHODS: Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. RESULTS: Overall, trainees made significant improvements in path length (P=.006), number of movements (P<.001), and time taken (P<.001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. DISCUSSION: Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy.     

Outcome of patients in laparoscopic training courses compared to standard patients

Background & aimCurrent Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk.MethodsThis was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n = 51] and Laparoscopic Inguinal Hernia (LIH) [n = 62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n = 51) and LIH (n = 62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months).ResultsIn the LC cohort, there was no significant difference in the length of hospital stay (p = 0.07) or readmission (p = 0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p = 0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p > 0.05) and early post-operative recurrence of hernia (p > 0.05).ConclusionThe post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.     

Analysis of errors in laparoscopic surgical procedures

Background: The determination of laparoscopic surgeon ability is essential to training error avoidance. The present study describes a practical method of surgical error analysis. Methods: After review of practice videotapes of the excisional phase of laparoscopic cholecystectomy, consensus on the identification of eight errors was achieved. Interrater agreement at the end of this phase was 84–96%. Fourteen study videotapes of gallbladder excision were then observed independently by expert reviewers blinded to surgical team identity. Procedures were assessed using a scoring matrix of 1-min segments with each error reported each minute. Results: Interrater agreement was 84–100% for all error catagories. Conclusions: The present study demonstrates that excellent interrater agreement of procedural errors can be achieved by carefully defining and training recognition of targeted events. Extension of this simple and reliable analysis tool to other procedures should be feasible to define behaviors leading to adverse clinical outcomes.