Methodological considerations in the application of virtual reality simulation for coronary artery bypass graft planning

Simulation-based teaching is an integral feature within medical education and following the emergence of virtual simulation, an array of possibilities exists for educators to choose between. However, evidence informing their use is scarce, particularly regarding outcomes assessing user experience and knowledge acquisition, and experimental studies comparing different approaches to virtual simulation. Therefore, this study compared immersive virtual reality (VR) simulation to computerized virtual patient (VP) simulation measuring their effect on knowledge acquisition and retention, as well as user experience, in fifth-year medical students. This pilot study, of a randomized crossover design, comprised 18 participants independently completing an immersive VR simulation and a computerized VP simulation. All participants completed the same two scenarios and received an induction to both modalities. Multiple-choice questions were employed to assess knowledge acquisition and retention, with participants completing the questions immediately before and after the simulation and following a 12-week interval. User experience questionnaires were completed after the simulation, utilizing both Likert scale and open-ended questions. Statistical analysis comprised a Student’s Both interventions achieved statistically significant levels of knowledge acquisition and retention. However, VR simulation achieved higher levels of acquisition (2.11; 95% CI = 0.89, 3.32, The findings indicated that both interventions are effective and acceptable educational tools. However, learning does not appear to be uniform across different virtual simulators, with participants achieving higher levels of learning following immersive VR simulation. Moreover, participants reacted significantly more positively to VR simulation, though potential applications were identified for both interventions. This study highlights the importance of an evidence-based approach to the implementation of novel simulation technologies. The findings contribute to an underexplored area of the literature and offer a step towards enabling medical educators to make an informed decision regarding the application of virtual simulation in their context.

Virtual reality can be applied preoperatively by surgeons to gain precise insights into a patient's anatomy for planning minimally invasive coronary artery bypass grafting (CABG) with in situ arterial grafts. This study aimed to examine virtual reality simulation for minimally invasive CABG with in situ arterial grafts. Preoperative stereolithographic files in 35 in situ arterial grafts were converted using 320-slice computed tomography and workstation. The accurate length and direction of each graft were confirmed through virtual reality glasses. The simulation of graft designs was performed by using an immersive virtual reality platform. The mean harvested lengths of in situ left internal thoracic artery (n = 17), right internal thoracic artery (n = 12), and gastroepiploic artery (n = 6) grafts predicted by virtual reality simulation were 21.4 ± 3.4 cm, 21.2 ± 3.6 cm, and 22.8 ± 4.8 cm. The required lengths of these grafts predicted by virtual reality simulation were 15.8 ± 2.3 cm, 16.4 ± 2.1 cm, and 14.5 ± 4.4 cm. Minimally invasive CABG using virtual reality simulation was completed in 17 patients, of whom 16 patients underwent aortic no-touch total arterial CABG. The surgical strategy was adjusted in 11.8% of the cases due to the 3-dimensional virtual reality-based anatomy evaluation. The early mortality and morbidity were 0%, and the patency of the graft was 100%. The median time to return to full physical activity was 7.1 days. This study demonstrated the successful development and clinical application of the first dedicated virtual reality platform for planning aortic no-touch total arterial minimally invasive CABG. Virtual reality simulation can allow the accurate preoperative understanding of anatomy and appropriate planning of the graft design with acceptable postoperative outcomes.

Hazard identification and risk assessment are at the core of an effective health and safety system. Despite this fundamental, during incident and accident investigation risk assessment processes are sometimes not used effectively and found to be deficient. The challenge facing both individuals and organizations is that individual risk tolerance and perception of hazards varies significantly according to a host of factors including social and personal values as well as prior experience and beliefs. To truly drive a reduction in incidents a variety of methods need to be used to ensure that workers are aware of the hazards, the risks and the consequences of action/inaction. This will also enable individuals to become aware of their own risk perception and how other factors can affect ones acceptance of risk thereby changing their risk taking behaviour. This paper presents an innovative method measuring task based risk perception in the form of a computer virtual reality simulation. While not widely used in the oil and gas industry the application of a computer simulation has been valuable in other contexts, such as testing of risk perception in drivers and pilots. This simulation is based on the physical location of a marine based rig during routine rig operations. This simulation therefore gives an important insight into the hazard identification, risk evaluation and risk awareness in the offshore context. Experiences from the application of the simulator are shared and some of the methods of reinforcing the lessons learnt are also discussed. Possible further developments are considered and in particular how this simulation can be used in the context of both new employees with lack of experience, and experienced staff who may be complacent, as the both groups are vulnerable.

Validating an augmented reality application in a virtual reality simulation can offer many advantages compared to testing in real conditions and can speed up development processes. With such a simulation, developers and designers do not need to have constant physical access to the real place. They can save physical navigation, experiment with different kinds of devices and isolate testing parameters. While the validity of functional testing in virtual reality simulations is not particularly challenged, the validity of such simulations to evaluate user experience and usability, similarly as in real conditions, still needs to be assessed. We then conducted a user study to explore the validity of evaluating these criteria with a virtual reality simulation tool and the importance of simulation fidelity for that purpose. Indeed, we also seek to determine whether it is necessary to simulate the limited field of view of augmented reality glasses and if the simulation can take place in a virtual world that is not a replica of the real targeted environment. To do so, we have developed an augmented reality application for smart-homes where a user can interact with different connected objects. One group of users performed the experiment in the real place with augmented reality glasses and three other groups performed the same experiment in virtual reality with various simulation conditions (field of view and environment). Users’ subjective feedback and quantitative results only highlight very few differences between real-world conditions and simulation in virtual reality, whatever the simulation parameters used. These results suggest the interest in using virtual reality simulation to evaluate an augmented reality application but should be confirmed on other use cases and interaction tasks.

Introduction: The last decade saw a significant introduction of minimally invasive surgery into medical practice. Laparoscopy has even become the gold standard for some interventions. This has led to an increased demand for qualified specialists. The acquisition of laparoscopic surgery skills entrains a time investment both on part of the trainee and the instructor. The need for an accelerated development of specific psycho-motor perceptions which are a requirement for the execution of laparoscopic procedures, led to the establishment of virtual reality simulator training. For the first time in Bulgaria, in 2016, the Medical University of Varna introduced formal education via the way of virtual reality laparoscopic simulators. They permit the development of laparoscopic skills even at the level of a medical student. Aim: The aim of the article is to analyze the efficiency of existing virtual reality simulators and their application in laparoscopic surgery training. Materials and Methods : А systematic literature analysis was performed via the databases PubMed , Web of Science , Scopus and Google Scholar using various combinations of the following keywords: “simulation”, “virtual*”, “VR”, “laparoscopic*”, “surgery”, “education”, “LapMentor”, “LapSim”, for articles published in the past 10 years. The keywords were in combination with Boolean operators “and”, “or”. After a thorough review of all pertinent articles the most relevant publications were selected. Results: The electronic inquiry yielded 106 articles in total. After the application of suitable inclusion and exclusion criteria, 98 of them were deemed unfit, leaving 8 randomized control trials. To meet the inclusion criteria, the publications needed to be systemized random prospective studies regarding virtual reality simulators in laparoscopic surgery. Conclusion: Advancements in the field of surgery follow closely the introduction of new technologies. This leads to the need for a change of traditional surgery training practices. The need of laparoscopic surgery specialists becomes greater with every passing year. The new generation of virtual reality simulators provides a complete set of basic skill procedures and complete operative procedures. Due to their limitless repeatability, an expert level of proficiency is able to be reached in a relatively short period of time. The surgical community must take note of the practices that have already been adopted by aviation training and introduce mandatory laparoscopic surgery training programs, which all specialists must undergo before undertaking procedures in the operating theater.

Objective To investigate the application of simulation in the training and assessment of North American specialists, and to discuss the problems and development of simulation used in specialist training and assessment in China. Methods Literature investigation and expert discussion. Results Simulation technology has been widely used in the training and certification of various specialties. In general, it used as a requirement for certification, maintenance of certification or in training process. The application of simulation in the training of specialists in China is just in the initial stage, and the main problems are lack of attention, inadequate investment, non-standard curriculum development and lack of teachers. Conclusions The application of simulation in North America specialist training and assessment is relatively deep, but in China it is still in its infancy. There is still much to do to get a better result. Key words: Medical simulation; North American; Specialist; Training; Certification

This study aimed to explore the educational impact of virtual reality (VR) simulation compared to high-fidelity (HF) simulation. Recently, VR simulation has been integrated into medical education, offering advantages such as cost- and space-efficiency, accessibility, and autonomy, enabling self-directed, repeated practice. Prior research comparing VR and HF simulations has focused primarily on knowledge acquisition, skill development, and learner satisfaction. Given that medical students often experience low confidence and high anxiety during clinical transitions, it is essential to examine the VR simulation’s impact on these emotional factors and students’ subjective experiences. This study investigated the effects of VR and HF simulations on anxiety, confidence, engagement, and perceived learning using multiple-item self-report scales. Data were analyzed using independent t-tests to compare the two simulation methods. The study included 40 fifth-year Korean medical students in a pediatric clerkship. Participants completed both VR and HF simulations, followed by a questionnaire assessing these variables. Results showed no statistically significant differences between VR and HF simulations across the measured domains. However, item-level analysis indicated slightly higher anxiety in VR simulation but greater perceived learning in cognitive domain, suggesting that VR may be more beneficial for cognitive learning compared to HF simulation. As VR simulation has only recently been incorporated into medical education, this study represents a first attempt to compare its impact with that of HF simulation focusing on subjective outcomes. Although no significant differences were found, the cost and space efficiency of VR simulation along with its support for autonomous learning underscore the need for further research, particularly on students’ experiences, and learning objectives.

Background: Intrapartum asphyxia accounts for the deaths of around 280,000 babies per year. Helping Babies Breathe® (HBB) is an evidence-based global neonatal resuscitation training program. HBB utilizes an in-person dissemination model. However, there are challenges to maintaining training fidelity, data collection, and continuous learning and improvement. Aim: The objective is to develop and test an integrated mobile virtual reality (VR) simulation application (eHBB) and data collection tool (mHBS) for healthcare worker training in neonatal resuscitation. Methods: eHBB, a VR training application developed on the Unreal™ platform and accessible on mobile devices …

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Objective To assess the validity of virtual-reality simulator UroMentorTM in skill training of ureteroscopy. Methods Thirty urologists were included and divided into groups A (n =18) and B (n =12 ) based on former ureteroscopy experience ( ≥ 20 or ＜ 20).Participants were assessed on their ability to perform cystoscopy,gnidewire insertion,semirigid ureteroscope advancement and basket extraction of a distal ureteric stone on the simulator.A blinded examiner assessed the subjects' performance using global rating scale (GRS).In addition,computer-generated parameters including time to complete the task,endoscope and instrument trauma,and the number of attempts to insert a guidewire were recorded as pretest.After 2 days of simulator training,they were retested with the same task. Results All participants had reduced time to completion (333 ± 32 s & 228 ± 18 s,P =0.001 ) and improved GRS (24.4 ± 2.1 & 28.1 ±1.2,P =0.010).Differences were significant between the two groups in the time to completion (before 405 ±40 s & 262 ±22 s,P =0.014; after 276 ± 12 s & 179 ±9 s,P =0.000),and GRS (before 19.6 ±2.5 & 29.2 ± 1.3,P =0.009 ; after 25.0 ± 1.1 & 31.2 ± 0.7,P =0.002).Previous ureteroscopy experience was correlated to GRS (before r=0.705,after r=0.756). Conclusion The UroMentor virtual-reality simulator is an appropriate and useful tool in training and assessing the skills of ureteroscopy. Key words: Ureteroscopes ; Teaching; Virtual-reality; Simulator; Skill training

Dear Madam, Virtual reality (VR) is an emerging technology that utilizes artificial intelligence (AI) - powered graphics to create realistic simulations. One of the most critical objectives in medical education is to optimize the quality of training and practical proficiency, and also to minimise errors. Coronary Artery Bypass Grafting (CABG) is a complex surgical procedure that involves a high level of technical expertise, as even minor deviations can have a substantial detrimental effect on patient outcomes. As a result, VR emerges as a valuable tool in the healthcare system, improving patient rehabilitation, surgical accuracy, and healthcare worker training, particularly for complex operations such as CABG. VR (Virtual Reality) can be used by Surgeons to precisely plan minimally invasive treatments using in situ artery grafts by employing virtual reality to evaluate patient-specific anatomy before surgery in CABG. Virtual reality makes it easier to evaluate anatomical features precisely before surgery and improves graft design planning. In a study employing 3D VR for minimally invasive CABG, 100% graft patency, no early complications, and a 7.1-day recovery were observed, with the surgical plan modified in just 11.8% of cases(1). An analysis of research conducted between 2000 and 2021 found that there is strong evidence to support the use of immersive virtual reality (VR) in surgical training, with improvements in procedure times, accuracy, user satisfaction, and cost-effectiveness(2). VR training can also help reduce surgical errors by increasing physicians’ competence, which improves decision-making, skills, and knowledge, and results in safer surgeries(3). Virtual reality (VR), particularly in cardiac surgery training, has gained significant popularity in recent years.. By reducing surgical error rates by 40%, virtual reality training has been shown to improve patient safety and the overall efficacy of the healthcare system(4)Hence, Virtual reality, along with dry-lab simulations, can transform medical education by providing advanced resources for procedural training, re-credentialing, and pre-operative planning. It is seen to improve accuracy, lower surgical errors, and refine techniques, especially for complex procedures such as coronary artery bypass grafting Integrating VR into medical training will make surgeries safer, recovery times shorter, and patient outcomes better.

To the Editor:With great interest, we have read the article of Fan and colleagues 1 on the effects of biatrial pacing in the prevention of postoperative atrial fibrillation after coronary artery bypass surgery.By measuring P-wave duration from 12-lead surface ECGs and calculating P-wave dispersion, they found that biatrial pacing resulted in a more significant reduction in P-wave dispersion when compared with single-site atrial pacing.Although these results are interesting, we believe that they should be considered cautiously because of the limited accuracy of electrocardiographic measurements performed manually on paper-printed ECGs obtained at a standard signal size and paper speed.Our research group has introduced P-wave dispersion as a simple electrocardiographic predictor of paroxysmal lone atrial fibrillation. 2Although acceptable intraobserver and interobserver errors in the measurement of P-wave duration in 12-lead ECGs have been reported, 2 well-known difficulties in defining P-wave onset and offset may restrict the accuracy and reproducibility of the measurements.To overcome some of these restrictions, we introduced a more advanced technology-assisted method that enables us to measure P-wave duration from digitally recorded and stored ECG data. 3A computer-based ECG system is used, which records all 12 ECG leads simultaneously at a sampling rate of 1200 Hz and with 12-bit analog-to-digital conversion. 3 A sufficient sampling rate and amplitude resolution are necessary for high-resolution ECG analysis.For each lead, the average complex is calculated, and P-wave duration is measured manually from the average complexes displayed on a high-resolution computer screen. 3 To compare the different methods for manual P-wave duration measurement in 12-lead ECGs, another study was conducted. 4 The conclusion reached was that manual measurement of P-wave duration in standard 12-lead ECGs is feasible and more stable and reliable when performed on the high-resolution screen of a digital ECG system than with more conventional methods involving paper-printed ECGs. 4 Therefore, manual measurement of P-wave duration performed on standard paper-printed ECGs is of limited accuracy.To achieve greater precision in measuring P-wave duration from 12-lead ECGs obtained and stored on paper, we believe that scanning and digitizing ECG signals from paper records using an optical scanner is a feasible and accurate alternative method.

Purpose:To evaluate the cost-effectiveness of phacoemulsification simulation training in virtual reality simulator and wet laboratory on operating theater performance.Methods:Residents were randomized to a combination of virtual reality and wet laboratory phacoemulsification or wet laboratory phacoemulsification. A reference control group consisted of trainees who had wet laboratory training without phacoemulsification. All trainees were assessed on operating theater performance in 3 sequential cataract patients. International Council of Ophthalmology Surgical Competency Assessment Rubric—phacoemulsification (ICO OSCAR phaco) scores by 2 masked independent graders and cost data were used to determine the incremental cost-effectiveness ratio (ICER). A decision model was constructed to indicate the most cost-effective simulation training strategy based on the willingness to pay (WTP) per ICO OSCAR phaco score gained.Results:Twenty-two trainees who performed phacoemulsification in 66 patients were analyzed. Trainees who had additional virtual reality simulation achieved higher mean ICO OSCAR phaco scores compared with trainees who had wet laboratory phacoemulsification and control (49.5 ± standard deviation [SD] 9.8 vs 39.0 ± 15.8 vs 32.5 ± 12.1, P < .001). Compared with the control group, ICER per ICO OSCAR phaco of wet laboratory phacoemulsification was $13,473 for capital cost and $2209 for recurring cost. Compared with wet laboratory phacoemulsification, ICER per ICO OSCAR phaco of additional virtual reality simulator training was US $23,778 for capital cost and $1879 for recurring cost. The threshold WTP values per ICO OSCAR phaco score for combined virtual reality simulator and wet laboratory phacoemulsification to be most cost-effective was $22,500 for capital cost and $1850 for recurring cost.Conclusions:Combining virtual reality simulator with wet laboratory phacoemulsification training is effective for skills transfer in the operating theater. Despite of the high capital cost of virtual reality simulator, its relatively low recurring cost is more favorable toward cost-effectiveness.

The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery. This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills. There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.

User evaluation of a virtual reality simulation for anaesthesiologists-intensivists for non-technical skills☆