Surgical Simulation Training Research Articles

Training novice robot surgeons: Proctoring provides same results as simulator-generated guidance.

To understand the influence of proctored guidance versus simulator generated guidance (SGG) on the acquisition dexterity skills in novice surgeons learning RAS (robot assisted surgery). Prospective non-blinded 3-arm randomised controlled trial (RTC). Exclusion criteria: previous experience in RAS or robotic surgery simulation. The participants were assigned to three different intervention groups and received a different form of guidance: (1) proctored guidance, (2) simulator generated guidance, (3) no guidance, during training on virtual reality (VR) simulator. All participants were asked to complete multiple questionnaires. The training was the same in all groups with the exception of the intervention part. Catharina Hospital Eindhoven, The Netherlands. A total of 70 Dutch medical students, PhD-students, and surgical residents were included in the study. The participants were randomly assigned to one of the three groups. Overall, all the participants showed a significant improvement in their dexterity skills after the training. There was no significant difference in the improvement of surgical skills between the three different intervention groups. The proctored guidance group reported a higher participant satisfaction compared to the simulator-generated guidance group, which could indicate a higher motivation to continue the training. This study showed that novice surgeons. Significantly increase their dexterity skills in RAS after a short time of practicing on simulator. The lack of difference in results between the intervention groups could indicate there is a limited impact of "human proctoring" on dexterity skills during surgical simulation training. Since there is no difference between the intervention groups the exposure alone of novice surgeons to the robotic surgery simulator could possibly be sufficient to achieve a significant improvement of dexterity skills during the initial steps of RAS learning.

Morphometric and density comparisons of Bos taurus scapulae as a proxy to human frontal crania

BackgroundIn the absence of cadaveric tissues, forensic simulation, trauma modelling, and cranial surgical training necessitates a surrogate for the human calvaria. This study investigates the validity of Bos taurus scapulae as a proxy for human frontal bones by comparing the laminar and cancellous bone thickness, as well as the bone mineral density (BMD) of cadaveric frontal bones and adult Bos taurus scapulae.ResultsThis study aimed to validate the bovine scapulae as a valid proxy for forensic experiments, which benefit researchers and investigators who need to recreate forensic scenarios where synthetic proxies are found unsuitable due to their non-viscoelastic nature and cadaveric human models are unavailable due to ethical restrictions. Our results identified different total thicknesses of the relative bones, but non-different cortical measurements between human frontal bone and bovine scapulae. The bone mineral density is similar between both groups.ConclusionThis study has found Bos taurus scapulae to be a suitable proxy for human frontal bones as it has a similar morphology with regard to thickness and structure as well as a comparable density. However, there is a significant difference between the cancellous bone, and therefore, the overall thickness.

Simulation in Surgical Trauma Training

Simulation is an important part of surgical trauma training with continued advancement in techniques and incorporation of these techniques into established education methods. This review details ways in which simulation is used in current surgical trauma training. There have been new developments in specific simulation techniques used in existing training programs. Additionally, there is ongoing development of more advanced simulation utilizing virtual reality training. Simulation is incorporated in surgical trauma training in a variety of ways. It is used for specific surgical techniques, it is included in several national trauma courses, it is used for team training, and it is used to teach communication skills. There are continued advances being made in the area of surgical trauma simulation including the use of virtual reality.

A multi-camera, multi-view system for training and skill assessment for robot-assisted surgery.

This paper introduces the concept of using an additional intracorporeal camera for the specific goal of training and skill assessment and explores the benefits of such an approach. This additional camera can provide an additional view of the surgical scene, and we hypothesize that this additional view would improve surgical training and skill assessment in robot-assisted surgery. We developed a multi-camera, multi-view system, and we conducted two user studies ([Formula: see text]) to evaluate its effectiveness for training and skill assessment. In the training user study, subjects were divided into two groups: a single-view group and a dual-view group. The skill assessment study was a within-subject study, in which every subject was shown single- and dual view recorded videos of a surgical training task, and the goal was to count the number of errors committed in each video. The results show the effectiveness of using an additional intracorporeal camera view for training and skill assessment. The benefits of this view are modest for skill assessment as it improves the assessment accuracy by approximately 9%. For training, the additional camera view is clearly more effective. Indeed, the dual-view group is 57% more accurate than the single-view group in a retention test. In addition, the dual-view group is 35% more accurate and 25% faster than the single-view group in a transfer test. A multi-camera, multi-view system has the potential to significantly improve training and moderately improve skill assessment in robot-assisted surgery. One application of our work is to include an additional camera view in existing virtual reality surgical training simulators to realize its benefits in training. The views from the additional intracorporeal camera can also be used to improve on existing surgical skill assessment criteria used in training systems for robot-assisted surgery.

Efficacy and Validity of Orthopaedic Simulators in Surgical Training: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The purpose of this study was to perform a systematic review and meta-analysis of the effects of training simulators on surgical skill measures across randomized controlled trials. The authors hypothesized that simulated training would (1) result in objective improvements in skill acquisition and (2) be heterogeneous regarding the outcomes and types of validity assessed. The Cochrane Database of Systematic Reviews, the Central Register of Controlled Trials, PubMed, EMBASE, and MEDLINE databases were queried for Level I studies on training simulators between 2007 and 2019 in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Exclusion criteria were studies without discrete assessment of skills acquisition after surgical simulator training and level of evidence II to V. The Jadad scale was used to assess the methodological quality of all included articles. Data pertaining to patient demographics, validity measures, simulator types, and study-specific outcome measures were extracted. Meta-analyses adjusted for random effects and heterogeneity analyses (I) were used to compare pooled time-to-completion and performance outcomes among included studies. A total of 24 studies with 494 participants were identified. The most common simulator type involved knee arthroscopy (11 studies, 45.8%). Eight studies reporting time-to-task completion and performance scores were included in the meta-analysis. Virtual reality training was favored in time-to-task completion (mean difference = -82.25 seconds, P = 0.002) and improvement in objective performance scores (mean difference = 1.24, P = 0.02) relative to traditional training. Sensitivity analysis of time-to-task completion based on the length of training interval revealed a mean difference of -45.24 (P = 0.07) and -137.74 (P < 0.001) seconds for the short-term and immediate posttesting subgroups, respectively. Overall, improved task efficiency and performance were observed with the use of orthopaedic simulators. However, simulator type, training protocols, and outcome measures were heterogeneous. Future studies are warranted to evaluate financial cost and longitudinal training programs and to standardize outcomes regarding the use of simulators in orthopaedic education. Level I.

Comment on: Systematic review of the current status of cadaveric simulation for surgical training

Comment on: Systematic review of the current status of cadaveric simulation for surgical training

Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training.

Reduced work hours and funding have fueled an increase in simulation-based training for plastic and orthopedic surgery residency programs. Unfortunately, certain simulation training can fail to enhance surgical skills because of availability, cost, or low fidelity. There is a growing interest among training programs for a cost-effective surgical simulator to improve basic skills and muscle memory of residents. The authors developed a three-dimensionally-printed, malleable, and anatomically accurate hand surgery simulator from a computed tomographic scan of an adult male subject. The bone matrix was specifically designed to provide proprioceptive feedback to hone drilling skills used in fracture repair and arthrodesis. The silicone soft-tissue covering provides excellent malleability to dissect and perform fracture-reducing maneuvers. Three-dimensional printing of "fracture bridges" allows the design of on-demand polyfracture models so the trainee can practice multiple types and locations of repairs as skills progress. To summarize, the authors' hand simulator is an anatomical, low-cost, multiprocedure tool that can be used to improve the muscle memory and basic surgery skills of residents in training.

Emergency surgical obstetrics simulation training: an ex vivo low-cost model using bovine uterus and porcine bladder for haemostatic uterine brace suture techniques

Postpartum haemorrhage remains a leading cause of maternal mortality and morbidity. While conventional obstetrics training curricula describe at length the management of postpartum haemorrhage, obstetrics trainees rarely have exposure to...

Training benchmarks based on validated composite scores for the RobotiX robot-assisted surgery simulator on basic tasks

The RobotiX robot-assisted virtual reality simulator aims to aid in the training of novice surgeons outside of the operating room. This study aimed to determine the validity evidence on multiple levels of the RobotiX simulator for basic skills. Participants were divided in either the novice, laparoscopic or robotic experienced group based on their minimally invasive surgical experience. Two basic tasks were performed: wristed manipulation (Task 1) and vessel energy dissection (Task 2). The performance scores and a questionnaire regarding the realism, didactic value, and usability were gathered (content). Composite scores (0–100), pass/fail values, and alternative benchmark scores were calculated. Twenty-seven novices, 21 laparoscopic, and 13 robotic experienced participants were recruited. Content validity evidence was scored positively overall. Statistically significant differences between novices and robotic experienced participants (construct) was found for movements left (Task 1 p = 0.009), movements right (Task 1 p = 0.009, Task 2 p = 0.021), path length left (Task 1 p = 0.020), and time (Task 1 p = 0.040, Task 2 p < 0.001). Composite scores were statistically significantly different between robotic experienced and novice participants for Task 1 (85.5 versus 77.1, p = 0.044) and Task 2 (80.6 versus 64.9, p = 0.001). The pass/fail score with false-positive/false-negative percentage resulted in a value of 75/100, 46/9.1% (Task 1) and 71/100, 39/7.0% (Task 2). Calculated benchmark scores resulted in a minority of novices passing multiple parameters. Validity evidence on multiple levels was assessed for two basic robot-assisted surgical simulation tasks. The calculated benchmark scores can be used for future surgical simulation training.

Development and Evaluation of Pediatric Mixed-Reality Model for Neuroendoscopic Surgical Training

Neurosurgical training requires several years of supervised procedures and represents a long and challenging process. The development of surgical simulation platforms is essential to reducing the risk of potentially intraoperative severe errors arising from inexperience. To present and perform a phase I validation process of a mixed reality simulation (realistic and virtual simulators combined) for neuroendoscopic surgical training. Tridimensional videos were developed by the 3DS Max program. Physical simulators were made with a synthetic thermoretractile and thermosensible rubber, which, when combined with different polymers, produces >30 different textures that simulate consistencies and mechanical resistance of human tissues. Questionnaires regarding the role of virtual and realistic simulators were applied to experienced neurosurgeons to assess the applicability of the mixed-reality simulation for neuroendoscopic surgical training. The model was considered as a potential tool for training new residents in neuroendoscopic surgery. It was also adequate for practical application with inexperienced surgeons. According to the overall score, 83% of the surgeons believed that the realistic physical simulator presents distortions when compared with the real anatomic structure, afterwards the model improved 66% tridimensional reconstruction and 66% reported that the virtual simulator allowed a multiangular perspective ability. This model provides a highly effective way of working with 3-dimensional data and significantly enhances the learning of surgical anatomy and operative strategies. The combination of virtual and realistic tools may safely improve and abbreviate the surgical learning curve.

Hyper-realistic and immersive surgical simulation training environment will improve team performance

BackgroundSurgical trauma care requires excellent multidisciplinary team skills and communication to ensure the highest patient survival rate. This study investigated the effects of Hyper-realistic immersive surgical team training to improve...

Fast or safe? The role of impulsiveness in laparoscopic simulator performance

BackgroundLittle is known about the relation between impulsiveness and surgical performance even though research in similar high-risk/high-skills shows evidence of more hazardous behavior by impulsive professionals. We investigated the impact of impulsiveness on laparoscopic simulator performance. MethodsEighty-three subjects participated in a four-session laparoscopic training course. Based on the Eysenck Personality test, we created equal sized high- and low impulsiveness groups and compared task duration and errors on tasks for two laparoscopic simulators. ResultsThe low impulsiveness group outperformed the high impulsiveness group on damage on the LapSim virtual reality trainer (U = 459, p < .049), and showed a trend towards better error performance on the FLS videotrainer. We found no differences on task duration. ConclusionsIn surgical simulation training, high impulsiveness is associated with creating more damage, but not with faster performance. Time needed to correct errors may have obscured faster performance in the high impulsiveness group. Summary for the table of contentsSubjects were divided into high- and low impulsiveness groups based on the Eysenck Impulsiveness Inventory test. Performance (time and errors) were compared between groups for tasks on the LapSim virtual reality trainer and FLS videotrainer. Low impulsive subjects outperformed high impulsive subjects on errors.

The impact of tiredness on virtual reality robotic surgical skills.

IntroductionThe effect of tiredness has been proved for the surgeons’ musculature performing laparoscopic or robotic procedures (physical stress). Mental stress after robotic surgery has been reported as well. It is still unclear how much the surgical skills are altered and which types of skills are more affected at the final steps of long, complex robotic surgical procedures.AimTo evaluate to what extent the surgeon’s skills are influenced by long procedures, using the objective assessment of different surgical skills by a virtual reality robotic simulator.Material and methodsFifteen surgeons were asked to perform a continuous 4 h virtual robotic surgical simulator training session. At the beginning of simulator training and at the end of each of the 4 h of training, three exercises of increasing difficulty were selected to be performed in order to assess the surgeons’ skills.ResultsThere were statistically significant differences between the initial and final overall scores for all the three exercises, the final outcomes being inferior. The specific metrics for each exercise slightly improved within 1 h from the beginning and thereafter decreased to a statistically significantly inferior value.ConclusionsThe specific metrics on the virtual reality robotic surgical simulator were altered after a 4-hour console training period. Further larger and more complex studies are necessary to evaluate the translation from the simulator to real-life robotic surgery.

The efficacy of immersive virtual reality surgical simulator training for pedicle screw placement: a randomized double-blind controlled trial.

To verify whether the pedicle screw placement (PSP) skills of young surgeons receiving immersive virtual reality surgical simulator (IVRSS) training could be improved effectively and whether the IVRSS-PSP training mode could produce a real clinical value in clinical surgery. Twenty-four young surgeons were equally randomized to a VR group and a NON-VR group. Participants in VR group received IVRSS-PSP training, and those in NON-VR group used the conventional model of observing a spinal model first and then watching a teaching video of spinal surgery for 40minutes x five. The nailing outcome of the participants before and after training was evaluated by statistical analysis in both groups. Post-training data analysis showed that the success rate and accuracy rate of screw placement in VR group and NON-VR group were 82.9% and 69.6% vs. 74.2% and 55.4%, respectively, showing statistically significant differences between the two groups by chi-square test (P < 0.05). The present study demonstrated that IVRSS-PSP was helpful to improve the success rate of PSP for young surgeons, and may provide valuable reference for PSP training of young surgeons. In addition, our study also showed a promising potential of the VR technology in surgical simulation training.

Simulation virtuelle pour l’apprentissage de la chirurgie de cataracte

The training in phacoemulsification cataract surgery in our context requires a long learning curve for a novice surgeon starting from the observation period to the realization of the different operating stages being supervised by a senior surgeon, all under stressful conditions. Topical or locoregional anesthesia limits the communication in the operating room between the novice surgeon and his mentor; thus, increasing the risk of having more operative complications. To reduce the teaching time of cataract surgery, our department has introduced virtual simulator trainings for phacoemulsification. To assess the impact of surgical simulator training on residents' performances. We conducted a prospective comparative study in our department in partnership with a private ophthalmology clinic where the simulator is installed. Twelve residents were included in this study, six of them were randomly selected to participate in the phacoemulsification surgical simulator training while the others never used the simulator. The training lasted 30hours in total. No residents had previous training in phacoemulsification. The parameters studied were: the operating time, the achievement of a circular capsulorhexis of 5-6mm in diameter and well centered, the number of capsular breaks with or without an anterior vitrectomy and finally the accumulated dissipated energy (EDC). The cataract surgery was performed on an Alcon Centurion platform. In the operating room, each resident operated 25cataracts; we compared the two user groups including the simulator and non simulator user and we noticed a statistically significant difference (P<0.05) in terms of average operating time respectively 20minutes and 37minutes. Regarding the realization of capsulorhexis; 22cases of rhexis wandering and 12poorly centred rhexis on 150operated cataracts were identified (22.7%) in the group of residents who received no simulator training versus 10cases in the simulator user group (6.7%). The cumulative dissipated energy (EDC) was significantly lower in the simulator user group (8.1 versus 18.7). The same is true for the rate of posterior capsular rupture, which is higher in the non-user group of simulator 37cases (24.6%) versus 10cases (8%) in the second group. Ophthalmic surgery has benefited from the introduction of endo-ocular surgical simulation tools through simulators of vitreoretinal surgery and phacoemulsification; whose main role is primarily pedagogical because a simulator allows young residents to acquire dexterity and autonomy over a shortened period of time in addition to minimizing the risk of complications. Initial learning of phacoemulsification cataract surgery should be an integral part of the virtual simulator program before moving to the real conditions of the operating room as it allows for better operative performance with a minimal complication rate.

Feasibility of ovine and porcine models for simulation training in parotid surgery and facial nerve dissection

To assess and compare the feasibility of using ovine and porcine models as surgical simulation training tools for otolaryngology trainees performing parotid surgery and facial nerve dissection. Trainees performed parotid surgery (total parotidectomy, retrograde facial nerve dissection and facial nerve grafting) on an ovine and porcine model. Participants completed a 22-item, five-point Likert scale questionnaire on each model, assessing three validation domains; face validity (FV), global content validity (GCV) and task-specific content validity (TSCV). Data were prospectively collected and analysed using descriptive and non-parametric statistics. Twelve trainees completed two consecutive parotidectomies and facial nerve dissections on an ovine and porcine model. Twenty-four dissections were completed. Validation questionnaires were completed for each model by all trainees. The ovine model achieved median validation threshold scores (≥ 4/5) for all aspects of FV, GCV and TSCV. The porcine model did not achieve validation threshold scores for any aspect of the validation questionnaire. Comparison of the ovine and porcine model demonstrated that the ovine model was statistically superior to the porcine model across most validation criteria excluding realistic appearance of skin, identification and ligation of the trans-oral parotid duct and facial nerve grafting. Adequate experience with facial nerve dissection during parotid surgery is vital to ensuring good outcomes and avoiding complications. This study is the first to compare validity of two animal models for simulation training in parotid surgery and facial nerve dissection. We have validated the ovine model as a useful tool for simulation training and advocate its incorporation into otolaryngology training programmes.

Three-Dimensional Printing of Congenital Heart Disease Models for Cardiac Surgery Simulation: Evaluation of Surgical Skill Improvement among Inexperienced Cardiothoracic Surgeons.

ObjectiveTo evaluate the impact of surgical simulation training using a three-dimensional (3D)-printed model of tetralogy of Fallot (TOF) on surgical skill development.Materials and MethodsA life-size congenital heart disease model was printed using a Stratasys Object500 Connex2 printer from preoperative electrocardiography-gated CT scans of a 6-month-old patient with TOF with complex pulmonary stenosis. Eleven cardiothoracic surgeons independently evaluated the suitability of four 3D-printed models using composite Tango 27, 40, 50, and 60 in terms of palpation, resistance, extensibility, gap, cut-through ability, and reusability of. Among these, Tango 27 was selected as the final model. Six attendees (two junior cardiothoracic surgery residents, two senior residents, and two clinical fellows) independently performed simulation surgeries three times each. Surgical proficiency was evaluated by an experienced cardiothoracic surgeon on a 1–10 scale for each of the 10 surgical procedures. The times required for each surgical procedure were also measured.ResultsIn the simulation surgeries, six surgeons required a median of 34.4 (range 32.5–43.5) and 21.4 (17.9–192.7) minutes to apply the ventricular septal defect (VSD) and right ventricular outflow tract (RVOT) patches, respectively, on their first simulation surgery. These times had significantly reduced to 17.3 (16.2–29.5) and 13.6 (10.3–30.0) minutes, respectively, in the third simulation surgery (p = 0.03 and p = 0.01, respectively). The decreases in the median patch appliance time among the six surgeons were 16.2 (range 13.6–17.7) and 8.0 (1.8–170.3) minutes for the VSD and RVOT patches, respectively. Summing the scores for the 10 procedures showed that the attendees scored an average of 28.58 ± 7.89 points on the first simulation surgery and improved their average score to 67.33 ± 15.10 on the third simulation surgery (p = 0.008).ConclusionInexperienced cardiothoracic surgeons improved their performance in terms of surgical proficiency and operation time during the experience of three simulation surgeries using a 3D-printed TOF model using Tango 27 composite.

Development of Manipulation Assistance for Surgical Training Simulator Using Haptic Device in Sagittal Split Ramus Osteotomy

Development of Manipulation Assistance for Surgical Training Simulator Using Haptic Device in Sagittal Split Ramus Osteotomy

Decentralized Virtual Reality Training of Mastoidectomy Improves Cadaver Dissection Performance: A Prospective, Controlled Cohort Study.

Virtual reality (VR) simulation training can improve temporal bone (TB) cadaver dissection skills and distributed, self-regulated practice is optimal for skills consolidation. Decentralized training (DT) at the trainees' own department or home offers more convenient access compared with centralized VR simulation training where the simulators are localized at one facility. The effect of DT in TB surgical training is unknown. We investigated the effect of decentralized VR simulation training of TB surgery on subsequent cadaver dissection performance. Prospective, controlled cohort study. Otorhinolaryngology (ORL) teaching hospitals and the Danish national TB course. Thirty-eight ORL residents: 20 in the intervention cohort (decentralized training) and 18 in the control cohort (standard training during course). Three months of access to decentralized VR simulation training at the local ORL department or the trainee's home. A freeware VR simulator (the visible ear simulator [VES]) was used, supplemented by a range of learning supports for directed, self-regulated learning. Mastoidectomy final-product scores from the VR simulations and cadaver dissection were rated using a modified Welling Scale by blinded expert raters. Participants in the intervention cohort trained decentrally a median of 3.5 hours and performed significantly better than the control cohort during VR simulation (p < 0.01), which importantly also transferred to a 76% higher performance score during subsequent cadaver training (mean scores: 8.8 versus 5.0 points; p < 0.001). Decentralized VR simulation training of mastoidectomy improves subsequent cadaver dissection performance and can potentially improve implementation of VR simulation surgical training.

Simulation-based surgical education in cardiothoracic training.

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part-task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three-dimensional printing and computer-based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.