Virtual Reality Laparoscopic Simulator Research Articles

Needs analysis for the development of a virtual reality laparoscopic hiatal hernia repair simulator

Needs analysis for the development of a virtual reality laparoscopic hiatal hernia repair simulator

Artificial intelligence in laparoscopic simulation: a promising future for large-scale automated evaluations.

IntroductionA limitation to expanding laparoscopic simulation training programs is the scarcity of expert evaluators. In 2019, a new digital platform for remote and asynchronous laparoscopic simulation training was validated. Through this platform, 369 trainees have been trained in 14 institutions across Latin America, collecting 6729 videos of laparoscopic training exercises. The use of artificial intelligence (AI) has recently emerged in surgical simulation, showing usefulness in training assessment, virtual reality scenarios, and laparoscopic virtual reality simulation. An AI algorithm to assess basic laparoscopic simulation training exercises was developed. This study aimed to analyze the agreement between this AI algorithm and expert evaluators in assessing basic laparoscopic-simulated training exercises.MethodsThe AI algorithm was trained using 400-bean drop (BD) and 480-peg transfer (PT) videos and tested using 64-BD and 43-PT randomly selected videos, not previously used to train the algorithm. The agreement between AI and expert evaluators from the digital platform (EE) was then analyzed. The exercises being assessed involve using laparoscopic graspers to move objects across an acrylic board without dropping any objects in a determined time (BD < 24 s, PT < 55 s). The AI algorithm can detect object movement, identify if objects have fallen, track grasper clamps location, and measure exercise time. Cohen’s Kappa test was used to evaluate the agreement between AI assessments and those performed by EE, using a pass/fail nomenclature based on the time to complete the exercise.ResultsAfter the algorithm was trained, 79.69% and 93.02% agreement were observed in BD and PT, respectively. The Kappa coefficients test observed for BD and PT were 0.59 (moderate agreement) and 0.86 (almost perfect agreement), respectively.ConclusionThis first approach of AI use in basic laparoscopic skills simulated training assessment shows promising results, providing a preliminary framework to expand the use of AI to other basic laparoscopic skills exercises.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09576-1.

Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module. A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared. Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations. Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

The application of virtual reality simulators in laparoscopic surgery training (a review)

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.

Training on a virtual reality laparoscopic simulator improves performance of live laparoscopic surgery.

IntroductionTo determine whether training laparoscopic nephrectomy (LN) with a virtual reality (VR) simulator improves the performance of porcine LN.MethodsTwelve urological residents were assigned to two groups: a training and a non‐training group. All participants performed baseline assessments of LN skills and time on the LapPASS® simulator. The training group received preoperative LapPASS® training. Both groups then performed LN using a porcine model. The operations were videotaped and evaluated using the Global Operative Assessment of Laparoscopic Skills (GOALS) system. After porcine LN, the training group performed a final LN with the LapPASS® simulator.ResultsThere was no significant difference in the operation time required for porcine LN. There were no significant differences in the total A (autonomy), B (bimanual dexterity), D (depth perception), or T (tissue handling) GOALS scores. However, the total E (efficiency) score in the training group was higher than that in the non‐training group (P = .030). The final LN score with LapPASS® was significantly higher than the baseline (P = .004).ConclusionsThe results of this study demonstrated that VR LN training improved performance in an actual operation. VR‐based procedural simulation could become a vital part of the laparoscopic training program for residents.

Correlation of surgical case volume and fellowship training with performance on simulated procedural tasks

High-volume and fellowship-trained surgeons have superior outcomes. However, in gynecology, a large proportion of cases are performed by low-volume surgeons. Simulation has been shown to be useful in assessing surgical skill and may be a useful tool in hospital credentialing and maintenance of privileges. To determine the correlation between a surgical case volume and fellowship training with performance on simulated procedural tasks. A total of 108 obstetricians and gynecologists with laparoscopic privileges at 2 academic institutions completed a pre-test survey and performed 3 tasks on the LapSim laparoscopic virtual reality simulator. The pre-test survey inquired about the monthly laparoscopic case volume and prior training. Simulations included a basic skills task (peg transfer) followed by a procedural task (salpingectomy) of 2 difficulty levels (low and moderate). Spearman correlation and Wilcoxon tests were used to determine correlations between the survey responses and performance metrics. Participants included 67 generalists (62%) and 41 fellowship-trained specialists (38%). There was an observed weak correlation among surgical volume (more than 6 cases per month), time to completion, and the amount of blood loss when performing the low-difficulty level salpingectomy (r=-0.32, P=.0007 and r=-0.29, P=.002, respectively). The economy of movement (instrument path length) was correlated to high surgical volume (r=-0.35, P=.0002). Compared with generalists, surgeons with fellowship training performed tasks faster (410.8 seconds [interquartile range, 309.7-595.2]) vs 530.2 seconds (interquartile range, 406.2-605.0; P=.0009), more efficiently at 6.1 m (interquartile range, 4.8-7.3) vs 8.1 m (interquartile range, 5.8-10.7; P=.0003), and with less blood loss at 21.7 mL (interquartile range, 11.8-37.7) vs 42.9 mL (interquartile range, 18.1-70.6; P=.002). Regarding the case volume and fellowship background, there was no difference in ovarian diathermy damage. In addition, there was no difference among most performance parameters for the peg transfer task and the moderate-difficulty salpingectomy procedure. Surgical experience obtained through higher case volume and fellowship training correlate with higher performance scores during simulated procedural tasks. In a previous study, we found a similar correlation with simulated basic skills tasks. The current study is a continuation of an ongoing quality initiative to establish a summative assessment of laparoscopic surgical skills using virtual reality simulator for the maintenance of credentials among obstetrical and gynecologic surgeons. Future studies will compare the performance metrics from laparoscopic procedures performed on virtual reality simulator with the performance in the operating room and clinical outcomes.

Virtual reality laparoscopic simulator

Background: Virtual reality laparoscopic simulators were introduced to provide an optimal and safe learning environment for surgical trainees. The simulators had been validated and proven to be beneficial. Materials and Methods: The aim of this study is to assess the performance of the local surgical trainees using a validated simulator and help in the development of a training program using the simulator. Prospective repeated measures study in a single center using a validated virtual reality simulator was performed. Years 1 and 2 local postgraduate surgical trainees with limited laparoscopic cholecystectomy experience were included in the study. The trainees underwent a proposed training module, and the simulator evaluated each performance. Comparison was made between the performance before and after the training module. Results: Nine surgical trainees (eight males, median age: 33 years old) with a median of 5 years of surgical experience after graduation were included in the study. The time to complete each basic laparoscopic skill improved between 26.5% and 64.3% (P Conclusion: Virtual reality laparoscopic training should be implemented as part of training as it improves certain skill sets.

Bimanual Fundamentals: Validation of a New Curriculum for Virtual Reality Training of Laparoscopic Skills.

Background. To determine face and construct validity for the new Bimanual Fundamentals curriculum for the Simendo® Virtual Reality Laparoscopy Simulator and prove its efficiency as a training and objective assessment tool for surgical resident’s advanced psychomotor skills. Methods. 49 participants were recruited: 17 medical students (novices), 15 residents (intermediates), and 17 medical specialists (experts) in the field of gynecology, general surgery, and urology in 3 tertiary medical centers in the Netherlands. All participants performed the 5 exercises of the curriculum for 3 consecutive times on the simulator. Intermediates and experts filled in a questionnaire afterward, regarding the reality of the simulator and training goals of each exercise. Statistical analysis of performance was performed between novices, intermediates, and experts. Parameters such as task time, collisions/displacements, and path length right and left were compared between groups. Additionally, a total performance score was calculated for each participant. Results. Face validity scores regarding realism and training goals were overall positive (median scores of 4 on a 5-point Likert scale). Participants felt that the curriculum was a useful addition to the previous curricula and the used simulator would fit in their residency programs. Construct validity results showed significant differences on the great majority of measured parameters between groups. The simulator is able to differentiate between performers with different levels of laparoscopic experience. Conclusions. Face and construct validity for the new Bimanual Fundamental curriculum for the Simendo virtual reality simulator could be established. The curriculum is suitable to use in resident’s training programs to improve and maintain advanced psychomotor skills.

Virtual Operating Room Simulation Setup (VORSS) for Procedural Training in Minimally Invasive Surgery \u2013 a Pilot Study

Virtual reality (VR) training is widely used in several minimal invasive surgery (MIS) training curricula for procedural training. However, VR training in its current state lack immersive training environments, such as using head-mounted displays that is implemented in military or aviation training and even entertainment. The virtual operating room simulation setup (VORSS) is explored in this study to determine the effectiveness of immersive training in MIS. Twenty-eight surgeons and surgical trainees performed a laparoscopic cholecystectomy on the VORSS comprising of a head-mounted 360-degree realistic OR surrounding on a VR laparoscopic simulator. The VORSS replicated a full setup of instruments and surgical team-members as well as some of the distractions occurring during surgical procedures. Questionnaires were followed by semi-structured interviews to collect the data. Experts and novices found the VORSS to be intuitive and easy to use (p = 0.001). The outcome of the usability test, applying QUESI and NASA-TLX, reflected the usability of the VORSS (p < 0.05), at the cognitive level, which indicates a good sense of immersion and satisfaction, when performing the procedure within VORSS. The need for personalized experience within the setup was strongly noted from most of the participants. The VORSS for procedural training has the potential to become a useful tool to provide immersive training in MIS surgery. Further optimizing of the VORSS realism and introduction of distractors in the OR should result in an improvement of the system.

Higher quality camera navigation improves the surgeon's performance: Evidence from a pre-clinical study.

Introduction:To objectively assess the quality of laparoscopic camera navigation (LCN), the structured assessment of LCN skills (SALAS) score was developed and validated for laparoscopic cholecystectomy. The aim of this pre-clinical study was to investigate the influence of LCN on surgical performance during virtual cholecystectomy (vCHE) using this score.Methods:A total of 84 medical students were included in this prospective study. Individual characteristics were assessed with questionnaires. Participants completed a structured 2-day training course on a validated virtual reality laparoscopic simulator. At the end of the course, all students took over LCN during vCHE, all performed by the same surgeon. The numbers of errors regarding centering, horizon adjustment and instrument visualisation as well as manual and verbal corrections by the surgeon were recorded to calculate the SALAS score (range 5–25) to investigate the influence of LCN on surgical performance. The study population was divided by the recorded SALAS score into low and medium performers (Group A; 1st–3rd quartile; n = 60) and high performers (Group B, 4th quartile, n = 21).Results:The SALAS score of the camera assistant correlates positively with the surgeon's overall performance in vCHE (P < 0.001), and the surgeon's virtual laparoscopic performance was significantly better in Group B (P < 0.001). Moreover, a significantly shorter operation time during vCHE was shown for Group B (Median (IQR); Group A: 508 s [429 s; 601 s]; Group B: 422 s [365 s; 493 s]; P = 0.001). Frequent gaming and a higher self-confidence to assist during a basic laparoscopic procedure were associated with a higher SALAS score (P = 0.013).Conclusion:In this pre-clinical setting, the surgeon's virtual performance is significantly influenced by the LCN quality. LCN by high performers resulted in a shorter operation time and a lower error rate.

2660 Bimanual Fundamentals: Validation of A New Virtual Reality Curriculum for Advanced Laparoscopic Skills Training

Study Objective To determine face- and construct validity for the new ‘Bimanual Fundamental Curriculum’ for the Simendo Virtual Reality Laparoscopy Simulator and prove efficiency as a training and objective assessment tool for surgical resident's advanced psychomotor skills. Design Prospective multi-center cohort study. Power calculation was performed. The curriculum was new developed for more experienced laparoscopic trainees. It consists of five exercises, focused on bimanual precision training. Setting Two University hospitals in the Netherlands. Patients or Participants Three groups according surgical experience: medical students (novices, N=17), residents PGY 4-6 (intermediate, N=15) and laparoscopic specialists (experts, N=15) in the field of gynecology, surgery and urology. Interventions Participants (N=47) performed the five exercises three consecutive times. The first run was used as introduction and the second and third run were used for analysis. Intermediates and experts filled out a questionnaire afterwards, regarding reality of the simulator and training goals of each exercise. Statistical analysis of performance was performed between novices, intermediates, and experts. Parameters task time, collisions/displacements, and path length were compared. Additionally, a total performance score was calculated for each participant. Measurements and Main Results Face validity scores regarding realism and training goals were overall positive (median scores of 4 on a 5-point Likert scale). Participants felt the curriculum was a useful addition to the previous curricula (71.9%) and the simulator would fit in their residency programs (96.8%). Construct validity results showed significant differences on the great majority of measured parameters between groups. Experts outperformed intermediate is the three most difficult exercises. The simulator is able to differentiate between performers with different levels of laparoscopic experience (p Conclusion Face- and construct validity for the new Bimanual Fundamental curriculum for this virtual reality simulator could be established. The curriculum is suitable to use in resident's training programs to improve and maintain advanced psychomotor skills.

Prospective Cohort Study of Haptic Virtual Reality Laparoscopic Appendicectomy Learning Curve Trajectory.

Background: Simulation training is strongly advocated by 24/7 risk-rich professions because swift learning curve inflection point attainment delivers earlier competence; the left-shift effect. The aim of this study was to determine the value of haptic laparoscopic virtual reality simulation, by iterative benchmark exercise (n = 8), before simulated laparoscopic appendicectomy (SLA); the hypothesis was that favorable benchmark learning curve trajectories would be associated with improved SLA competence when compared with consultant expert performance. Methods: A 28-trainee cohort completed 1349 Laparoscopic Haptic Virtual Reality Skills (LHVRS) tasks, during which 19 ergonomic variables were assessed by virtual interface, including force feedback (Surgicalscience.com), before 153 SLAs. Primary outcome measure was SLA composite competence score related to six consultant trainer experts. Results: Of the eight LHVRS tasks, the three with the steepest learning curve trajectories correlated with better median overall SLA competence scores, namely tissue grasping/lifting (rho = 0.362, P = .049), fine dissection (rho = 0.388, P = .028), and camera navigation (rho = 0.518, P = .007); fine dissection was the only haptic laparoscopic virtual reality simulation task that predicted a SLA score within a Youden index defined, 70% of the consultant expert level (area under curve [AUC] = 0.803, P = .028). A significant SLA learning curve emerged, with a learning curve trajectory inflection point at the fourth SLA attempt (first SLA 30.5% versus fourth SLA score 76.0%, gradient 76°, P = .010). Conclusion: Learning curve trajectory can be measured, influenced, and accelerated significantly; a pronounced left-shift effect, with translational potential for enhanced shorter training time and improved patient safety.

Management of Bleeding Complications in Virtual Reality Laparoscopy

The aim of this study was to compare the impact of induced bleeding complication training with regular training on a virtual reality laparoscopic (VRL) simulator. Although bleeding complications occur rarely during laparoscopic surgery, they usually arise without warning and may have severe consequences for the patient because complication management training is not currently widespread. Third-year medical students (n = 41) were randomly selected for 2 curricular courses on how to perform a bimanual task on a VRL simulator. Both the regular training group (RTG) and the induced bleeding complication training (ICT) group performed 2 regular training sessions and 9 training sessions. For the ICT group the training sessions were with a bleeding complication. The 2 groups were comparable regarding their initial performance levels and improved significantly in task time and handling economics throughout the course (P &amp;lt; 0.001). When a bleeding complication occurred during the initial phase, performance parameters were significantly worse (P &amp;lt; 0.05). During a bleeding complication, the ICT group showed a significant improvement in time, handling economics, and blood loss (P &amp;lt; 0.001) throughout the training course, whereas the RTG group showed no improvement. Induced complication training has a positive influence on the management of bleeding on the VRL simulator. Structured laparoscopic complication management training should be implemented during surgical education as an add-on to regular procedural training.

Subjective and Objective Quantification of the Effect of Distraction on Physician's Workload and Performance During Simulated Laparoscopic Surgery.

BackgroundDistracting interference cognitive tasks place undeniable pressure on the minds of people who need high precision and attention during the tasks, such as those tasks performed during surgery; these tasks might affect current surgical procedures. We measured the effect of additional cognitive tasks on the mental load of the physician by measuring the mean change in pupil size, blink rate, and subjective assessment during surgery.Material/MethodsWe recruited 24 participants with different levels of laparoscopic surgery to perform a complete appendectomy using a standardized virtual reality laparoscopic surgery simulator. The participants then performed the cognitive task (arithmetic problem), after that they performed an appendectomy surgery task while completing the cognitive task on the simulator. All participants wore trackers to monitor pupil size and blink rate during surgery and the cognitive task. The National Aeronautics and Space Administration (NASA) Task Load Index (TLX) score also recorded performance parameters during the surgical mission.ResultsThe double-task pupil size and the blink rate were significantly increased compared to the single-task observation, and the associated increase in psychological load might have been affected by surgical performance, and the performance parameters were also statistically significant. However, for the aforementioned parameters, experienced surgeons had some differences compared with inexperienced surgeons, but these differences did not reach statistical significance.ConclusionsDistracted cognitive task stimulation in the operating room can increase the surgeon’s psychological burden while also affecting their operational skills, thereby threatening patient safety; reduced cognitive costs might be obtained by improving or managing cognitive deficits.

Performance and perception of haptic feedback in a laparoscopic 3D virtual reality simulator

Background: The benefit of haptic feedback in laparoscopic virtual reality simulators (VRS) is ambiguous. A previous study found 32% faster acquisition of skills with the combination of 3 D and haptic feedback compared to 2 D only. This study aimed to validate perception and effect on performance of haptic feedback by experienced surgeons in the previously tested VRS. Material and methods: A randomized single blinded cross-over study with laparoscopists (>100 laparoscopic procedures) was conducted in a VRS with 3 D imaging. One group started with haptic feedback, and the other group without. After performing the suturing task with haptics either enabled or disabled, the groups crossed over to the opposite setting. Face validity was assessed through questionnaires. Metrics were obtained from the VRS. Results: The haptics for ‘handling the needle’, ‘needle through tissue’ and ‘tying the knot’ was scored as completely realistic by 3/22, 1/22 and 2/22 respectively. Comparing the metrics for maximum stretch damage between the groups revealed a significantly lower score when a group performed with haptics enabled p = .027 (haptic first group) and p < .001(haptic last group). Conclusion: Haptic feedback in VRS has limited fidelity according to the tested laparoscopic surgeons. In spite of this, significantly less stretch damage was caused with haptics enabled.

Validation of a virtual reality laparoscopic appendicectomy simulator: a novel process using cognitive task analysis.

Virtual reality (VR) simulation is a vital component of surgical training with demonstrated improvements in surgical quality and clinical outcome. To validate the LAP Mentor (Simbionix™) laparoscopic appendicectomy (LA) VR simulator with inclusion of a novel tool, Cognitive Task Analysis (CTA). Thirty-two novices and nine experienced surgeons performed two simulated LAs. An expert-consensus questionnaire guided face validity assessment. Content validity was assessed using CTA-derived questions encompassing eight operative steps and four decision points. Construct validity was evaluated using dexterity metrics, masked assessment of surgical quality using the OSATS global rating scale, and mental workload from two validated tools: the NASA-TLX and SMEQ. Ten novices performed eight further LAs for learning curve assessment. Face validity was demonstrated across all domains. Considering content validity, the essential technical and non-technical steps were evident. The experienced group performed the procedure quicker (median time 361 vs. 538s, P= 0.0039) with fewer total movements (426 vs. 641, P< 0.0001) and shorter idle time (131 vs. 199s, P= 0.0006). This correlated with higher OSATS scores (median 33.5 vs. 22.2, P< 0.0001) and lower mental demand (NASA-TLX: 9.0 vs. 13.75, P= 0.012; SMEQ: 60 vs. 80, P= 0.0025), indicating construct validity. Learning curve data showed statistically significant improvements after the 7th session for procedure time, total movements and idle time, which correlated with reduction in mental demand. The LAP Mentor demonstrates face, content and construct validity for LA; thus, it can be used as an effective tool in surgical training. Task repetition leads to achievement of expert benchmarks.

Artificial Versus Video-Based Immersive Virtual Surroundings: Analysis of Performance and User's Preference.

Immersive virtual reality (VR) laparoscopy simulation connects VR simulation with head-mounted displays to increase presence during VR training. The goal of the present study was the comparison of 2 different surroundings according to performance and users' preference. With a custom immersive virtual reality laparoscopy simulator, an artificially created VR operating room (AVR) and a highly immersive VR operating room (IVR) were compared. Participants (n = 30) performed 3 tasks (peg transfer, fine dissection, and cholecystectomy) in AVR and IVR in a crossover study design. No overall difference in virtual laparoscopic performance was obtained when comparing results from AVR with IVR. Most participants preferred the IVR surrounding (n = 24). Experienced participants (n = 10) performed significantly better than novices (n = 10) in all tasks regardless of the surrounding ( P < .05). Participants with limited experience (n = 10) showed differing results. Presence, immersion, and exhilaration were significantly higher in IVR. Two thirds assumed that IVR would have a positive influence on their laparoscopic simulator use. This first study comparing AVR and IVR did not reveal differences in virtual laparoscopic performance. IVR is considered the more realistic surrounding and is therefore preferred by the participants.

Development of an objective assessment tool for total laparoscopic hysterectomy: A Delphi method among experts and evaluation on a virtual reality simulator.

IntroductionTotal Laparoscopic hysterectomy (LH) requires an advanced level of operative skills and training. The aim of this study was to develop an objective scale specific for the assessment of technical skills for LH (H-OSATS) and to demonstrate feasibility of use and validity in a virtual reality setting.Material and methodsThe scale was developed using a hierarchical task analysis and a panel of international experts. A Delphi method obtained consensus among experts on relevant steps that should be included into the H-OSATS scale for assessment of operative performances. Feasibility of use and validity of the scale were evaluated by reviewing video recordings of LH performed on a virtual reality laparoscopic simulator. Three groups of operators of different levels of experience were assessed in a Marseille teaching hospital (10 novices, 8 intermediates and 8 experienced surgeons). Correlations with scores obtained using a recognised generic global rating tool (OSATS) were calculated.ResultsA total of 76 discrete steps were identified by the hierarchical task analysis. 14 experts completed the two rounds of the Delphi questionnaire. 64 steps reached consensus and were integrated in the scale. During the validation process, median time to rate each video recording was 25 minutes. There was a significant difference between the novice, intermediate and experienced group for total H-OSATS scores (133, 155.9 and 178.25 respectively; p = 0.002). H-OSATS scale demonstrated high inter-rater reliability (intraclass correlation coefficient [ICC] = 0.930; p<0.001) and test retest reliability (ICC = 0.877; p<0.001). High correlations were found between total H-OSATS scores and OSATS scores (rho = 0.928; p<0.001).ConclusionThe H-OSATS scale displayed evidence of validity for assessment of technical performances for LH performed on a virtual reality simulator. The implementation of this scale is expected to facilitate deliberate practice. Next steps should focus on evaluating the validity of the scale in the operating room.

Predictors of laparoscopic simulation performance among practicing obstetrician gynecologists

While simulation training has been established as an effective method for improving laparoscopic surgical performance in surgical residents, few studies have focused on its use for attending surgeons, particularly in obstetrics and gynecology. Surgical simulation may have a role in improving and maintaining proficiency in the operating room for practicing obstetrician gynecologists. We sought to determine if parameters of performance for validated laparoscopic virtual simulation tasks correlate with surgical volume and characteristics of practicing obstetricians and gynecologists. All gynecologists with laparoscopic privileges (n=347) from 5 academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a presimulation survey gathering physician self-reported characteristics and then performed 3 basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) on the LapSim virtual reality laparoscopic simulator (Surgical Science Ltd, Gothenburg, Sweden). The association between simulation outcome scores (time, efficiency, and errors) and self-rated clinical skills measures (self-rated laparoscopic skill score or surgical volume category) were examined with regression models. The average number of laparoscopic procedures per month was a significant predictor of total time on all 3 tasks (P= .001 for peg transfer; P= .041 for lifting and grasping; P < .001 for cutting). Average monthly laparoscopic surgical volume was a significant predictor of 2 efficiency scores in peg transfer, and all 4 efficiency scores in cutting (P=.001 to P= .015). Surgical volume was a significant predictor of errors in lifting/grasping and cutting (P < .001 for both). Self-rated laparoscopic skill level was a significant predictor of total time in all 3 tasks (P < .0001 for peg transfer; P= .009 for lifting and grasping; P<.001 for cutting) and a significant predictor of nearly all efficiency scores and errors scores in all 3 tasks. In addition to total time, there was at least 1 other objective performance measure that significantly correlated with surgical volume for each of the 3 tasks. Higher-volume physicians and those with fellowship training were more confident in their laparoscopic skills. By determining simulation performance as it correlates to active physician practice, further studies may help assess skill and individualize training to maintain skill levels as case volumes fluctuate.

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

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. 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. Participants' times for fine dissection were significantly longer during the IVR session (regular: 86.51s [62.57s; 119.62 s] vs. IVR: 112.35s [82.08s; 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. 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.