LAP Mentor Validation & Publication

Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts.

School of Sport and Health Sciences, University of Exeter, St Luke's Campus, Exeter, EX1 2LU, UK,

Surg Endosc. 2010 Mar 24

METHODS: A total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups.

RESULTS: The experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools.

CONCLUSION: The findings of the study provide support for the utility of assessing strategic gaze behavior to better understand the way in which surgeons utilize visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed.

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The Role of Haptic Feedback in Laparoscopic Training Using the LapMentor II

Mohamad W. Salkini, M.D., 1,,3 Charles R. Doarn, M.B.A., 2 Nicholai Kiehl, M.D., 1 Timothy J. Broderick, M.D., 2 James F. Donovan, M.D., 1 ,Krishnanath Gaitonde, M.D. 1

1Division of Urology, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.

2Department of Surgery, Center for Surgical Innovation, University of Cincinnati, Cincinnati, Ohio.

Journal of EndourologyVolume: 24 Issue 1: January 10, 2010

Introduction Laparoscopic surgery has become the standard of care for many surgical diseases. Haptic (tactile) feedback (HFB) is considered an important component of laparoscopic surgery. Virtual reality simulation (VRS) is an alternative method to teach surgical skills to surgeons in training. Newer VRS trainers such as the Simbionix Lap Mentor II provide significantly improved tactile feedback. However, VRSs are expensive and adding HFB software adds an estimated cost of $30,000 to the commercial price. The HFB provided by the Lap Mentor II has not been validated by an independent party. We used the Simbionix Lap Mentor II in this study to demonstrate the effect of adding an HFB mechanism in the VRS trainer.

Materials and Methods The study was approved by the University of Cincinnati Institutional Review Board. Twenty laparoscopically novice medical students were enrolled. Each student was asked to perform three different tasks on the Lap Mentor II and repeat each one five times. The chosen tasks demanded significant amount of traction and counter traction. The first task was to pull leaking tubes enough and clip them. The second task was stretching a jelly plate enough to see its attachments to the floor and cut these attachments. In the third task, the trainee had to separate the gallbladder from its bed on the liver. The students were randomized into two groups to perform the tasks with and without HFB. We used accuracy, speed, and economy of movement as scales to compare the performance between the two groups. The participants also completed a simple questionnaire that highlighted age, sex, and experiences in videogame usage.

Results The two groups were comparable in age, sex, and videogame playing. No differences in the accuracy, the economy, and the speed of hand movement were noticed. In fact, adding HFB to the Lap Mentor II simulator did not contribute to any improvement in the performance of the trainees. Interestingly, we found that videogame expert players tend to have faster and more economic motion in their dominant hands. However, the performance accuracy was not significantly affected.

Conclusions The presence of HFB has less effect than it thought to be on the performance of the novice trainees. This may suggest that better HFB is still needed. However, there may be visual compensation for the lack of haptics. Playing videogames has a positive impact on economy, and the speed of the dominant had motion without affecting its accuracy. Further research is needed to clarify the value of haptics to the expert surgeon and compare it to the new trainees.

Assessment of the Laparoscopic Training Validity of a Virtual Reality Simulator (LAP Mentor™)

Tae Hyo Kim, Jung Min Ha, Jae Wook Cho, Youn Chul You, Gyung Tak Sung

The Department of Urology, College of Medicine, Dong-A University, Busan, Korea

Korean J Urol 2009;50:989-995

Purpose The need for efficient and optimal training through a structured laparoscopic training program has become increasingly evident. Virtual reality simulation may provide a safe and efficient means of acquiring laparoscopic skills. The LAP Mentor™ is a high-fidelity virtual reality simulator with haptic feedback that allows a trainee to practice 9 basic laparoscopic tasks including laparoscopic suturing. The purpose of this study was to evaluate the predictive validity of performance on the LAP Mentor before surgical simulators are incorporated into training programs.

Materials and Method Eleven participants (6 medical students and 5 residents) underwent laparoscopic skills training on the virtual reality simulator LAP Mentor. Each participant was tested on 5 sets of 4 LAP Mentor basic laparoscopic tasks (grasping, cutting, clipping, and suturing) in a 3-week period. Total time and accuracy were measured for each task.

Results There was a significant difference between the initial session and the final session for total time and accuracy in both groups. Among the medical students, as they progressed through the training step by step, total time decreased for the grasping task, the cutting task, the clipping task, and the suturing task. At the same time, accuracy improved for the grasping task, the cutting task, the clipping task, and the suturing task, respectively. The residents group showed a similar progression.

Conclusions: Basic skills straining on a LAP Mentor virtual reality simulator improves learning of the basic skills for laparoscopy. Education with virtual reality simulators, therefore, may provide an effective teaching method and lead to improved operating performance.

Development of a virtual reality training curriculum for laparoscopic cholecystectomy

R. Aggarwal, P. Crochet, A. Dias, A. Misra, P. Ziprin and A. Darzi

Department of Biosurgery and Surgical Technology, St Mary’s Campus, Imperial College Healthcare NHS Trust, LondonW2 1NY, UK

British Journal of Surgery 2009; 96: 1086–1093

Background: Training within a proficiency-based virtual reality (VR) curriculum may reduce errors during real surgical procedures. This study used a scientific methodology for development of a VR training curriculum for laparoscopic cholecystectomy.
Methods: Inexperienced (had performed fewer than ten laparoscopic cholecystectomies), intermediate (20–50) and experienced (more than 100) surgeons were recruited. Construct validity was defined as the ability to differentiate between the three levels of experience, based on simulator-derived metrics for nine basic skills, four procedural tasks and full laparoscopic cholecystectomy on a high-fidelity VR simulator. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency
measures were based on the performance of experienced surgeons.
Results: Thirty inexperienced, 11 intermediate and 16 experienced operators were recruited. Eight of nine basic skills and three of four procedural tasks were found to be construct valid. The full procedure revealed significant intergroup differences for time (1541, 673 and 816 s; P = 0·002), movements (1021, 595 and 638; P = 0·006) and path length (2038, 1235 and 1303 cm; P = 0·033). Learning curves plateaued between the second and ninth sessions.
Conclusion: This study shows that it is possible to define and develop a whole-procedure VR training curriculum for laparoscopic cholecystectomy using structured scientific methodology.

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The following abstract was presented at the Annual Meeting of the Association of Surgical Educators (ASE) April 28-30, 2009, Salt lake City, Utah

Virtual reality training on basic laparoscopic tasks vs. virtual reality training of an entire surgical procedure: A randomized controlled trial using real world operations as an outcome

Allan Okrainec, MD1, Ara Tekian, MHPE, PhD2, Mary-Anne Aarts, MD1, Teodor Grantcharov, MD, PhD1, Jaime Escallon, MD1, and Richard Reznick, MD, MEd1

1Department of Surgery, University of Toronto, Toronto, Ontario
2Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois

Objective: Several studies have shown that practicing basic laparoscopic tasks on a virtual reality (VR) simulator improves skills in the operating room.  Newer high fidelity simulators now allow practice of entire surgical procedures in VR with haptic feedback.  To date, no studies have examined whether there is any added benefit to these procedural simulators compared to more basic models.  The purpose of this study was to compare the training benefit of practice on high fidelity procedural-based VR simulators compared to task-based VR simulators. Operative performance on a laparoscopic cholecystectomy was used as the outcome.
Methods: Twenty surgical residents in their first month of residency were randomized to either the basic task module on the LapMentor™ designed to teach general enabling laparoscopic skills (Basic VR Group) or the LapMentor™ procedural Lap Chole module designed to teach the actual operation (Procedural VR Group).  In addition to receiving a didactic session on the basics of laparoscopic cholecystectomy, participants practiced until predetermined proficiency criteria were met.  Residents were then assessed during an actual laparoscopic cholecystectomy by a blinded observer using a previously validated global rating scale (Global Operative Assessment of Laparoscopic Skills-GOALS).
Results: Groups were equivalent with regards to demographics and previous operative experience.  Mean GOALS score was significantly higher in the Procedural VR group compared to the Basic VR group (14.3 ± 2.8 vs. 9.7 ± 2, p=.001).  Operative time, blood loss, and gallbladder perforation rate were the same in both groups. 
Conclusions:  Training on high fidelity procedural VR simulators is superior to training on basic VR simulators, leading to improved performance in the operating room.  These results provide evidence for the inclusion of procedural VR simulators into surgical training programs.

CONCURRENT VALIDITY AND SKILL DECAY FOR THE LAP MENTOR LAPAROSCOPIC SURGICAL SIMULATOR

Stacey A Cohen BS, Martin P Edwards BS, Amir Szold

Department of Surgery B, Tel Aviv Sourasky Medical Center, the Sackler School of Medicine, Tel Aviv, Israel

Introduction: We hypothesized that the LAP Mentor virtual reality (VR) simulator (figure 1) can improve scores on a video test, which has previously been proven to accurately measure surgical skill, thus establishing concurrent validity. Furthermore, we suspected that a decline in performance would be noted following a one month period without training.
Methods and Procedures: We tested 20 medical students interested in becoming surgeons. Each student completed three tasks on a video trainer before training on the VR trainer: bead drop, bead transfer, and needle pass. Students then completed the three tasks again immediately after completing the VR basic skills training program. The VR training consisted of the following tasks: clipping and grasping, two-handed maneuvers and electrocautery. Finally, after a 3-4 week absence of training, students completed the video tests for a third time. Completion time and number of errors on the video trainer tasks were compared using analysis of variance.
Results: A total of 20 students were tested. For all three tasks, completion times significantly decreased after training and maintained this improvement after a one month absence of training. Regarding number of errors, for two tasks, there was a significant decrease in errors immediately after training. However for the third task, no significant difference in numbers of errors was found, regardless of training
After an absence of training of one month, there was no significant change in timing of performance. For one of the two improved tasks, the number of errors continued to decrease significantly after an interruption in training, while for the other task, there was an increase in the number of errors after absence of training. Overall, virtual training improved video trainer times significantly immediately after training, and they remained so a month later. The differences in numbers of errors amongst tasks before and after absence of training varied according to each task.
Conclusions: The LAP Mentor basic skills module has concurrent validity. Completion of the LAP Mentor training protocol improved completion times and number of errors
on the video trainer, which correlates with improved surgical skill. After an interruption of training for one month, completion times generally remained improved as compared
to the initial scores, but did not significantly increase or decrease from the scores achieved immediately after training. Thus, LAP Mentor training provided a lasting improvement in skill. The results regarding number of errors cannot be generalized among the three tasks, demonstrating that errors are a more task-specific measurement than completion time. The effects of longer-term interruptions in training may be examined in future studies.

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Training on a virtual reality laparoscopic simulator improves performance of an unfamiliar live laparoscopic procedure.

Lucas SM, Zeltser IS, Bensalah K, Tuncel A, Jenkins A, Pearle MS, Cadeddu JA.

University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.

J Urol. 2008 Dec;180(6):2305-6.

PURPOSE: Virtual reality simulators provide a safe and efficient means of acquiring laparoscopic skills. We evaluated whether training on a virtual reality laparoscopic cholecystectomy simulator (Lap Mentor) improves the performance of a live, unrelated laparoscopic urological procedure.
MATERIALS AND METHODS: A total of 32 medical students with no previous laparoscopic experience were oriented to the Lap Mentor, and then performed virtual reality laparoscopic cholecystectomy which was assessed by 2 experienced laparoscopists using the previously validated Objective Structured Assessment of Technical Skills scoring. Subjects were randomized to group 1, in which participants completed 6, 30-minute virtual reality training sessions within 3 weeks, or group 2, in which participants received no training. All participants then performed live laparoscopic nephrectomy in a porcine model and performance was evaluated using Objective Structured Assessment of Technical Skills by 2 experts blinded to training status.
RESULTS: Mean total pretraining laparoscopic cholecystectomy Objective Structured Assessment of Technical Skills scores were comparable between the groups (16.9 +/- 4.3 for group 1 vs 15.4 +/- 6.2 for group 2, p = 0.4). After training total Objective Structured Assessment of Technical Skills scores for live porcine laparoscopic nephrectomy were significantly higher in group 1 compared to group 2 (21.0 +/- 6.8 vs 15.7 +/- 6.6, respectively, p = 0.03). Likewise, individual subcategory Objective Structured Assessment of Technical Skills scores were higher in group 1 than in group 2, although significant differences were noted only in the categories of instrument handling and knowledge of the procedure.
CONCLUSIONS: Surgical skills acquired as a result of training on a virtual reality laparoscopic simulator are not procedure specific but improve overall surgical skills, thereby translating into superior performance of an unrelated live laparoscopic urological procedure.

The following abstract was presented at the Canadian Association of General Surgeons Annual Meeting in September 11-14, 2008 Halifax, Nova Scotia, Canada

Do Performance Measures on the LapMentor VR Simulator Predict FLS Performance?

Greco, E. M.D., Escallon, J. M.D., Grantcharov, T. M.D., Okrainec, A. M.D.

University Health Network, Department of Surgery, University of Toronto, Canada

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) simulator has been extensively studied and its assessment of technical skill has been found to be reliable and valid.  One of the disadvantages of this simulator is that it requires a trained proctor for scoring.  The LapMentor (LM) is a high fidelity virtual reality simulator with haptic feedback. It allows a trainee to practice 9 basic laparoscopic tasks including laparoscopic suturing.  The purpose of this study was to determine the predictive validity of performance on the LapMentor with FLS score.

METHODS: 16 participants (9 novice, 3 intermediate, and 4 experienced surgeons) were tested on 8 LapMentor basic laparoscopic tasks and the 5 FLS tasks. Total time (TT), number of instrument movements (NIM), and total path length (TPL) were measured for each task on the LapMentor, with lower values indicating a higher skill level.  Pearson correlation was used to assess the association between TT, NIM and TPL on each LapMentor task and the overall FLS score.

RESULTS:

Table 1: Pearson correlation between eight LapMentor (LM) tasks and total FLS score.

* Significant at the 0.05 level (2-tailed) ** Significant at the 0.01 level (2-tailed).

Construct validity testing of a laparoscopic surgery simulator (Lap Mentor): evaluation of surgical skill with a virtual laparoscopic training simulator.

Zhang A, Hünerbein M, Dai Y, Schlag PM, Beller S.

Department of Surgery and Surgical Oncology, Charite Universitätsmedizin Berlin, Berlin, Germany.

Surg Endosc. 2008 Jun;22(6):1440-4. Epub 2007 Oct 31.

BACKGROUND: Before surgical simulators can be implemented for assessment of surgical training, their construct validity should be assessed. METHODS: Nine novices (NOV), nine medical students (MS), and nine residents (RES) underwent a laparoscopic skills training on the virtual reality (VR) simulator Lap Mentor. Assessment of laparoscopic skill was based on parameters measured by the computer system before and after training.
RESULTS: Significant difference existed between RES and NOV at seven of nine tasks before training on the VR simulator. After the training in some tasks significant differences were observed between the experienced group (RES) and the nonexperienced groups (MS and NOV) or between medical groups (RES and MS) and nonmedical group (NOV).
CONCLUSIONS: Performance parameters of the Lap-Mentor can be used to distinguish between subjects with varying laparoscopic experience.

Virtual Reality Training improves simulated Laparcscopic Surgery Performance in Laparcscopy Naive Medical Students

Steven Lucas, Altug Tuncel, Karim Bensalah, Ilia Zeltser, Adam Jenkins, Margaret Pearle, and Jeffrey Cadeddu

Department of Urology, the University of Texas Southwestern Medical Center, Dallas, Texas, USA.

J Endourol. 2008 May;22(5):1047-51.

Purpose: With the expanding role of laparoscopy in urologic practice, efficient and safe training has become paramount. Virtual reality simulation may potentially aid training, but it requires validation before it can be incorporated into training programs. The objective of this study was to assess whether training on a virtual reality (VR) laparoscopy simulator (L.AP Mentor™) can improve performance of virtual laparoscopic procedures.
Materials and Methods: After a basic introduction to the LAP Mentor. 32 inexperienced medical students performed a baseline VR cholecystectomy that was observed and scored by two observers using the Objective Structured Assessment of Technical Skills (OSATS). The students were then randomized to two groups: Group 1 trained on the simulator without supervision during a total of six 3O-minute sessions and group 2 received no training. Students were then reevaluated on a second VR cholecystectomy by the same observers.
Results: All 32 students completed the study. The two groups were comparable with regard to baseline OSATS scores (group 1. 16.6 +/-.1.3 v group 2. 15.67 +/- 6.3, P = 0.2). On the second evaluation. the trained students (group 1) performed significantly better than the control group (group 2) 27.9 +/- 7.2 v 17.6 +/- 6.2. P <0.001). Group 1 students outperformed group 2 students in each category of the OSATS. Moreover. Trained students improved their scores by at least 20% (P < 0.001) in each category, while the untrained students improved only in the "knowledge of procedure" category by 25%(P = 0.03).
Conclusions: Skills training on a LAP Mentor VR simulator improved VR surgical performance. Before incorporating this simulator into resident education, the LAP Mentor will have to undergo testing for predictive and construct validity.

The following abstract was presented at the Annual Meeting of the American Urological Association (AUA) May 17 - 22, 2008. Orange County Convention Center, Orlando, Florida, USA.

Positive Correlation between Motion Analysis Data on LapMentor Virtual Reality Laparoscopic Surgical Simulator and Video Tape Assessment Results

Tadashi Matsuda, Yoshinari Ono, Shiro Baba, Matsuga Iwamura, Toshiro Terachi, Seiji Nait, Ryohei Hattori and Elspeth McDougall,

Nagoya University, Nagoya, Japan
University of California Irvine, Orange USA

The development of realistic simulators for various minimally invasive surgery techniques may potentially provide comprehensive training, a method to maintain surgical skills, and evaluation and certification of surgical competence. Dr. Matsuda reported the correlation of videotape scores (VS) of actual surgical procedures, as assessed by the Endoscopic Surgical Skill Qualification (ESSQ) System to motion analysis data on the LapMentor system, a virtual reality laparoscopic surgical simulator. There were a total of 43 physicians enrolled in the study with a laparoscopic experience of 20-79 cases. The ESSQ system qualified 26 surgeons (Group Q) whereas 17 surgeons did not qualify (Group NQ). The age, years of experience and number of laparoscopic surgeries between the 2 groups did not show a statistical difference. The analysis of motion scores based on skill task 5 (application of clips) and skill task 8 (cutting of bands) correlated with VS scores. Group Q achieved higher scores than Group NQ.
In conclusion, SK5 and SK8 of the LapMentor demonstrated construct validity and its possible usefulness for pre-clinical evaluation of laparoscopic skills that may be used in future studies.

The following abstract was presented at the Association for Surgical Education Annual Meeting in April 15-19, 2008 Toronto, Canada

Does assessment during virtual surgery predict actual intraoperative performance?

Okrainec A , Greco E, Arts MA, Grantcharov T

University Health Network, University of Toronto, Canada

Introduction: Recent advances in simulation technology have produced a second generation of high fidelity virtual reality (VR) simulators which allow a trainee to practice entire surgical procedures with haptic feedback.  There is very little evidence, however, examining whether automated measures of performance during full procedure VR simulation correlates with actual intraoperative performance.  The purpose of this study was to assess the concurrent validity of automated assessment metrics on the LapMentor VR laparoscopic cholecystectomy module using the previously validated Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale.

Methods: 22 subjects (15 novice and 7 expert surgeons) were evaluated performing the VR gallbladder dissection task on the LapMentor simulator.  Total time (TT), instrument movement (IM), path length (PL), efficiency of cautery (EC), and accuracy of cautery (AC) were recorded by the simulator.  Mean (SD) scores for novice and experienced subjects were compared using Student’s t-test.  All subjects were then assessed intraoperatively using the previously validated  GOALS assessment tool during a laparoscopic cholecystectomy.  Spearman’s correlation was used to assess the relationship between LapMentor metrics and intraoperative score.

Results:  Table 1 shows that there was a significant difference between novices and experts in TT, IM, and PL. There was no difference in EC or AC between novices and experts.  There was excellent correlation between intraoperative GOALS score and TT (R= -.721, p<.001), IM (R=
-.705, p<.001) and PL (R= -.6, p=003).  There was no correlation found between GOALS score and either EC (R=.245, p=.27) or AC (R= -.04, p=.86).

Conclusion:   This study provides evidence that performance on a high fidelity VR laparoscopic cholecystectomy correlates with actual intraoperative performance.  Total time and instrument movement were the most robust predictors of intraoperative skill.  In the future, consideration could be given to expecting residents to demonstrate proficiency in full virtual reality surgical procedures prior to operating on real patients.

Stefanidis D, Acker CE, Swiderski D, Heniford BT, Greene FL.

Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina

J Surg Educ. 2008 Jan-Feb;65(1):4-7.

The purpose of this article is to describe our experience with the incorporation of a proficiency-based laparoscopic skills curriculum in a busy surgical training program that aims to improve the technical proficiency of residents. The curriculum has a cognitive component and a manual skills component and is adjusted to resident training level. It is based on the Fundamentals of Laparoscopic Surgery program and includes basic laparoscopic virtual-reality tasks of the Lap Mentor simulator (Simbionix USA Corp., Cleveland, Ohio). Training occurs in weekly 1-hour sessions until expert-derived performance goals are achieved. Maintenance training ensures skill retention. Performance is assessed with objective metrics and is supported with feedback and an award system. Resident workload is assessed at regular intervals. Knowledge tests and manual skills tests are administered at the beginning and end of the academic year to assess resident performance improvement and curriculum effectiveness. Resident attendance rates and training progress are monitored continuously, and training sessions are adjusted to individual needs. Our curriculum has been implemented for several months. Our experience so far suggests that it is imperative to have dedicated supervising personnel and dedicated training time in the busy week of the surgical resident to ensure attendance. Our next step is to incorporate the 20 modules of the new Association of Program Directors in Surgery (ADPS)/American College of Surgeons (ACS) national skills curriculum into our skills training program, to expand its cognitive component by incorporating additional procedural videos, and to adapt scenario-based training on trauma and critical care on human patient simulators.

Construct validity for eye-hand coordination skill on a virtual reality laparoscopic surgical simulator.

Yamaguchi S, Konishi K, Yasunaga T, Yoshida D, Kinjo N, Kobayashi K, Ieiri S, Okazaki K, Nakashima H, Tanoue K, Maehara Y, Hashizume M.

Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Surg Endosc. 2007 May 4

Face validation of the Simbionix LAP Mentor virtual reality training module and its applicability in the surgical curriculum

I. D. Ayodeji¹, M. Schijven², J. Jakimowicz³ and J. W. Greve¹

¹Department of General Surgery, University Hospital, Maastricht, the Netherlands; ²Department of General Surgery, Ijsselland Hospital, Capelle aan den Ijssel, the Netherlands; ³Department of General Surgery, Catharina Hospital, Eindhoven, the Netherlands

Surgical Endoscopy March 2007 ISSN 0930-2794 (Print) 1432-2218 (Online)

Background The goal of our study was to determine expert and referent face validity of the LAP Mentor, the first procedural virtual reality (VR) laparoscopy trainer.
Methods  In the Netherlands 49 surgeons and surgical trainees were given a hands-on introduction to the Simbionix LAP Mentor training module. Subsequently, a standardized five-point Likert-scale questionnaire was administered. Respondents who had performed over 50 laparoscopic procedures were classified as “experts.” The others constituted the “referent” group, representing nonexperts such as surgical trainees.
Results Of the experts, 90.5% (n = 21) judge themselves to be average or above-average laparoscopic surgeons, while 88.5% of referents (n = 28) feel themselves to be less-than-average laparoscopic surgeons (p = 0.000). There is agreement between both groups on all items concerning the simulator’s performance and application. Respondents feel strongly about the necessity for training on basic skills before operating on patients and unanimously agree on the importance of procedural training. A large number (87.8%) of respondents expect the LAP Mentor to enhance a trainee’s laparoscopic capability, 83.7% expect a shorter laparoscopic learning curve, and 67.3% even predict reduced complication rates in laparoscopic cholecystectomies among novice surgeons. The preferred stage for implementing the VR training module is during the surgeon’s residency, and 59.2% of respondents feel the surgical curriculum is incomplete without VR training.
Conclusion Both potential surgical trainees and trainers stress the need for VR training in the surgical curriculum. Both groups believe the LAP Mentor to be a realistic VR module, with a powerful potential for training and monitoring basic laparoscopic skills as well as full laparoscopic procedures. Simulator training is perceived to be both informative and entertaining, and enthusiasm among future trainers and trainees is to be expected. Further validation of the system is required to determine whether the performance results agree with these favorable expectations.

The following abstract was accepted to be presented at the e 24th annual World Congress of Endourology , Aug. 17-20, 2006 in Cleveland, Ohio.

CONSTRUCT VALIDITY TESTING OF THE LAPMENTOR LAPAROSCOPIC SURGICAL SIMULATOR

Peter D Vlaovic, Tadashi Matsuda, Federico A Corica, John R Boker, Leandro G Sala, Gabriella Stoliar, James F Borin, Yoshinari Ono, Ralph V Clayman, Elspeth M McDougall
University of California Irvine, Orange USA,
Nagoya University, Nagoya, Japan.

Introduction: Validation studies are necessary prior to the introduction of simulators into the surgical education curriculum. This study focuses on the construct validity of the LapMentor simulator. Method: The LapMentor is a virtual reality surgical simulator that offers both basic laparoscopic skills training and advanced procedures training. Previous studies have shown that Skill Task 8 (SK8) of the LapMentor has the highest level of construct validity. SK8 involves diathermy of highlighted bands with the use of L-hooks in both hands and dual foot control. Fifty-six experienced Japanese surgeons (JPN) were tested, following a single practice trial, on SK8. These surgeons were then compared to the previously collected SK8 data from 22 medical students (MS), 22 residents/ fellows (R/F), 23 experienced surgeons with less than 30 prior laparoscopic cases (ES<30), and 29 experts with greater than 30 prior laparoscopic cases (ES>30). Participants’ performance was recorded and group scores were compared using one-way analysis of variance and independent group t-tests. Results: The JPN had the highest overall scores (85.4), followed by the ES>30 (75.5), R/F (59.0), ES<30 (54.5), and MS (43.3). All of the differences were statistically significant (p<0.0005), except that the R/F and ES<30 were equivalent. Conclusion: This study provides further evidence of the high level of construct validity of the LapMentor basic laparoscopic skills training and testing.

The following abstract was accepted to be presented in the 15th Annual
Medicine Meets Virtual Reality (MMVR) Conference, February 6 - 9, 2007 in Long Beach, California.

The development of a proficiency-based training curriculum on the Lapmentor virtual reality laparoscopic simulator

Aggarwal R, Dias A, Balasundaram I, Darzi A

Department of Biosurgery and Surgical Technology, Imperial College London, U.K.

Background: The implementation of a competency-based laparoscopic surgical skills curriculum necessitates the development of tools to enable structured training, with in-built objective measures of assessment. Simulation in the form of virtual reality and synthetic models has been proposed for technical skills training at the early part of the learning curve. In order to be efficacious, these tools must convey a sense of realism, and a degree of standardization to enable graded acquisition of technical skills. Progression along the curriculum is charted by passing pre-defined expert benchmark criteria, which lead onto more technically demanding tasks. The aim of this study was to determine the construct validity and training potential of a commercially available laparoscopic VR simulator with force (haptic) feedback (Lapmentor, Simbionix, USA). A subsequent aim was to derive a competency-based laparoscopic training curriculum based upon this evidence.
Tools and methods: The study recruited 20 general surgeons of varying levels of experience: 10 inexperienced (performed <10 laparoscopic cholecystectomies [LCs]), 5 intermediate (20-50 LCs) and 5 experienced (>100 LCs). The basic skills module has nine tasks which were performed twice by all surgeons recruited to the study. Further to this, the 10 surgeons inexperienced in laparoscopic procedures continued to train on the simulator for a further eight sessions, making a total of 10 sessions. During the tasks, performance was recorded objectively and instantly by the VR simulator for the parameters of time taken, economy of movement (path length, number of movements) and error/accuracy scores.
Results: For the basic skills module of this simulator, all nine tasks demonstrated construct validity for time taken (Kruskal- Wallis test, p<0.05). The economy parameters were construct valid for six of the nine tasks, though error scores did not validate, apart from for two of the tasks (cutting and object translocation). Analysis of the learning curves for novices revealed significant improvements in performance on the basis of
quantitative metrics, i.e. time taken and economy scores (p<0.05). The median results of experienced surgeons for each task for each validated parameter enabled the definition of benchmark levels of performance to achieve.
Conclusion: The results of this study enable the definition of a competency-based training curriculum for laparoscopic surgery. All tasks have been proven to be construct valid, and learning curve analysis proves that novice surgeons improve their performance with repeated practice on the simulator. The derivation of benchmark criteria from the performance metrics of experienced surgeons ensures that it is acquisition of technical skill, and not the length of time spent on the simulator that determines progression onto real cases. This can serve to ensure that junior trainees have acquired pre-requisite levels of skill prior to entering the operating room, where they can be put into practice.
References:
1. Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004; 91(12):1549-1558.
2. Aggarwal R, Grantcharov T, Moorthy K, Hance J, Darzi A. A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 2006; 191(1): 128-133. 

The following abstract was accepted to be presented in the 15th Annual
Medicine Meets Virtual Reality (MMVR) Conference, February 6 - 9, 2007 in Long Beach, California.

The Virtual Interventional Suite for Training & Assessment (VISTA): a pilot study

Aggarwal R, Jacklin R, Wetzel C, Nestel D, Kneebone RL, Tierney T, Darzi A.

Department of Biosurgery and Surgical Technology, Imperial College London, U.K.

Background: At under- and post-graduate levels, medical curricula are beginning to place a strong emphasis not only upon simulation-based training, but also upon the need to ensure that progression through the curriculum is proficiency-based. This must be underpinned by objective measures of performance at each stage of the curriculum.
Yet technical simulation alone, however sophisticated, can only provide a one-sided picture of a clinician’s overall competence. It is clearly desirable to assess a number of skills together, in order to build up a composite picture of a clinician’s abilities in the real world. There is also an increasing awareness of the importance of nontechnical skills within the operating theatre. The ultimate goal of simulation has been to deliver procedural, multidisciplinary sessions in an authentic setting for the purposes of both formative and summative assessment. It is with this aim that we developed and piloted a virtualreality based simulated surgical scenario, from patient admission through to discharge.
Tools and methods: Each simulated scenario (laparoscopic cholecystectomy) was divided into pre-, intra- and post-operative phases, and all phases delivered in high-fidelity simulated environments: consultation room, operating theatre and ward respectively. The operative procedure was performed on a virtual reality simulator (Lapmentor, Simbionix, USA) in the presence of a full operative team, and simulated patients employed for pre- and postoperative phases. A multi-modal assessment of communication (video-based ratings), decision-making (video, think aloud during operative phase, medical notes and post-operative questionnaire), technical skills (videobased) and surgeon stress levels (physiological measures,
pre- and post-operative questionnaire and coping strategy
interview) was performed.
Results: Ten surgeons of varying experience levels completed the
simulated scenarios. Technical difficulty was adjusted to ensure appropriate levels of challenge for each operator’s level of experience. Evaluation confirmed high levels of perceived value and realism, and each complete scenario took between 90 and 120 minutes. Scores from the simulator are reported for time taken (mean 1813 seconds, standard deviation 441 seconds), total path length (28.88 metres, 10.07 metres) and number of movements (1480, 417). The global rating score (marked out of 35, 21 = competent) revealed a mean of 21 with a standard deviation of 4. Pre-operative consultations lasted between 7 and 11 minutes (rounded up to the next minute) while recovery ward interactions lasted between 2 and 4 minutes. Perceived stressfulness of the simulated operation was rated by the participants at a moderate level (mean 3.9, SD 2.2) on a Likert scale from 0 to 10. Reagrding decision-making, one senior participant requested conversion to open procedure in the face of uncontrolled bleeding from the cystic artery, whilst a junior surgeon did not request senior help even though he suspected biliary leakage from the proximal cystic duct after clipping. Justifications and thought processes leading up to the decisions are illuminated by the commentaries.
Conclusion: Surgical proficiency comprises a complex set of interdependent skills and abilities, necessitating a multi-modal approach to evaluation. This study describes an innovative approach to the training and assessment of operative skills, using high fidelity simulation to create a surgical environment which spans pre-, intra- and post-operative care. VR simulator technology, simulated patients (SP) and simulated clinical settings are combined to provide a safe yet authentic setting for exploring surgical performance in its wider sense. Key to the concept is the integration of multiple aspects of clinical practice which are more usually addressed in isolation, if at all. By emphasising the holistic context of surgical care, we counter a reductionist approach to surgical assessment. Although written from the perspective of the operating surgeon, it is proposed that this concept could underpin a structured, proficiency-based approach to curriculum design and assessment within the healthcare professions.
References:
1. Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med 2002; 77: 232-7.
2. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 2006; 139: 140-9.
3. Kneebone R et al. Blurring the boundaries: scenario-based simulation in a clinical setting. Medical Education 2005; 39: 580-7.
4. Wetzel CM et al. The effects of stress on surgical performance. Am J Surg 2006; 191: 5-10.
5. Aggarwal R, Undre S, Moorthy K, Vincent C, Darzi A. The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care 2004; 13 Suppl 1: i27-i32.

Laparoscopic skills are improved with LapMentor training: results of a randomized, double-blinded study

Pamela B Andreatta; Derek T Woodrum; John D Birkmeyer; Rajani K Yellamanchilli; Gerard M Doherty; Paul G Gauger; Rebecca M Minter

Departments of Medical Education and Surgery, University of Michigan, Ann Arbor, MI.

Ann Surg. 2006 Jun;243(6):854-60; discussion 860-3

OBJECTIVE: To determine if prior training on the LapMentor laparoscopic simulator leads to improved performance of basic laparoscopic skills in the animate operating room environment. SUMMARY BACKGROUND DATA: Numerous influences have led to the development of computer-aided laparoscopic simulators: a need for greater efficiency in training, the unique and complex nature of laparoscopic surgery, and the increasing demand that surgeons demonstrate competence before proceeding to the operating room. The LapMentor simulator is expensive, however, and its use must be validated and justified prior to implementation into surgical training programs.
METHODS: Nineteen surgical interns were randomized to training on the LapMentor laparoscopic simulator (n = 10) or to a control group (no simulator training, n = 9). Subjects randomized to the LapMentor trained to expert criterion levels 2 consecutive times on 6 designated basic skills modules. All subjects then completed a series of laparoscopic exercises in a live porcine model, and performance was assessed independently by 2 blinded reviewers. Time, accuracy rates, and global assessments of performance were recorded with an interrater reliability between reviewers of 0.99.
RESULTS: LapMentor trained interns completed the 30 degrees camera navigation exercise in significantly less time than control interns (166 +/- 52 vs. 220 +/- 39 seconds, P < 0.05); they also achieved higher accuracy rates in identifying the required objects with the laparoscope (96% +/- 8% vs. 82% +/- 15%, P < 0.05). Similarly, on the two-handed object transfer exercise, task completion time for LapMentor trained versus control interns was 130 +/- 23 versus 184 +/- 43 seconds (P < 0.01) with an accuracy rate of 98% +/- 5% versus 80% +/- 13% (P < 0.001). Additionally, LapMentor trained interns outperformed control subjects with regard to camera navigation skills, efficiency of motion, optimal instrument handling, perceptual ability, and performance of safe electrocautery.
CONCLUSIONS: This study demonstrates that prior training on the LapMentor laparoscopic simulator leads to improved resident performance of basic skills in the animate operating room environment. This work marks the first prospective, randomized evaluation of the LapMentor simulator, and provides evidence that LapMentor training may lead to improved operating room performance.

Construct validity testing of a laparoscopic surgical simulator.
McDougall EM, Corica FA, Boker JR, Sala LG, Stoliar G, Borin JF, Chu FT, Clayman RV.
Departments of Urology and Family Medicine, University of California,
Irvine, Orange, CA. J Am Coll Surg. 2006 May;202(5):779-87.

BACKGROUND: We present initial data on the construct, content, and face validity of the LAPMentor (Simbionix), virtual reality laparoscopic surgical simulator. STUDY DESIGN: Medical students (MS), residents and fellows (R/F), and experienced laparoscopic surgeons (ES), with < 30 laparoscopic cases per year (ES<30) and those with > 30 laparoscopic cases per year (ES>30), were tested on 9 basic skill tasks (SK) including manipulation of 0-degree and 30-degree cameras (SK1, SK2), eye-hand coordination (SK3), clipping (SK4), grasping and clipping (SK5), two-handed maneuvers (SK6), cutting (SK7), fulguration (SK8), and object-translocation (SK9). RESULTS: Mean MS (n=23), R/F (n=24), ES<30 (n=26), and ES>30 (n=30) ages were 26 years (range 21 to 32 years), 31 years (range 27 to 39 years), 49 years (range 31 to 70 years) and 47 years (range 34 to 69 years), respectively. In the lower level skill tasks (SK3, SK4, SK5, and SK6) the ES>30, ES<30, and R/F had similar scores, but were all substantially better than the MS scores. In the higher level skill tasks (SK7, SK8, and SK9), the ES>30 scores tended to be better than the R/F and ES<30, which were similar, and these, in turn, were markedly better than the MS. The ES>30 had notably higher SK8 scores than the R/F and ES<30, who had similar scores, and these had notably better scores than the MS. CONCLUSIONS: The noncamera skills (SK3 to 9) of the LAPMentor surgical simulator can distinguish between laparoscopically naive and ES. SK8 showed the highest level of construct validity, by accurately differentiating among the MS, R/F, ES<30 and ES>30.

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Determination of Face Validity for the Simbionix LAP Mentor Virtual Reality Training Module.
Ayodeji ID, Schijven MP, Jakimowicz JJ.
Department of General Surgery, Maxima MC, Eindhoven, Netherlands
Stud Health Technol Inform. 2006;119:28-30

This study determines the expert and referent face validity of LAP Mentor, the first procedural virtual-reality (VR) trainer. After a hands-on introduction to the simulator a questionnaire was administered to 49 participants (21 expert laparoscopists and 28 novices). There was a consensus on LAP Mentor being a valid training model for basic skills training and the procedural training of laparoscopic cholecystectomies. As 88% of respondents saw training on this simulator as effective and 96% experienced this training as fun it will likely be accepted in the surgical curriculum by both experts and trainees. Further validation of the system is required to determine whether its performance concurs with these favourable expectations.

Biliary and Vascular Anatomical Variations in a New Virtual Reality Simulator for Endoscopic Surgery Training
Amir Szold MD, Boaz Sagie MD
Endoscopic Surgery Service and the Department of Surgery B, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

The abstract was published and presented as part of the poster session at the 2004 SAGES meeting, March 31 - April 3 2004 in Denver , Colorado . New Techniques/Technology, Poster P392

This article provides a thorough description and evaluation of the LAP Mentor simulator with particular emphasis on the features and benefits of training with the simulator. It concludes that the simulator addressed the issues of providing realistic picture of surgical procedures and the tasks are aimed at specific skills required to perform laparoscopic surgery. The simulator was well accepted by the trainees and it is now included in a structured basic training program for laparoscopic surgery.

The following abstract on topics involving the LAP Mentor™ simulator was published and presented at the 20th World Congress on Endourology and SWL, 18th Basic Research Symposium, September 19-22, 2002 in Genoa, Italy.

P16-27 LAPAROSCOPIC & ENDOUROLOGIC SIMULATORS FOR TRAINING. Steiner, Charles, Inderbir S. Gill, Ran Cohen, Inbal Mazor. The abstract discusses a study designed to investigate the efficacy of an endourologic simulator and a laparoscopic surgical simulator as part of a formal training course. Residents were divided into 2 groups after being initially scored on basic endourologic and laparoscopic skills in the inanimate trainer and an acute porcine model. One group then underwent 8 hours of training on each of the two simulators and the second group received more classic training involving observation and training on the inanimate trainer. Preliminary results indicate significantly superior technical skill acquisition for the group trained on the simulators.