LAP Mentor Clinical Validations

The new approach for the surgical residents “Basic Endoscopy skills” Training & Certification in the Ukraine

PhD,DSc, Prof. Volodymyr Artyomenko: Md Mykhailo Pervak.

Odessa National Medical university. Dep of Simulation Medicine, Educational – Innovative Centre for the Physician Practical Training.

The study was presented as part of the poster session at the 2016 SESAM meeting, June 15 – 17 2016 in Lisbon, Portugal.

Background and Aims: The mistakes and complications rate during laparoscopy operations remains still high especially at young surgeons. Laparoscopy operations rate in the Ukraine clinics varies from 12 to 70% depending on equipment and surgeon experience especially during urgent cases. Today we faced the necessity of the endoscopic surgery basic skills thorough mastering by surgical residents before their practical application on real patients. The aim of our study was the surgical residents “Basic Endoscopy Skills” training and certification program development and evaluation with the use of virtual reality simulators (VRS).

Materials and Methods: For the first time in the Ukraine specialists of the Educational – Innovative Center for the Physicians Practical Training and Department of Simulation Medicine of Odessa National Medical University the surgical residents “Basic Endoscopy Skills” training and certification program with the virtual simulators use was developed and evaluated. 75 general surgery residents underwent the program followed by their state board exam during 2014-2015 years. The program consists of 7 continuous steps total 108 hours (4 weeks), based on SAGES and EAES programs.

These steps are:

  • Primary testing of subjective skills assessment box trainers skills management;
  • Live and recorded surgical operations video translations;
  • Mini-lectures;
  • Virtual reality simulators;
  • Intermediate testing;
  • Hybrid systems skills management;
  • Final testing and skills evaluation.

We use virtual reality simulator (3D Systems Simbionix LAP Mentor) both for the residents training and certification.

The training was performed in small groups of 5-6 residents. The program was part of the general surgeon licensure procedure to obtain the “general surgeon” certificate. The residents were marking down their skills score (subjective assessment versus objective evaluation). For the first time the skills evaluation score was not only complex but included objective statistic results made by VRS (LAPMentor) individual calculation.

Results and Conclusions: All the residents gave the highest score for the program actuality, practicality, necessity and appreciated very much the possibility of such training. One of the most important things is virtual reality simulators actuality and necessity approval for the future mandatory use and implementation in all surgical specialities educational programs. Except clinical experience in safe surroundings without patients risk and harm, unlimited number of practical skills repetitions especially in threating – life conditions we would like to point out the virtual reality simulators advantages such as:

  • Objective assessment of the mastering level
  • Multiple tutors functions
  • Stress tension reliable decrease during first independent operations

The following abstract was presented at the annual British Society for Gynaecological Endoscopy (BSGE ASM) June 3-5, 2015 London, UK

Harmonic instrumentation significantly reduces the mental load compared with diathermy during simulated laparoscopic salpingectomy: A Randomised Cross-over Trial.

Bharathan R, Kovoor E.

St George’s Healthcare NHS Trust, Blackshaw Rd, London SW17 0QT

Maidstone and Tunbridge Wells Hospital

Introduction: Laparoscopic salpingectomy (LS) is an essential gynaecological procedure, which may be performed for tubal ectopic pregnancy or ovarian cancer risk reduction. Harmonic devices are purported to offer superior ergonomics. This study examines the impact of instrumentation on surgeons’ mental load.

Method: Nine participants were stratified at recruitment to this cross-over randomisd comparative study, using computer generated allocation. Participants were first trained to proficiency in salpingectomy. All the performances were completed on LAP Mentor virtual reality simulator which captured the dexterity metrics and simultaneously recorded videos of the procedures. Each participant performed a salpingectomy using harmonic and diathermy (bipolar/monopolar) techniques during separate sessions. During the salpingectomy participants were required to perform simultaneously, a validated visuo-cognitive secondary task. After the procedures, participants completed two validated questionnaires – NASA-TLX and subjective mental effort questionnaire (SMEQ).

Results: In all six dimensions of NASA-TLX, harmonics resulted in significant improvement in workload measures [mental demand (P=0.02), physical demand (P=0.008), temporal demand (P=0.004), performance (P=0.007), effort (P=0.02) and frustration (P=0.003). SMEQ measure also reflected significant reduction in mental load associated with harmonic instrument (P=0.037).

The visuo-cognitive secondary task measures of mental load, revealed a significant reduction associated with harmonics: the overall detection rate (P=0.0004) and correct detection rates (P=0.0004) were significant. Pearson correlation coefficient between mental load (NASA-TLX) and SMEQ was 0.74 for diathermy group and 0.76 for the harmonics group, thus demonstrating a moderately strong concurrent validity of outcome measures. This fortifies our findings.

Conclusion: Harmonic instrument significantly reduces mental load during simulated laparoscopic salpingectomy.


The following abstract was presented at the annual British Society for Gynaecological Endoscopy (BSGE ASM) June 3-5, 2015 London, UK

A warm-up strategy is effective in reducing mental load during laparoscopic prophylactic bilateral salpingo-oophorectomy: A Randomised Controlled Trial.

Bharathan – Maidstone and Tunbridge Wells Hospital

McLaren -, Croydon University Hospital

Ind -, St.Georges Hospital London

Introduction: Laparoscopic prophylactic bilateral salpingo-oophorectomy (LapBSO) is performed as a risk reduction intervention for ovarian cancer. Pre-task warm-up is proven to enhance performance. This is the first trial to explore mental load during surgery.

Method: This is a cross-over randomised trial. Participants were stratified prior to computer generated allocation. Eighteen participants were first trained to proficiency bench. Training and assessments were completed on LAP Mentor virtual reality simulator. Each participant performed a ‘control’ LapBSO and a warm-up task followed by LapBSO. The warm-up task was ‘circle cutting’ which is FLS validated; this is time-limited to five minutes. During the LapBSO the participants were required to simultaneously perform a validated visuo-cognitive secondary task. After the LapBSO tasks, participants completed two validated questionnaires – NASA-TLX and subjective mental effort questionnaire (SMEQ).

Results: Warm-up intervention lead to significant reduction in SMEQ scores (P=0.02). In n four of the six dimensions of NASA-TLX, warm-up intervention resulted in significant improvement in workload measures [mental demand (P=0.04), temporal demand (P=0.015), performance (P=0.007) and frustration (P=0.003). The ratings approached statistical significance for physical demand (P=0.051) and effort (P=0.06). The visuo-cognitive secondary task measure of mental load, revealed a significant reduction in mental load: the overall detection rate (P=0.003) and correct detection rates (P<0.05) were significantly higher in the interventional arm. The correlation coefficient between mental load and SMEQ is significant for the control group (0.801) and interventional group (0.72); this strengthens our findings.

Conclusion: Pre-task warm-up is an effective technique in reducing mental load during LapBSO.


The following abstract was presented at the 132nd Congress of the German Society of Surgery (DGCH), April 28 – May 1, 2015, Munich, Germany

Validation of a simulation module for laparoscopic appendectomy using the LapMentor Virtual Reality Trainer

Neumann PA, Brinkmann C, Fritz M, Senninger N, Rijcken E

Department of Surgery University Clinic of Muenster‘ Muenster, Germany

Introduction: Simulation training has become a well-accepted method in operative training of surgical residents. During the last years Simbionix (Cleveland, OH, USA) has developed an updated module for laparoscopic appendectomy using the Lap-Mentor II simulation trainer. We have now performed a validation study to test face-, content- and construct validity of the module in 2 different groups. Group A: Students without previous experience in laparoscopy; Group B: Students that have completed a one week intensive training in laparoscopy as well as young residents in general surgery.

Methods and material: Each participant performed 2 simulated appendectomies in different clinical settings (regular position, retrocecal, perforated, gangrenous appendicitis). Different instruments (electric hook, ultracision, scissors) as well as different methods for specimen resection (stapler, endo-loop, clips) could be selected. Subsequently a standardized questionnaire was filled out to evaluate face validity and content validity. Construct validity was evaluated using the objective data recorded by the lab-mentor (total procedure time, idle time, number of movements). Results of the two groups were statistically compared to evaluate whether the module could differentiate between the different levels of experience.

Results: A total of 41 participants have been included (Group A: 21; Group B: 20). In Group A 1 participant had experience with the lap mentor (5%), in Group B 11 had previous experience on the lap mentor (55%). Differences in operative experience were well reflected by differences in „idle time“ (Group A: 213 ± 31,8s vs. Group B: 139 ± 19,1s, p=0,055), „number of movements“ (Group-A: 606 ± 58,1 vs. Group-B: 541 ± 33,3, p=0,34). Analysis of the questionnaires showed the following results without differences between the groups: Face validity: majority of the participants found the module to be easy to use (n=28/41), clinical simulation by the module was found to be realistic to very realistic (n=32/42). Content validity: 39 of 41 participants recommended using the simulator for operative training of surgical residents.

Conclusion: The simulation module for laparoscopic appendectomy was evaluated by participants with different operative experience. The majority recommended using the module for surgical education. Through recording of different objective criteria the module showed valid construct validity. Especially the possibility to use different clinical settings (retrocecal position, perforated appendicitis) for operative training is an interesting feature in using the lap mentor for surgical training. Further evaluation will be performed to also include participants of advanced surgical experience.


Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices.

Nickel F, Brzoska JA, Gondan M, Rangnick HM, Chu J, Kenngott HG, Linke GR, Kadmon M, Fischer L, Müller-Stich BP.

Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany (FN, JAB, HMR, JC, HGK, GRL, MK, LF, BPM-S); and Department of Psychology, University of Copenhagen, Copenhagen, Denmark (MG).

Medicine (Baltimore). 2015 May;94(20)

This study compared virtual reality (VR) training with low cost-blended learning (BL) in a structured training program.Training of laparoscopic skills outside the operating room is mandatory to reduce operative times and risks.Laparoscopy-naïve medical students were randomized in 2 groups stratified for sex. The BL group (n = 42) used E-learning for laparoscopic cholecystectomy (LC) and practiced basic skills with box trainers. The VR group (n = 42) trained basic skills and LC on the LAP Mentor II (Simbionix, Cleveland, OH). Each group trained 3 × 4 hours followed by a knowledge test concerning LC. Blinded raters assessed the operative performance of cadaveric porcine LC using the Objective Structured Assessment of Technical Skills (OSATS). The LC was discontinued when it was not completed within 80 min. Students evaluated their training modality with questionnaires.The VR group completed the LC significantly faster and more often within 80 min than BL (45% v 21%, P = .02). The BL group scored higher than the VR group in the knowledge test (13.3 ± 1.3 vs 11.0 ± 1.7, P < 0.001). Both groups showed equal operative performance of LC in the OSATS score (49.4 ± 10.5 vs 49.7 ± 12.0, P = 0.90). Students generally liked training and felt well prepared for assisting in laparoscopic surgery. The efficiency of the training was judged higher by the VR group than by the BL group.VR and BL can both be applied for training the basics of LC. Multimodality training programs should be developed that combine the advantages of both approaches.


The following abstract was presented at annual meeting of the British Society for Gynaecological Endoscopy (BSGE), June 3-5, 2015, London, UK and at the Royal Society of Medicine Meeting, March 2015.

Virtual Reality Laparoscopic Simulator: Face Validity of Essential Gynecological Procedures

Bharathan R, McLaren J.S, Ind T.

St George’s Healthcare NHS Trust, Blackshaw Rd, London SW17 0QT

INTRODUCTION: Simulation-based skills training in laparoscopic surgery leads to enhanced quality of performance, reduced errors, shorter operative time and superior patient safety profile. The aim of this study was to determine trainers and trainees assessment of face validity of the Simbionix LAP MentorTM III in three essential gynecological procedures.

METHODS: 27 gynecologists (5 Consultants, 3 Senior Registrars, 13 Registrars, 6 Senior House Officers) were orientated to the training modules. Subsequently, at their convenience they performed bilateral tubal ligation, bilateral salpingo-oopherectomy and right salpingectomy, for tubal ectopic pregnancy. Following completion, a ten-point Likert-scale questionnaire was completed evaluating each task based on appearance of instruments and pelvic tissue, manoeuvring and function of instruments, response to tissue manipulation, depth perception, ergonomics of the simulator and overall utility as a training tool.

RESULTS: The median Likert-scale scores for the appearance of instruments, hand-eye coordination and utility as a training device tasks were scored 9. The instrument manoeuvring & function of instruments, appearance of tissue and response to manipulation, depth perception, bimanual handing and simulator’s ergonomics were rated a median score of 8.

CONCLUSION: Instrumentation, tissue depiction and response to manipulation appear to have high face validity. The Simbionix LAP Mentor™ III was regarded as a valid training tool. In our next steps, construct and predictive validity assessments will enable construction of a proficiency based curriculum. We believe the simulation based training can translate to clinical benefit in gynecology.


The following abstract was presented at annual meeting of the  British Society for Gynaecological Endoscopy (BSGE), June 3-5, 2015, London, UK.

Laparoscopic Hysterectomy Training for Endometrial Cancer Surgery: Validation of a Virtual Reality Simulator

Bharathan R, McLaren J.S, Ind T.

St George’s Healthcare NHS Trust, Blackshaw Rd, London SW17 0QT Bharathan R, McLaren J.S, Ind T.

INTRODUCTION:  Laparoscopy is the preferred route for hysterectomy. Surgical errors are more prevalent during the learning curve. High quality evidence supports simulation based training over standard training. Prior to adopting a simulator, the device must be tested for face and content validity. We present the first study of a hysterectomy simulator.

 METHODS:  Twelve consultant and five subspecialty trainees who are certified to perform TLH for endometrial cancer, were recruited. The Simbionix virtual reality simulator offers a hysterectomy module and suturing tasks. The participants performed TLH + BSO and vault closure before completing the assessment. Participants rated the ten features of face validity and the seven features of content validity using a ten point Likert scale: a score of one equals minimum and ten indicates maximum. Qualitative feedback was captured.

RESULTS:  The face validity assessment scores were high, with median scores ranging 7-9: instruments’ appearance (9), instrument manoeuvring (8), instrument functionality (8), tissue appearance (8), response to manipulation (7), depth perception (7), hand-eye coordination training (8), bimanual coordination training (8), value as a training device (8) ergonomics (7). The scores for content validation are uterine manipulation (9), IP ligament (8), bladder dissection (7), UA (8), colpotomy (7), identification of ureter (7) and vault closure (4).

DISCUSSION:  The study demonstrates face and content validity of the VR-LH simulator. The vault closure task on this VR simulator was not highly rated. We believe this simulator will enhance the learning of LH. The next steps would be assessments of construct validity and learning curves.


Crossover Study of the Effect of Coffee Consumption on Simulated Laparoscopy Skills

Quan V1, Alaraimi B2, Elbakbak W3, Bouhelal A3, Patel B2.

1Barts and The London School of Medicine and Dentistry, Garrod Building, Turner St, Greater London, E1 2AD, UK; Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK. Electronic address: Vincent_quan@hotmail.co.uk.

2Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK; Academic Department of Upper GI Surgery, Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London, E1 1BB, UK.

3Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.

Int J Surg. 2015 Feb;14:90-5. doi: 10.1016/j.ijsu.2015.01.004. Epub 2015 Jan 14.

AIMS: To observe the effect of caffeine on performing laparoscopic skills in novices in a simulated setting.

BACKGROUND: Coffee is consumed almost ubiquitously by surgeons not just as a stimulant but also socially in the well-rested individual. It’s therefore worth investigating its potentially negative effect on performance of surgical skills as it is known that coffee has psychomotor effects.

METHODS: This is a single-blind crossover study in which 31 novices were tested under three different conditions: decaffeinated, 100 mg caffeine and 200 mg caffeine. Candidates were asked to perform 3 repetitions of task 3, 6, 7 and 8 using the Lap Mentor™ (Simbionix(®)). Outcomes measured were completion time, accuracy, number of movements and total path length. The candidates were crossed over to the other caffeine doses on a different day.

RESULTS: 20 candidates completed the study, mean age 21.3 years, with 10 males and 10 females. Candidates performed tasks 7 and 8 faster in the decaffeinated group than the caffeinated groups with significant differences between decaffeinated and 100 mg caffeine (p-value = 0.001, 0.019 respectively) and decaffeinated and 200 mg in task 8(p-value = 0.042). Total path length was significantly less in the decaffeinated group in tasks 7 and 8 and total number of movements was less in tasks 3, 7 and 8.

CONCLUSION: Caffeine had no marked effect on accuracy, but had a negative effect on task economy (hand movements, total path length and completion time).

Development of a Knowledge, Skills, and Attitudes Framework for Training in Laparoscopic Cholecystectomy

Harrysson I1, Hull L2, Sevdalis N2, Darzi A2, Aggarwal R2.

1Department of Surgery and Cancer, Imperial College London, QEQM Building, Praed Street, London W2 1NY, UK. Electronic address: ilianaj@stanford.edu.

2Department of Surgery and Cancer, Imperial College London, QEQM Building, Praed Street, London W2 1NY, UK.

Am J Surg. 2014 May;207(5)

BACKGROUND: The implementation of duty-hour restrictions and a heightened awareness of patient safety has changed resident education and training. A new focus has been placed on high-yield training programs and simulation training has naturally grown to fill this need.

METHODS: This article discusses the development of a training framework, knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. Five residents were recruited for a pilot study of the curriculum.

RESULTS: A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. The curriculum consisted of classroom and virtual reality simulation training and was completed in 3.1 to 4.8 hours.

CONCLUSIONS: The current curricula that have been developed for surgical education cover the breadth of a surgical residency well. This curriculum went beyond these curricula and developed a structured framework for surgical training, a method that can be applied to any procedure.

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The Use of Virtual Reality Simulation to Determine Potential for Endoscopic Surgery Skill Acquisition

Mann T1, Gillinder L, Szold A.

1Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel.

Minim Invasive Ther Allied Technol. 2014 May 5. [Epub ahead of print]

BACKGROUND: Efficient acquisition of endoscopic technique is essential for high-level care in surgical practice. In contrast to similar substantial risk industries, there is no standard instrument capable of detecting the potential of surgical residency candidates to develop such skills.

MATERIAL AND METHODS: We used the Simbionix “Lapmentor” Virtual reality simulator basic skills tasks 1, 5 and 6 to establish baseline performance of 17 subjects lacking surgical experience, then divided them into two groups. One group trained on the Lapmentor, a validated trainer. The second group trained on a video box trainer using 3 FLS tasks, which correlate with real OR performance. After completing the training program, each group was tested on its training modality and correlations were sought between performance in the screening tasks and final scores in both groups.

RESULTS: Time in Lapmentor task 1 showed significant correlations with total FLS scores (R 0.807 P 0.015), in addition to other benchmark parameters. With the Lapmentor group, time on task 5 demonstrated correlation with itself on the final scores (R 0.794 P 0.011).

CONCLUSIONS: Time in the Lapmentor task 1 demonstrates correlations with FLS scores, which translate to better OR performance. The Lapmentor thus shows potential to be used as a screening test for surgical talent.

The following abstract was presented at Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), April 2-5, 2014, Salt Lake City, Utah

Assessment of Medical Students Laparoscopic Skills Using Virtual Reality and Fundamentals of Laparoscopic Surgery Skills

Erica Sutton MD, Craig Ziegler MS, Kevin Martin BS, Stuart Crawford BS, Matthew Golden MD, J. David Richardson MD Hiram C. Polk Jr.

Department of Surgery, University of Louisville School of Medicine, Louisville, KY

INTRODUCTION: This study evaluates if undergraduate medical trainees’ laparoscopic skills acquisition could be monitored and assessed using a virtual reality (VR) simulator and how the resultant metrics correlate with actual performance of Fundamentals of Laparoscopic Surgery™ (FLS) tasks.  A central tenet in creating competency-based curricula in undergraduate medical education is the development of meaningful assessments of medical student performance.  Therefore, we studied the use of VR to characterize and assess the laparoscopic skills attained in a competency-based curriculum designed for graduating medical students applying for general surgery residency.  Our overall goal is to integrate the milestone competencies for surgery across the educational continuum and document trainee progress toward proficiency.

METHODS: Ten fourth year medical students applying for surgical residency completed a monitored virtual reality training curriculum comprised of camera navigation (CN), hand eye coordination (HEC) and FLS tasks: circle cutting (CC), ligating loop (LL), peg transfer (PT), and intracorporeal knot tying (IKT).  Students completed the curriculum at their own pace over eight weeks.  Performance goals were those of the simulator for CN and HEC tasks and the standard goals given in the FLS instruction manual for FLS tasks.  Progress through the VR curriculum was monitored weekly by a single faculty member (FLS certified) using online software (Mentorlearn™).

After eight weeks, students were observed and recorded performing FLS tasks.  The best VR performance for each FLS task and the observed performance of the FLS tasks were scored by assigning penalties as described in the FLS instruction manual.  The ability of the VR simulator to detect penalties in each of the FLS tasks as well as correlations of time taken to complete tasks are reported.  Additional metrics from the VR simulator (speed, number of movements, path length, strain, needle drops passes, and loading time) were examined for correlation to the commission of penalties.

RESULTS: All ten students trained in 100% of the curriculum, though no student achieved proficiency in all of the VR modules assigned by the end of eight weeks.  All students were proficient in CN and HEC tasks.  Proficiency was achieved in CC, LL PT and IKT by 8, 6, 8, and 1 student respectively.

VR simulation showed high specificity for predicting zero penalties on the observed CC, LL, and PT tasks (78%, 80%, and 60%).  VR ability to predict IKT penalties was most sensitive at two VR penalties (75%).  VR consistently underestimates time for CC, LL, PT, and IKT tasks.  Speed, number of movements, path length, strain, needle drops, passes, time needle is out of view and loading time did not correlate with penalties for any task

DISCUSSION: At the University of Louisville, we are implementing curricula to improve the readiness of our undergraduate medical students to enter surgical training.  This competency-based curriculum in laparoscopic skills is part of the Acting Internship in Surgery elective offered by the School of Medicine.  In 2011, Edelman et al. found that medical students who trained on FLS tasks had a durable improvement of laparoscopic skills during their intern year when compared to interns who had not trained prior to entering internship and recommended the integration of FLS skills into undergraduate medical education.1,2  Our study uses performance of FLS tasks to assign meaning to assessments of medical students made on VR simulators for such curricula.

CONCLUSION: VR can be used to monitor and assess medical student acquisition of laparoscopic skills.  The absence of penalties in the simulator reasonably predicts the absence of penalties in manual demonstration of CC, LL and PT skills, but not IKT.  The documented skills acquired by trainees can be transferred to a graduate medical education program for further monitoring of progress toward proficiency.

References

  1. Edelman DA, Mattos MA, Bouwman DL. Impact of fundamentals of laparoscopic surgery training during medical school on performance by first year surgical residents. J Surg Res. 2011 Sep;170(1):6-9.
  2. Edelman DA, Mattos MA, Bouwman DL. Value of fundamentals of laparoscopic surgery training in a fourth-year medical school advanced surgical skills elective. J Surg Res. 2012 Oct;177(2):207-10.

Hybrid Simulation: Bringing Motivation to the Art of Teamwork Training in the Operating Room

Kjellin A, Hedman L, Escher C, Felländer-Tsai L.

Scand J Surg. 2014 Feb 18. [Epub ahead of print]

BACKGROUND AND AIMS: Crew resource management-based operating room team training will be an evident part of future surgical training. Hybrid simulation in the operating room enables the opportunity for trainees to perform higher fidelity training of technical and non-technical skills in a realistic context. We focus on situational motivation and self-efficacy, two important factors for optimal learning in light of a prototype course for teams of residents in surgery and anesthesiology and nurses.

MATERIAL AND METHODS: Authentic operating room teams consisting of residents in anesthesia (n = 2), anesthesia nurses (n = 3), residents in surgery (n = 2), and scrub nurses (n = 6) were, during a one-day course, exposed to four different scenarios. Their situational motivation was self-assessed (ranging from 1 = does not correspond at all to 7 = corresponds exactly) immediately after training, and their self-efficacy (graded from 1 to 7) before and after training. Training was performed in a mock-up operating theater equipped with a hybrid patient simulator (SimMan 3G; Laerdal) and a laparoscopic simulator (Lap Mentor Express; Simbionix). The functionality of the systematic hybrid procedure simulation scenario was evaluated by an exit questionnaire (graded from 1 = disagree entirely to 5 = agree completely).

RESULTS AND CONCLUSIONS: The trainees were mostly intrinsically motivated, engaged for their own sake, and had a rather great degree of self-determination toward the training situation. Self-efficacy among the team members improved significantly from 4 to 6 (median). Overall evaluation showed very good result with a median grading of 5. We conclude that hybrid simulation is feasible and has the possibility to train an authentic operating team in order to improve individual motivation and confidence.

Virtual Reality Simulator Training for Laparoscopic Colectomy: What Metrics Have Construct Validity?

Shanmugan S1, Leblanc F, Senagore AJ, Ellis CN, Stein SL, Khan S, Delaney CP, Champagne BJ.

11Division of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio 2Department of Digestive Surgery, University Hospitals of Bordeaux, Bordeaux, France 3Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 4Division of Colorectal Surgery, Veterans Administration Gulf Coast Veterans Health Care System, Biloxi, Mississippi.

Dis Colon Rectum. 2014 Feb;57(2):210-4.

BACKGROUND: Virtual reality simulation for laparoscopic colectomy has been used for training of surgical residents and has been considered as a model for technical skills assessment of board-eligible colorectal surgeons. However, construct validity (the ability to distinguish between skill levels) must be confirmed before widespread implementation.

OBJECTIVE: This study was designed to specifically determine which metrics for laparoscopic sigmoid colectomy have evidence of construct validity.

DESIGN: General surgeons that had performed fewer than 30 laparoscopic colon resections and laparoscopic colorectal experts (>200 laparoscopic colon resections) performed laparoscopic sigmoid colectomy on the LAP Mentor model. All participants received a 15-minute instructional warm-up and had never used the simulator before the study. Performance was then compared between each group for 21 metrics (procedural, 14; intraoperative errors, 7) to determine specifically which measurements demonstrate construct validity. Performance was compared with the Mann-Whitney U-test (p < 0.05 was significant). RESULTS: Fifty-three surgeons; 29 general surgeons, and 24 colorectal surgeons enrolled in the study. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 of 14 procedural metrics by distinguishing levels of surgical experience (p < 0.05). The most discriminatory procedural metrics (p < 0.01) favoring experts were reduced instrument path length, accuracy of the peritoneal/medial mobilization, and dissection of the inferior mesenteric artery. Intraoperative errors were not discriminatory for most metrics and favored general surgeons for colonic wall injury (general surgeons, 0.7; colorectal surgeons, 3.5; p = 0.045). LIMITATIONS: Individual variability within the general surgeon and colorectal surgeon groups was not accounted for.

CONCLUSIONS: The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 procedure-specific metrics. However, using virtual reality simulator metrics to detect intraoperative errors did not discriminate between groups. If the virtual reality simulator continues to be used for the technical assessment of trainees and board-eligible surgeons, the evaluation of performance should be limited to procedural metrics.

The following abstract was presented at Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), April 17-20, 2013, Baltimore, Maryland

Short-Duration Virtual-Reality Simulation Training Positively Impacts Performance During Laparoscopic Colectomy in an IMAL Model: Results of a Randomized Trial

Sergio E Araujo, MD, PhD, Conor P Delaney, Md, MCh, PhD, Victor E Seid, MD, Antonio R Imperiale, MD, Paulo Herman, MD, PhD, Sergio C Nahas, MD, PhD, Ivan Cecconello, MdPhD

Colorectal Surgery Division at University of Sao Paulo Medical Center, Sao Paulo, Brazil and Case Western Reserve University Center for Skills and Simulation, Cleveland, OH

PURPOSE: Several studies have demonstrated transferring of skills after virtual reality (VR) simulation training in laparoscopic surgery. However, most studies have demonstrated improved simulation performance only after simulation training. Moreover, the impact of VR simulation training on transfer of skills specific to laparoscopic colectomy remains unknown. The present study aimed at determining the impact of VR simulation warm-up on surgical trainees performance during laparoscopic colectomy in the porcine model.

METHODS: Fourteen residents naive to laparoscopic colectomy were randomly assigned to two groups. Seven trainees completed a 2-hour VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a laparoscopic anterior resection with anastomosis on a pig. All operations were recorded on DVD. Performance evaluation was independently assessed by two board-certified colorectal surgeons blinded to trainee’s identity. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. General and specific technical skills were analyzed.

RESULTS: Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig based on general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5 – 18) for the control group and 20.1 (16.5 – 22) for the study group (p=0.002). Regarding specific skills, the average score for the control group was 20.2 (19 – 21.5), and 24.2 (21 – 27.5) for the study group (p = 0.001).

CONCLUSIONS: A single short-duration VR simulator practice positively impacted surgeons’ generic and specific skills performance required to accomplish laparoscopic colectomy in the porcine model.

Can Virtual Reality Simulators be a Certification Tool for Bariatric Surgeons?

Giannotti D, Patrizi G, Casella G, Di Rocco G, Marchetti M, Frezzotti F, Bernieri MG, Vestri AR, Redler A.

Department of Surgical Sciences, Policlinico “Umberto I”, “Sapienza” – University of Rome, Viale Regina Elena 324, 00161, Rome, Italy

Surg Endosc. 2013 Aug 31.

BACKGROUND:  Construct validity of virtual laparoscopic simulators for basic laparoscopic skills has been proposed; however, it is not yet clear whether the simulators can identify the actual experience of surgeons in more complex procedures such as laparoscopic Roux-en-Y gastric bypass. This study tested the ability of the Lap Mentor simulator to recognize the experience in advanced laparoscopic procedures and to assess its role in the certification of bariatric surgeons.

METHODS: Twenty surgeons were divided into two groups according to their experience in laparoscopic and bariatric surgery. The general group included 10 general surgeons performing between 75 and 100 nonbariatric laparoscopic procedures. The bariatric group included 10 bariatric surgeons performing between 50 and 100 laparoscopic bariatric procedures. Participants were tested on the simulator in one basic task (task 1: eye-hand coordination) and in two tasks of the gastric bypass module (task 2: creation of the gastric pouch; task 3: gastrojejunal anastomosis).

RESULTS: Comparing the groups, no significant differences were found in task 1. Analyzing the results from the gastric bypass module (bariatric vs. general), in task 2, significant differences (p < 0.05) were found in the median volume of the gastric pouch (21 vs. 48 cm3), in the percentage of fundus included in the pouch (8.4 vs. 29.4 %), in the complete dissection at the angle of His (10 vs. 3), and in safety parameters. In task 3, significant differences were found in the size and position of enterotomies. CONCLUSIONS: The Lap Mentor may be proposed as a certification tool for bariatric surgeons because it also recognizes their specific skills in the technical details of the procedure that affect long-term results. Furthermore, the possibility of analyzing the performance in detail can help define areas where the surgeon is lacking. These findings indicate a potential role of the Lap Mentor in tailoring the training to maximize improvement.

The following abstract was presented at Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), April 17-20, 2013, Baltimore, Maryland

Skills Acquisition and Procedural Proficiency in Novices Using Virtual Reality

Amina Bouhelal, MBBS, MSc, Hitendra Patel, PhD, Reza Farhanandfar, MSc, Allan Benjamin, MSc, Badriya Alaraimi, MSc, Bijendra Patel, MS, FRCS

London Simulation Center , Barts Cancer Institute , Queen Mary University of London

INTRODUCTION: Surgical training has long relied on the Halstedian framework, the diminishing working hours, along with the ever-escalating procedural complexity; apprenticeship is no longer a valid choice to guarantee the supply of qualified safe surgeons to satisfy the demand.

AIM: Our study using a validated procedural specific, laparoscopic Cholecystectomy curriculum with expert performance as proficiency criteria, objectively investigated the possibility of skill acquisition and procedural proficiency using virtual reality

METHODS: 30 novices were randomly recruited and trained on 9 basic tasks, 4 procedural tasks and full laparoscopic Cholecystectomy, on a high-fidelity, commercially available VR simulator, Lap Mentor, Simbionix, using a validated training curriculum with proficiency criteria.

RESULTS: A total of 30 novices successfully completed the training curriculum & reached proficiency level in all tasks, (P<0.000) In basic tasks 5 the average time taken to finish the task decreased from 2:21 to 1:21 minute in mean total simulator time of 12:49 minute with average number trials of 7.3. In basic tasks 6 the average time taken to finish the task decreasing from 2:19 to 1:17 minute in mean total simulator of 12:20 minute with average number of trials of 7.2. In procedural task 3, participant’s average time taken to finish the task decreased from 7:48 to 3:43 minute in mean total simulator of 26:42 minute with average number of trials of 5.33 .In procedural task 4 the average time taken to finish the task decreased from 6:27 to 3:46 minute in mean total simulator of 27:40 minute with average number of trials of 5.2 The average time taken to finish the Full Procedural LC decreased from 9:57 to 7:10 minute in mean total simulator time of 30:04 minute with average number of trials of 3.4 CONCLUSION: the role of VR in surgical training is evident, in addition to the objective assessment VR provides, it also offers the long anticipated individualized focused training.

Basic Laparoscopic Skills Training Using Fresh Frozen Cadaver: A Randomized Controlled Trial

Sharma M, Macafee D, Horgan AF.

Newcastle Surgical Training Centre, Department of General Surgery, Freeman Hospital NHS Trust, Newcastle Upon Tyne NE7 7DN, UK. Electronic address: dr_miteshsharma@yahoo.co.uk.

Am J Surg. 2013 Jul;206(1):23-31. doi: 10.1016/j.amjsurg.2012.10.037. Epub 2013 Apr 25.

BACKGROUND: The purpose of this study was to determine whether training on fresh cadavers improves the laparoscopic skills performance of novices.

METHODS: Junior surgical trainees, novices (<3 laparoscopic procedure performed) in laparoscopic surgery, were randomized into control (group A) and practice groups (group B). Group B performed 10 repetitions of a set of structured laparoscopic tasks on fresh frozen cadavers (FFCs) improvised from fundamentals of laparoscopic skills technical curriculum. Performance on cadavers was scored using a validated, objective Global Operative Assessment of Laparoscopic Skills scale. The baseline technical ability of the 2 groups and any transfer of skills from FFCs was measured using a full procedural laparoscopic cholecystectomy task on a virtual reality simulator before and after practice on FFCs, respectively. Nonparametric tests were used for analysis of the results. RESULTS: Twenty candidates were randomized; 1 withdrew before the study commenced, and 19 were analyzed (group A, n = 9; group B; n = 10). Four of 5 tasks (nondominant to dominant hand transfer, simulated appendectomy, intracorporeal, and extracorporeal knot tying) on FFCs showed significant improvement on learning curve analysis. After training, significant improvement was shown for safety of cautery (P = .040) and the left arm path length (P = .047) on the virtual reality simulator by the practice group.

CONCLUSIONS: Training on FFCs significantly improves basic laparoscopic skills and can improve full procedural performance.

The following abstract was presented at Annual Meeting of European Association for Endoscopic Surgery (EAES) June 19-22, 2013, Vienna, Austria

Comparing Hardware on 1st and 2nd Generation LAP Mentor

Cecilie Våpenstad (MSc) 1,2,3, Ronald Mårvik (PhD) 2, 3, 4, Jack Jakimowicz (PhD)5,6, Sonja Buzink (PhD) 5,6

1SINTEF Technology and Society, Dept. Medical Technology, Trondheim, Norway

2National Center for Advanced Laparoscopic Surgery, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway

3National Competence Services for Ultrasound and Image guided Therapy, St. Olav’s Hospital, Trondheim University Hospital, Norway

4Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway

5 Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands

6 Department of Education and Research, Catharina Hospital Eindhoven, Eindhoven, the Netherlands

AIMS: The use of virtual reality (VR) simulators has the potential to reduce adverse events by moving skills training out of the operating room. An important aspect of VR simulation is realistic haptic feedback, which it has been difficult to achieve. We conducted a study to assess the influence of different haptic feedback systems on psychomotor performance by comparing the 1st with the recent 2nd generation haptic system of the LapMentorTM VR simulator (SimbionixTM Ltd).

METHODS: Surgeons with different levels of experience in laparoscopy were asked to test the two different VR simulators. The order by which the systems were tested was random. They performed the tasks peg transfer and clipping and cutting. After having tested the systems they answered 34 questions on how they perceived the hardware on the two simulators. Their actual performances were compared.

RESULTS: Fourteen surgeons participated in the study (5 experts, 9 residents). Ten surgeons thought the 2nd generation system succeeds best in simulating tissue resistance for the peg transfer task, four surgeons did not notice a difference. The surgeons performed the peg transfer task faster on the 2nd generation system with an average of 145 s on the 1st generation system and 117 s on the 2nd generation system. For the clipping and cutting task two surgeons found that the 1st generation system succeeds best in simulating tissue resistance, six the 2nd generation system and six did not notice a difference. The surgeons performed the clipping and cutting task faster on the 2nd generation system with an average of 128 s on the 1st generation system and 109 s on the 2nd generation system. On a scale from one (disagree) till five (agree) the surgeons gave the 1st generation system a median score of 3 and the 2nd generation system a median score of 4 when asked if the system can be used to train tissue manipulation like push and pull.

CONCLUSIONS: Haptic feedback on VR simulators seems to influence performance score and the way surgeons perceive simulators. The surgeons found the haptic feedback system on the 2nd generation system to be more realistic.

Improved Nondominant Hand Performance on a Laparoscopic Virtual Reality Simulator After Playing the Nintendo Wii

Middleton KK, Hamilton T, Tsai PC, Middleton DB, Falcone JL, Hamad G.

Department of Surgery, University of Pittsburgh Medical Center, 3945 Forbes Avenue, Suite 325, Pittsburgh, PA, 15213, USA

Surg Endosc. 2013 Jun 13.

BACKGROUND: Video games have been shown to improve eye-hand coordination, spatial visualization, manual dexterity, and rapid mental processing, which are important in the acquisition of laparoscopic skills. This study investigated the relationship between playing Nintendo® Wii™ and virtual reality (VR) laparoscopic surgery simulator performance. We hypothesized that playing the Wii would improve surgical skills performance on a VR laparoscopic simulator and hoped to elucidate which tasks, in particular, would be most beneficial for nondominant hand training.

METHODS: This was a single-blinded, randomized, prospective study conducted with 23 student volunteers. VR laparoscopic skills were assessed at baseline on a Simbionix LapMentor™ Surgical Simulator (Simbionix Ltd., Israel) and after the gaming period of 2 weeks. Simulator performance metrics were compared between groups using nonparametric statistics and an alpha of 0.05.

RESULTS: Compared with the control group, the Wii-playing group demonstrated greater improvement of six measures, including accuracy on the eye-hand coordination task (p = 0.04), faster completion time (p = 0.04), decreased number of left-handed movements (p = 0.03), decreased left handed total path length (p = 0.03), decreased total number of grasping attempts (p = 0.04), and improved left-handed economy of movement (p = 0.05) for the bimanual clipping and grasping task. When comparing the number of measures improved upon by the Wii-playing group and the control group for all three tasks, the Wii-playing group consistently outperformed the control group in 18 measures compared with the control group’s improvement in 6.

CONCLUSIONS: This study further characterizes the association between video game playing and surgical performance. Improvements following the intervention were made in the most basic of surgical skills, most notably with the nondominant hand, suggesting that short-term playing of the Wii could improve bimanual dexterity and expedite the acquisition of basic surgical skills.a

Psychomotor Skills and Cognitive Load Training on a Virtual Reality Laparoscopic Simulator for Tubal Surgery is Effective

Bharathan R, Vali S, Setchell T, Miskry T, Darzi A, Aggarwal R.

Eur J Obstet Gynecol Reprod Biol. 2013 Apr 19. pii: S0301-2115(13)00147-4. doi: 10.1016/j.ejogrb.2013.03.017. [Epub ahead of print]

Department of Surgery and Cancer, Imperial College, St. Mary’s Hospital, 10th Floor QEQM, South Wharf Road, Paddington, London W2 1NY, United Kingdom. Electronic address: r.bharathan@imperial.ac.uk.

OBJECTIVES: Validation of a virtual reality (VR) simulator for the training and assessment of laparoscopic tubal surgery and mapping of cognitive load.

STUDY DESIGN: Prospective cohort study conducted at the Imperial College Virtual Reality Surgical Skills laboratory amongst 25 trainees and nine senior gynaecologists. Participants performed two sessions of salpingectomy and salpingotomy procedures on a VR simulator to assess construct validity. Nine novices performed ten such sessions to enable assessment of the learning curve. The relationship between cognitive load and the dexterity parameters was assessed. Simulator fidelity was reported by experienced and intermediate level gynaecologists. Statistical analyses utilised non-parametric tests, Kruskall-Wallis and Mann-Whitney U tests. Learning curves were assessed using the Friedman test and Wilcoxon Signed Ranks test. Relationship between dexterity metrics and cognitive load was performed using Spearman’s rank order correlation.

RESULTS: Salpingectomy demonstrated construct validity for time taken by experienced, intermediate and novice gynaecologists (median 170 vs. 191 vs. 313s (P=0.003) respectively) and movements (median 200 vs. 267 vs. 376s, P=0.045). Salpingotomy demonstrated construct validity for time taken (median 183 vs. 191 vs. 306s, P=<0.001) and movements (median 210 vs. 233 vs. 328s, P=0.005). Learning curve analysis for salpingectomy displayed a plateau for time taken after the eighth session, and the fourth session for movements. Salpingotomy displayed a plateau after the eighth session for both time taken and movements. Cognitive load correlated significantly with dexterity parameters. The fidelity scores were not significantly different between the two procedures (P=0.619). CONCLUSION: The LAP Mentor VR laparoscopic simulator is a valid and effective tool for training novice surgeons in ectopic pregnancy surgery. Reduction in cognitive load significantly correlates with the learning curves

Effects of Night-Float and 24-h Call on Resident Psychomotor Performance

Yi WS, Hafiz S, Sava JA.

Department of General Surgery, Medstar Washington Hospital Center, Washington, DC.

J Surg Res. 2013 Mar 30. pii: S0022-4804(13)00224-2. doi: 10.1016/j.jss.2013.03.029. [Epub ahead of print]

INTRODUCTION: Night-float work schedules were designed to address growing concerns of the affect of fatigue on resident psychomotor and cognitive skills after traditional 24-h call work schedules. Whether this transition has achieved these results is debatable. This study was designed to compare the psychomotor performance of general surgery residents on both work schedule types. We hypothesized that when measured with novel laparoscopic simulator tasks, residents on a 24-h call schedule would exhibit worse psychomotor performance compared with those on a night-float work schedule.

METHODS: Nine general surgery residents at the post-graduate year (PGY) 2, 3, and 5 levels were recruited and trained on the Simbionix LAP Mentor Simulator (Simbionix, Cleveland, OH). Performance on two tasks was tested before and after a 24-h call work shift and a night-float shift. A survey assessing levels of work shift activity and fatigue were administered after all work shifts.

RESULTS: There was no statistically significant difference in resident accuracy, speed of movement, economy of movement, and time to completion of the two simulation tasks. The only measures of work shift activity achieving statistically significant difference were number of patients seen and numbers of steps walked on call. There was no statistically significant difference in subjective evaluation of fatigue.

CONCLUSIONS: In this study of general surgery residents, a statistically significant difference in psychomotor performance between residents working 24-h call shift versus a 12-h night-float shift could not be found. Psychomotor performance does not appear to suffer after a work shift. Additionally, post-shift subjective evaluations of fatigue are comparable regardless of shift type.

Play to Become a Surgeon: Impact of Nintendo Wii Training on Laparoscopic Skills.

Giannotti D, Patrizi G, Di Rocco G, Vestri AR, Semproni CP, Fiengo L, Pontone S, Palazzini G, Redler A.

Source

Department of Surgical Sciences, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy.

PLoS One. 2013;8(2):e57372. doi: 10.1371/journal.pone.0057372. Epub 2013 Feb 27.

BACKGROUND: Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopic procedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms is ongoing. We investigated the influence of a four-week structured Nintendo® Wii™ training on laparoscopic skills by analyzing performance metrics with a validated simulator (Lap Mentor™, Simbionix™).

METHODOLOGY/ PRINCIPAL FINDINGS: We performed a prospective randomized study on 42 post-graduate I-II year residents in General, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and then randomized to group 1 (Controls, no training with the Nintendo® Wii™), and group 2 (training with the Nintendo® Wii™) with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testing session on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improved significantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement in performance (p<0.05) for 13 of the 16 considered performance metrics. CONCLUSION / SIGNIFICANCE: The Nintendo® Wii™ might be helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room.

The following abstract was presented at Annual Meeting of CREOG & APGO February 27- March 2, 2013, Phoenix, Arizona, USA

Acquisition of Laparoscopic Skills: Box Trainer Versus Virtual Reality Simulator

Hyakutake MT

University of Alberta, Edmonton, Alberta, Canada

Objective Assessment of Skills Acquisition During Laparoscopic Surgery Courses

Sarker SJ, Telfah MM, Onuba L, Patel BP.

Queen Mary University of London, London, UK.

Surg Innov. 2012 Dec 14.

BACKGROUND: The aim of this prospective study is to objectively assess the acquisition of skills of trainees attending laparoscopic surgery courses.

METHODS: Thirty-four junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate runs of 3-day core skills in laparoscopic surgery course. Nine control trainees were also included who did not attend the course. Three virtual tasks (camera navigation, hand-eye coordination, and 2-handed maneuver) were used from a virtual reality simulator (Simbionix) for assessment. Camera navigation was assessed by completion time and maintenance of horizontal view, whereas the other 2 tasks were assessed by completion time, path length (both hands), and the number of movements (both hands). A composite score of overall performance was calculated by combining all the 12 parameters.

RESULTS: The course significantly (P < 0.001) improved 91% of the junior trainees’ precourse laparoscopic skills. Around 70% to 85% of the participants had improvement in skills in all the parameters following the course. The significant improvements were seen in 10 out of 12 task-specific parameters (P ≤ .004) except path length of the left hand. No significant improvement in skills was seen in any 1 of the 12 parameters for the control participants except for a slight reduction in performance matrics. Foundation and core trainees had acquired significantly (P = .02) more skills (23% improvement) than the specialist trainees (8% improvement). Overall acquired skills did not differ significantly in terms of age, sex, or dominant hand of trainees. CONCLUSION: Objective validated methods can be used to demonstrate course efficacy in addition to providing participants with an insight into their skills. Junior trainees with little or no previous experience benefit the most from such courses irrespective of their age, sex, and dominant hand.

Positive Correlation Between Motion Analysis Data on the LAP Mentor Virtual Reality Laparoscopic Surgical Simulator and the Results from Videotape Assessment of Real Laparoscopic Surgeries

Matsuda T, McDougall EM, Ono Y, Hattori R, Baba S, Iwamura M, Terachi T, Naito S, Clayman RV.

Department of Urology and Andrology, Kansai Medical University , Hirakata, Japan ; Department of Urology, University of California Irvine, Orange County, California USA

J Endourol. 2012 Nov;26(11):1506-11.

ABSTRACT PURPOSE: We studied the construct validity of the LapMentor, a virtual reality laparoscopic surgical simulator, and the correlation between the data collected on the LapMentor and the results of video assessment of real laparoscopic surgeries.

MATERIALS AND METHODS: Ninety-two urologists were tested on basic skill tasks No. 3 (SK3) to No. 8 (SK8) on the LapMentor. They were divided into three groups: Group A (n=25) had no experience with laparoscopic surgeries as a chief surgeon; group B (n=33) had <35 experiences; and group C (n=34) had ≥35 experiences. Group scores on the accuracy, efficacy, and time of the tasks were compared. Forty physicians with ≥20 experiences supplied unedited videotapes showing a laparoscopic nephrectomy or an adrenalectomy in its entirety, and the videos were assessed in a blinded fashion by expert referees. Correlations between the videotape score (VS) and the performances on the LapMentor were analyzed. RESULTS: Group C showed significantly better outcomes than group A in the accuracy (SK5) (P=0.013), efficacy (SK8) (P=0.014), or speed (SKs 3 and 8) (P=0.009 and P=0.002, respectively) of the performances of LapMentor. Group B showed significantly better outcomes than group A in the speed and efficacy of the performances in SK8 (P=0.011 and P=0.029, respectively). Analyses of motion analysis data of LapMentor demonstrated that smooth and ideal movement of instruments is more important than speed of the movement of instruments to achieve accurate performances in each task. Multiple linear regression analysis indicated that the average score of the accuracy in SK4, 5, and 8 had significant positive correlation with VS (P=0.01).

CONCLUSIONS: This study demonstrated the construct and predictive validity of the LapMentor basic skill tasks, supporting their possible usefulness for the preclinical evaluation of laparoscopic skills.

Personality Traits and Virtual Reality Performance

Rosenthal R, Schäfer J, Hoffmann H, Vitz M, Oertli D, Hahnloser D.

Department of Visceral Surgery, Basel University Hospital, Spitalstrasse 26, 4031, Basel, Switzerland,

Surg Endosc. 2012 Jun 30. [Epub ahead of print]

BACKGROUND: Surgeons’ personalities have been described as different from those of the general population, but this was based on small descriptive studies limited by the choice of evaluation instrument. Furthermore, although the importance of the human factor in team performance has been recognized, the effect of personality traits on technical performance is unknown. This study aimed to compare surgical residents’ personality traits with those of the general population and to evaluate whether an association exists between their personality traits and technical performance using a virtual reality (VR) laparoscopy simulator.

METHODS: In this study, 95 participants (54 residents with basic, 29 with intermediate laparoscopic experience, and 12 students) underwent personality assessment using the NEO-Five Factor Inventory and performed five VR tasks of the Lap Mentor™ basic tasks module. The residents’ personality traits were compared with those of the general population, and the association between VR performance and personality traits was investigated.

RESULTS: Surgical residents showed personality traits different from those of the general population, demonstrating lower neuroticism, higher extraversion and conscientiousness, and male residents showed greater openness. In the multivariable analysis, adjusted for gender and surgical experience, none of the personality traits was found to be an independent predictor of technical performance.

CONCLUSIONS: Surgical residents present distinct personality traits that differ from those of the general population. These traits were not found to be associated with technical performance in a virtual environment. The traits may, however, play an important role in team performance, which in turn is highly relevant for optimal surgical performance.

Can Virtual Reality Simulation be Used for Advanced Bariatric Surgical Training?

Lewis TM, Aggarwal R, Kwasnicki RM, Rajaretnam N, Moorthy K, Ahmed A, Darzi A.

Department of Cancer and Surgery, St. Marys Hospital, Imperial College London, London, UK.

Surgery. 2012 Jun;151(6):779-84

INTRODUCTION: Laparoscopic bariatric surgery is a safe and effective way of treating morbid obesity. However, the operations are technically challenging and training opportunities for junior surgeons are limited. This study aims to assess whether virtual reality (VR) simulation is an effective adjunct for training and assessment of laparoscopic bariatric technical skills.

METHODS: Twenty bariatric surgeons of varying experience (Five experienced, five intermediate, and ten novice) were recruited to perform a jejuno-jejunostomy on both cadaveric tissue and on the bariatric module of the Lapmentor VR simulator (Simbionix Corporation, Cleveland, OH). Surgical performance was assessed using validated global rating scales (GRS) and procedure specific video rating scales (PSRS). Subjects were also questioned about the appropriateness of VR as a training tool for surgeons.

RESULTS: Construct validity of the VR bariatric module was demonstrated with a significant difference in performance between novice and experienced surgeons on the VR jejuno-jejunostomy module GRS (median 11-15.5; P = .017) and PSRS (median 11-13; P = .003). Content validity was demonstrated with surgeons describing the VR bariatric module as useful and appropriate for training (mean Likert score 4.45/7) and they would highly recommend VR simulation to others for bariatric training (mean Likert score 5/7). Face and concurrent validity were not established.

CONCLUSION:This study shows that the bariatric module on a VR simulator demonstrates construct and content validity. VR simulation appears to be an effective method for training of advanced bariatric technical skills for surgeons at the start of their bariatric training. However, assessment of technical skills should still take place on cadaveric tissue.

Laparoscopic Warm-up Exercises Improve Performance of Senior-Level Trainees During Laparoscopic Renal Surgery

Lee JY, Mucksavage P, Kerbl DC, Osann KE, Winfield HN, Kahol K, McDougall EM.

Department of Urology, University of California , Irvine, Orange, California.

J Endourol. 2012 May;26(5):545-50. Epub 2012 Jan 4.

BACKGROUND AND PURPOSE: Surgery is a high-stakes “performance.” Yet, unlike athletes or musicians, surgeons do not engage in routine “warm-up” exercises before “performing” in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery.

MATERIALS AND METHODS: Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER (+POWER) and one without (-POWER). Subjects were randomly assigned to +POWER or -POWER for the initial case of each pairing, and all cases were performed ≥1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0.

RESULTS: A total of 28 study cases (14+POWER, 14-POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the +POWER group (P≤0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the +POWER group for MC (P=0.04) but not iSKT (P=0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach ∝=0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores.

CONCLUSION: Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.

Validation of Three Virtual Reality Fundamentals of Laparoscopic Surgery (FLS) Modules

Pitzul KB, Grantcharov TP, Okrainec A.

Division of General Surgery, University Health Network, 190 Elizabeth Street, Toronto, Ontario, Canada, M5G2C4.

Stud Health Technol Inform. 2012;173:349-55.

The Fundamentals of Laparoscopic Surgery (FLS) box trainer is the gold standard for development of laparoscopic technical skills however the scoring metrics require a trained proctor and do not allow for immediate feedback. The Lap Mentor™ virtual-reality (LMVR) FLS tasks, with automated scoring metrics and haptic feedback, may be a suitable alternative. We determined the construct and concurrent validity of LMVR-FLS. Participants with a range of laparoscopic experience performed 3 FLS tasks on both simulators. The LMVR-FLS demonstrated moderate concurrent validity and evidence for construct validity. Further research is required to determine if skill acquisition on these modules is transferable to the operating room.

The following abstract was presented at the International Surgical Congress of the Association of Surgeons of Great Britain and Ireland, May 9-11 2012, Liverpool, UK

Construct Validity of Endoloop Task on LAP Mentor™; A High Fidelity, Virtual Reality Laparoscopic Surgical Simulator

M. Sharma*, A. Horgan

Newcastle Surgical Training Centre, Freeman Hospital NHS trust, Newcastle Upon Tyne, UK

AIMS: To investigate if the endoloop task on a high fidelity virtual reality simulator (LAP Mentor™) is construct valid.

METHODS: Expert surgeons (> 50 laparoscopic appendicectomies) and novices (no operative experience) were tested using the endoloop task on the LAP Mentor™ (Simbionix, UK). Data for each performed task were measured objectively by the LAP Mentor™. Performance scores of two groups were compared to assess construct validity. A 5- point Likert’s scale questionnaire was used in addition to score perceptive opinion of experts. Novices also performed ten repetitions for learning curve analysis. The data were analysed with SPSS® 17.0 using non-parametric tests.

RESULTS: Twenty-eight participants were recruited (15 expert; 13 novices). The choice of at least 13 subjects per group was based on a two-tailed test, with alpha=0.05 and power = 0.90, and an expected difference of 50 percent in the ‘time taken to complete the task’ between expert and novice groups, based on a pilot study. The parameter of ‘time taken to complete the task’ was chosen for sample size calculation based on a previous validation study on LAP Mentor™. The median (IQR) time taken (seconds) was significantly shorter for experts compared to novices [88 (60), 146(130), p= 0.016]. The expert group also achieved a lower median (IQR) score for number of movements [84 (71), 145 (106), p<0.001] and path length (cm) [90.3(69.8), 183.5 (191.7), p<0.001] of right hand instrument and a faster speed (cm/sec) of the left instrument [3.8(1), 3.1(1.4), p<0.001]. The expert group rated LAP Mentor’s™ ‘overall value as a learning aid to train juniors on endoloop skill’ as 4(median) out of 5 on the Likert’s scale. Novices’ learning curve analyses for valid metrics revealed significant improvement within 10 repetitions for time taken (p<0.001) and left instrument’s speed (p<0.025). CONCLUSIONS: LAP Mentor™ can effectively differentiate between the skills of experts and novices for the endoloop task on specified metrics, establishing the construct validity. Experts agree that the LAP Mentor™ is a useful tool to train junior trainees in the endoloop exercise.

The following abstract was presented at the International Surgical Congress of the Association of Surgeons of Great Britain and Ireland, May 9-11 2012, Liverpool, UK

Minimal Invasive Surgery Skills Acquisition in Novices Using Virtual Reality

A.A. Bouhelal*, M.R. Farahmandfar, A.M. Benjamin, H. Patel, B. Patel

Barts Cancer Institute, London, UK

AIMS: Surgical training has long relied on the Halstedian framework, the diminishing working hours, along with the ever escalating procedural complexity; apprenticeship is no longer a valid choice to guarantee the supply of qualified safe surgeons to satisfy the demand. In the UK 50000 Cholecystectomies are performed annually of which up to 90% are carried out laparoscopically. Our study using a validated published procedural specific, laparoscopic Cholecystectomy curriculum investigated the attempts and time needed by a novice to reach procedural proficiency. Quantitative analysis of time and attempts needed by novices, to reached proficiency in laparoscopic Cholecystectomy using virtual reality

METHODS: 32 novices were randomly recruited and trained on 9 basic tasks, 4 procedural tasks and full laparoscopic Cholecystectomy, on a high-fidelity, commercially available VR simulator, Lap Mentor, Simbionix ,using a validated training curriculum with proficiency criteria.

RESULTS: A total of 30 novices successfully completed the training curriculum & reached proficiency level, however at different paces. In basic tasks 5 the average time taken to finish the task decreased from 2:21 to 1:21 minute in mean total simulator time of 12:49 minute with average number trials of 7.3. In basic tasks 6 the average time taken to finish the task decreasing from 2:19 to 1:17 minute in mean total simulator of 12:20 minute with average number of trials of 7.2. In procedural task 3, participant’s average time taken to finish the task decreased from 7:48 to 3:43 minute in mean total simulator of 26:42 minute with average number of trials of 5.33 .In procedural task 4 the average time taken to finish the task decreased from 6:27 to 3:46 minute in mean total simulator of 27:40 minute with average number of trials of 5.2 The average time taken to finish the Full Procedural LC decreased from 9:57 to 7:10 minute in mean total simulator time of 30:04 minute with average number of trials of 3.4

CONCLUSIONS: The role of VR in surgical training is evident, in addition to the objective assessment VR provides, it also offers the long anticipated individualized focused training.

Single Versus Multimodality Training Basic Laparoscopic Skills

Willem M Brinkman, Sanne Y Havermans, Sonja N Buzink, Sanne M B I Botden, Jack J Jakimowicz, Benedictus C Schoot

Department of Urology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands,

Surg Endosc. 2012 Feb 21;:   22350237

INTRODUCTION: Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills.

METHODS: Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S)(n = 18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M)(n = 18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks + one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test.

RESULTS: Both groups improved their performance significantly (Wilcoxon signed-rank, P < 0.05). The performances of group S and group M in the additional basic task and the salpingectomy did not differ significantly (Mann-Whitney U test, P > 0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P ≤ 0.05), which can be explained by the fact that they were much more familiar with these tasks. CONCLUSIONS: Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.

Basic Laparoscopic Training Using the Simbionix LAP Mentor: Setting the Standards in the Novice

GroupMartin W. von Websky, MD. Martina Vitz, Dr., Dimitri A. Raptis, MD, R. Rosenthal, MD,P.A. Clavien, MD. Dieter Hahnloser, MD

Department of Visceral Surgery, University Hospital of Zurich, Zurich, Switzerland; Laparoscopic Training Center, Zurich, Switzerland

Journal of Surgical Education published online 06 February 2012.

BACKGROUND: Virtual reality devices are becoming the backbone for laparoscopic training in surgery. However, without knowledge of the achievable metrics of basic training within the trainee group, these simulators cannot be used effectively. Currently, no validated task metrics of the performance of larger trainee groups are available.

STUDY DESIGN: From April 2004 to December 2009, we collated an extensive prospective database using the Simbionix LAP Mentor (Simbionix USA, Cleveland, Ohio) for basic laparoscopic training of novice surgeons. This database was used to determine benchmarks for basic skill exercises and procedural tasks that combine stimulus to improve and feasibility with acceptance of the training program and the goal to train for safe surgery.

RESULTS: In all, 18,996 task performances of 286 novice trainees were analyzed. For the basic skill exercises, the total time for correct execution ranged between 45 seconds for basic skill 3 (eye-hand coordination) and 269 seconds for basic skill 9 (object placement). For the procedural tasks, the total time for correct execution ranged between 68 seconds for procedural task 1 (clipping and cutting) and 256 seconds for procedural task 3 (dissection). The total time to task completion depended mainly on right instrument path length with high correlation to left instrument path length. Learning curve analyses of the 4 procedural tasks demonstrated performance plateaus after 10–15 repetitions. Most complications occurred during the initial repetitions of the respective task. The best quartile of performances was chosen as peer group benchmark because it provides sufficient stimulus for improvement without discouraging trainees, thus enhancing adherence to the training program. The benchmark for safety and accuracy parameters was set at a predefined level of 95% correct execution.

CONCLUSIONS: As experience with virtual reality (VR) training is growing, curricula must be based on benchmarks for efficient training derived from large trainee groups to optimize use of the still costly simulators. Safety parameters should be included in trainee assessment. We share a set of metrics that take into account both performance and feasibility for basic laparoscopic training of surgical novices using the Simbionix LAP Mentor.

Prospective Randomized Controlled Trial of Simulator-Based Versus Traditional In-Surgery Laparoscopic Camera Navigation Training

Franzeck FM, Rosenthal R, Muller MK, Nocito A, Wittich F, Maurus C, Dindo D, Clavien PA, Hahnloser D.

Department of Visceral and Transplantation Surgery, University Hospital Zurich, 8091, Zurich, Switzerland.

Surg Endosc. 2012 Jan;26(1):235-41. Epub 2011 Aug 19.

BACKGROUND: Surgical residents often use a laparoscopic camera in minimally invasive surgery for the first time in the operating room (OR) with no previous education or experience. Computer-based simulator training is increasingly used in residency programs. However, no randomized controlled study has compared the effect of simulator-based versus the traditional OR-based training of camera navigation skills.

METHODS: This prospective randomized controlled study included 24 pregraduation medical students without any experience in camera navigation or simulators. After a baseline camera navigation test in the OR, participants were randomized to six structured simulator-based training sessions in the skills lab (SL group) or to the traditional training in the OR navigating the camera during six laparoscopic interventions (OR group). After training, the camera test was repeated. Videos of all tests (including of 14 experts) were rated by five blinded, independent experts according to a structured protocol.

RESULTS: The groups were well randomized and comparable. Both training groups significantly improved their camera navigational skills in regard to time to completion of the camera test (SL P = 0.049; OR P = 0.02) and correct organ visualization (P = 0.04; P = 0.03). Horizon alignment improved without reaching statistical significance (P = 0.20; P = 0.09). Although both groups spent an equal amount of actual time on camera navigation training (217 vs. 272 min, P = 0.20), the SL group spent significantly less overall time in the skill lab than the OR group spent in the operating room (302 vs. 1002 min, P < 0.01). CONCLUSION: This is the first prospective randomized controlled study indicating that simulator-based training of camera navigation can be transferred to the OR using the traditional hands-on training as controls. In addition, simulator camera navigation training for laparoscopic surgery is as effective but more time efficient than traditional teaching.

The following abstract was presented at the 2011 Association of Laparoscopic Surgeons meeting, Nov 17-18 Cardiff, UK

Comparison of Fresh Frozen Human Cadaver; High Fidelity Virtual Reality Simulator (LAP Mentor™, Simbionix) and Box Trainer as Methods of Training in Laparoscopic Insicional Hernia Repair

M Sharma, Alan Horgan

Newcastle Surgical Training Centre, Freeman Hospital NHS Trust, Newcastle upon Tyne, Tyne and Wear, UK

AIMS: A number of modalities are available to train surgeons in procedural tasks such as laparoscopic incisional hernia repair. These include Fresh Frozen Human Cadaver (FFC); high fidelity Virtual Reality Simulator (VR) i.e. LAP Mentor™ and Box Trainer (BT).

METHODS: This was a prospective comparative face validity study. Senior registrars and consultant surgeons performed laparoscopic incisional hernia on FFC, VR and BT. Perceptive ratings on different aspects of these models (nine domains like tactile feedback and tissue handling) were obtained using a 5-point Likert-type questionnaire and analysed using non-parametric tests.

RESULTS: 36 surgeons were recruited. FFC scored higher than others in all nine domains (p<0.05). VR and BT achieved similar ratings in domains like tactile feedback (p=0.78), replication of operative steps (p=0.23) and overall learning value (p=0.52). VR was superior than BT in tissue handling (p<0.01) and demonstration of anatomy (p<0.01). CONCLUSION: Fresh frozen human cadaver is perceived as a significantly better model than high fidelity virtual reality simulator and box trainer for training in procedures of intermediate complexity like laparoscopic incisional hernia. Conventional box trainer is still an acceptable model of training in such procedures when compared to virtual reality simulation.

KEY STATEMENT: New training models have emerged in technical skills training laboratories which need to be compared for their training potential. The present study establishes their comparative value as training tools.

Faster Simulated Laparoscopic Cholecystectomy with Haptic Feedback Technology

Yiasemidou M, Glassman D, Vasas P, Badiani S, Patel B

Barts and the London School of Medicine and Dentistry, Department of Upper GI Surgery, Barts and The Royal London Hospital, London, UK

Open Access Surgery Volume 2011:4 Pages 39 – 44

BACKGROUND: Virtual reality simulators have been gradually introduced into surgical training. One of the enhanced features of the latest virtual simulators is haptic feedback. The usefulness of haptic feedback technology has been a matter of controversy in recent years. Previous studies have assessed the importance of haptic feedback in executing parts of a procedure or basic tasks, such as tissue grasping. The aim of this study was to assess the role of haptic feedback within a structured educational environment, based on the performance of junior surgical trainees after undergoing substantial simulation training.

METHODS: Novices, whose performance was assessed after several repetitions of a task, were recruited for this study. The performance of senior house officers at the last stage of a validated laparoscopic cholecystectomy curriculum was assessed. Nine senior house officers completed a validated laparoscopic cholecystectomy curriculum on a haptic simulator and nine on a nonhaptic simulator. Performance in terms of mean total time, mean total number of movements, and mean total path length at the last level of the validated curriculum (full procedure of laparoscopic cholecystectomy) was compared between the two groups.

RESULTS: Haptic feedback significantly reduced the time required to complete the full procedure of laparoscopic cholecystectomy (mean total time for nonhaptic machine 608.83 seconds, mean total time for haptic machine 553.27 seconds; P = 0.019) while maintaining safety standards similar to those of the nonhaptic machine (mean total number of movements: nonhaptic machine 583.74, haptic machine 603.93, P = 0.145, mean total path length: for nonhaptic machine 1207.37 cm, for haptic machine 1262.36 cm, P = 0.101).

CONCLUSION: Haptic feedback significantly reduced the time required to complete the full procedure of laparoscopic cholecystectomy.

Criterion-Based Laparoscopic Training Reduces Total Training Time

Wilson MR, Wilson MR, Brinkman WM, Buzink SN, Alevizos L, de Hingh IH, Jakimowicz JJ

Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands

Surg Endosc. 2011 Nov 1.

INTRODUCTION: The benefits of criterion-based laparoscopic training over time-oriented training are unclear. The purpose of this study is to compare these types of training based on training outcome and time efficiency.

METHODS: During four training sessions within 1 week (one session per day) 34 medical interns (no laparoscopic experience) practiced on two basic tasks on the Simbionix LAP Mentor virtual-reality (VR) simulator: ‘clipping and grasping’ and ‘cutting’. Group C (criterion-based) (N = 17) trained to reach predefined criteria and stopped training in each session when these criteria were met, with a maximum training time of 1 h. Group T (time-based) (N = 17) trained for a fixed time of 1 h each session. Retention of skills was assessed 1 week after training. In addition, transferability of skills was established using the Haptica ProMIS augmented-reality simulator.

RESULTS: Both groups improved their performance significantly over the course of the training sessions (Wilcoxon signed ranks, P < 0.05). Both groups showed skill transferability and skill retention. When comparing the performance parameters of group C and group T, their performances in the first, the last and the retention training sessions did not differ significantly (Mann-Whitney U test, P > 0.05). The average number of repetitions needed to meet the criteria also did not differ between the groups. Overall, group C spent less time training on the simulator than did group T (74:48 and 120:10 min, respectively; P < 0.001). Group C performed significantly fewer repetitions of each task, overall and in session 2, 3 and 4. CONCLUSION: Criterion-based training of basic laparoscopic skills can reduce the overall training time with no impact on training outcome, transferability or retention of skills. Criterion-based should be the training of choice in laparoscopic skills curricula.

Validation of SINERGIA as Training Tool: A Randomized Study to Test the Transfer of Acquired Basic Psychomotor Skills to LAP Mentor

Sánchez-González P, Gómez-Aguilera EJ, Usón-Gargallo J.Source

Bioengineering and Health Technology Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres,

Int J Comput Assist Radiol Surg. 2011 Nov;6(6):839-46

PURPOSE: Laparoscopic surgery is commonly used in many surgical procedures but requires a learning process to develop the necessary skills. Virtual reality simulators play an essential role within the training curricula. This paper aims to determine whether training in SINERGIA VR simulator allows novice surgeons to improve their basic psychomotor laparoscopic skills.

METHODS: Forty-two people participated in this study, including 28 unexperience medical students and 14 expert surgeons who developed previously more than 100 laparoscopic procedures. Medical students made a pre-training test in LapMentor II; then, they trained in SINERGIA and they finally accomplished a post-training test in LapMentor II. Experts just made one trial in LapMentor II. A statistical analysis was carried out and results of pre- and post-training tests of novices were compared with Wilcoxon signed-rank test. Pre- and post-training tests of novices were also compared with results of experts with Mann-Whitney U test.

RESULTS: Most metrics provided by LapMentor II and included in this study show significant differences when comparing pre- and post-training tests of novices. Analysis of pre-training test of novices and experts results show significant differences in all analyzed metrics for all studied tasks. On the other hand, LapMentor was not able to distinguish between experts and novices after training in SINERGIA for any metric in the camera manipulation task and for some metrics of the other tasks.

CONCLSION: Training in SINERGIA VR simulator allows improvement of basic psychomotor laparoscpic skills and transferring them to another virtual simulator. Therefore, it could be used in laparoscopic surgery training programs.

Preoperative Warm-Up Using a Virtual Reality Simulator

Radu Moldovanu, MD, PhD, Eugen Târcoveanu, MD, PhD, Gabriel Dimofte, MD, PhD, Cristian Lupaşcu, MD, PhD, and Costel Bradea, MD, PhD

First Surgical Unit, “St. Spiridon” Hospital Iaşi, University of Medicine and Pharmacy “Gr.T. Popa” Iaşi, Romania.

JSLS. 2011 Oct-Dec; 15(4): 533–538.

BACKGROUND AND OBJECTIVES: All modern surgical procedures require a high level of cognitive and psychomotor skills achieved using different training methods, but could be influenced by fatigue and other psychological factors. We evaluated the effect of warm-up exercises on operative laparoscopic performances.

METHODS: The surgical team operated on a consecutive series of 20 patients with gallstones. Patients were randomly allocated in 2 groups: group A to be operated on without warm-up exercises and group B to be operated on after a short-term warm-up. All the patients were operated on by the same surgical team. The full-time records of the operation were analyzed by 2 independent reviewers. A modified simplified Global Rating Score (GRS) was used to assess the surgical procedures. A training module using the Lap Mentor simulator was designed for the warm-up.

RESULTS: Better performances were noted by both observers in group B only regarding “Respect for tissue” scores (3.75±0.16 vs 4.43±0.20, P=.021 and 3.87±0.22 vs 4.57±0.20, P=.041) achieving significant or marginally significant differences for all categories; GRS scores for “time and motion” and “overall impression” tend to be better after warm-up, but differences failed to reach statistical significance in our series.

CONCLUSION: Surgeons, even the most experienced in laparoscopic surgery, can increase specific psychomotor skills associated with a laparoscopic environment by doing simple exercises on a virtual reality simulator, just before an operation. These improvements are reflected in more accurate handling of tissue during laparoscopic cholecystectomy.

Acquisition of Fundamental Laparoscopic Skills: Is a Box Really as Good as a Virtual Reality Trainer?

Vitish-Sharma P, Knowles J, Patel B.

Barts and The London School of Medicine & Dentistry, Institute of Cancer, Mile End Road, London E1 4NS, UK.

Int J Surg. 2011;9(8):659-61. Epub 2011 Sep 20.

BACKGROUND: Laparoscopic surgery requires working in a three-dimensional environment with a two-dimensional view. Skills such as depth perception, hand to eye co-ordination and bimanual manipulation are crucial to its efficacy.

AIM: To compare the efficiency of training in laparoscopic skills on a VR simulator with a traditional box trainer.

METHOD: Twenty medical students were recruited. An initial training session on the relevant anatomy and steps of a laparoscopic cholecystectomy was given. Baseline skills were recorded using a pre-training laparoscopic cholecystectomy on the VR trainer. Parameters measured were: (1) total time taken (mins); (2) number of movements right and left instrument; (3) path length (cms) of right and left instrument was recorded. Ten students trained on a VR simulator, and ten on a box trainer, for three hours each. The box trainer group exercises were based on the Royal College of Surgeons core laparoscopic skills course, and the VR trainer exercises were based on the Simbionix LapMentor basic skills tasks. Following this both groups were reassessed by a laparoscopic cholecystectomy on the VR trainer.

RESULTS: Both groups showed improvement in all measured parameters. A student T-test at 95% confidence interval showed no statistically significant difference between the two groups pre and post training.

CONCLUSION: Both the VR and box trainer are effective in the acquisition of laparoscopic skills.

Impact of Laparoscopy Simulator Training on the Technical Skills of Future Surgeons in the Operating Room: A Prospective Study.

Beyer L, Troyer JD, Mancini J, Bladou F, Berdah SV, Karsenty G.

CERC (Centre d’Enseignement et de Recherche Chirurgicale) Faculté de Médecine de Marseille Secteur Nord, Université de la Méditerranée, Boulevard Pierre Dramard, 13916 Marseille, France.

Am J Surg. 2011 Sep;202(3):265-72.

BACKGROUND: The efficacy of laparoscopy simulators remains controversial.

METHODS: This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed.

RESULTS: Before/after scores were significantly improved in the MISTELS (P = .042) and LAPMentor (P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS (P = .026) and LAP Mentor (P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups.

CONCLUSION: Simulator training provides a more rapid acquisition of competence in surgical technique.

The following abstract was presented at the AAME (An International Association for Medical Education) meeting August 27-31, 2011, Vienna, Austria

Training the Digital Generation – Perception of Usefulness of Virtual Reality Laparoscopic Simulators Among the Fourth Year Medical Student Population

P Berlinger*1,2, B Shaw3, RA Kadir2, HW Potts (Centre for Screen Based Medical Simulation, Royal Free Hospital, London, UK; UCL Medical School, University College London, London, UK; Department of Obstetrics & Gynaecology, Royal Free Campus, University College London, London, UK)

BACKGROUND: Virtual reality (VR) laparoscopic simulators hold great potential for surgical training, medical students being only just exposed to them. This prospective questionnaire-based study evaluated whether medical students perceive VR laparoscopic simulators as being useful educational tools in terms of learning anatomy, managing clinical conditions and supporting career choice. Summary of work: During the academic year 2009-10, medical students from University College London undertaking Obstetrics & Gynaecology placements attended a structured tutorial using VR laparoscopic simulators (LAP Mentor, Simbionix Ltd, USA); a fivepoint Likert scale anonymous questionnaire pre and post tutorial was filled. Summary of results: Seventy out of 80 consecutive students (87.5%) attended the tutorials, the response rate being 100%. Students felt VR laparoscopic simulator sessions were useful clinically (87.1%, 61/70) and for learning anatomy (91.4%, 64/70), considering their potential of being an adjunct or even a replacement of dissection. Interestingly, 53.1% (17/32) of participants who were not intending to pursue a surgical career said the experience had made them reconsider their career pathway.

CONCLUSIONS: Medical students perceive VR laparoscopic simulators to be useful at an undergraduate level as an educational tool for learning both clinical conditions, anatomy, and helping to make decisions regarding career pathways. Take-home messages: VR simulation has the potential to continue growing in undergraduate medical education.

Gaze Training Enhances Laparoscopic Technical Skill Acquisition and Multi-Tasking Performance: A Randomized, Controlled Study.

Vine SJ, Bright E, Masters RS, Defriend D, McGrath JS.

College of Life and Environmental Sciences, University of Exeter, St Luke’s Campus, Exeter, EX1 2LU, UK

Surg Endosc. 2011 Jun 14.

BACKGROUND: The operating room environment is replete with stressors and distractions that increase the attention demands of what are already complex psychomotor procedures. Contemporary research in other fields (e.g., sport) has revealed that gaze training interventions may support the development of robust movement skills. This current study was designed to examine the utility of gaze training for technical laparoscopic skills and to test performance under multitasking conditions.

METHODS: Thirty medical trainees with no laparoscopic experience were divided randomly into one of three treatment groups: gaze trained (GAZE), movement trained (MOVE), and discovery learning/control (DISCOVERY). Participants were fitted with a Mobile Eye gaze registration system, which measures eye-line of gaze at 25 Hz. Training consisted of ten repetitions of the “eye-hand coordination” task from the LAP Mentor VR laparoscopic surgical simulator while receiving instruction and video feedback (specific to each treatment condition). After training, all participants completed a control test (designed to assess learning) and a multitasking transfer test, in which they completed the procedure while performing a concurrent tone counting task.

RESULTS: Not only did the GAZE group learn more quickly than the MOVE and DISCOVERY groups (faster completion times in the control test), but the performance difference was even more pronounced when multitasking. Differences in gaze control (target locking fixations), rather than tool movement measures (tool path length), underpinned this performance advantage for GAZE training.

CONCLUSION: These results suggest that although the GAZE intervention focused on training gaze behavior only, there were indirect benefits for movement behaviors and performance efficiency. Additionally, focusing on a single external target when learning, rather than on complex movement patterns, may have freed-up attentional resources that could be applied to concurrent cognitive tasks.

Limited Value of Haptics in Virtual Reality Laparoscopic Cholecystectomy Training

Moyano-Cuevas JL, Sánchez-Margallo FM, Sánchez-Peralta LF, Pagador JB, Enciso S,Thompson JR, Leonard AC, Doarn CR, Roesch MJ, Broderick TJ.

Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267, USA.

Surg Endosc. 2011 Apr;25(4):1107-14.

BACKGROUND: Haptics is an expensive addition to virtual reality (VR) simulators, and the added value to training has not been proven. This study evaluated the benefit of haptics in VR laparoscopic surgery training for novices.

METHODS: The Simbionix LAP Mentor II haptic VR simulator was used in the study. Randomly, 33 laparoscopic novice students were placed in one of three groups: control, haptics-trained, or nonhaptics-trained group. The control group performed nine basic laparoscopy tasks and four cholecystectomy procedural tasks one time with haptics engaged at the default setting. The haptics group was trained to proficiency in the basic tasks and then performed each of the procedural tasks one time with haptics engaged. The nonhaptics group used the same training protocol except that haptics was disengaged. The proficiency values used were previously published expert values. Each group was assessed in the performance of 10 laparoscopic cholecystectomies (alternating with and without haptics). Performance was measured via automatically collected simulator data.

RESULTS: The three groups exhibited no differences in terms of sex, education level, hand dominance, video game experience, surgical experience, and nonsurgical simulator experience. The number of attempts required to reach proficiency did not differ between the haptics- and nonhaptics-training groups. The haptics and nonhaptics groups exhibited no difference in performance. Both training groups outperformed the control group in number of movements as well as path length of the left instrument. In addition, the nonhaptics group outperformed the control group in total time.

CONCLUSION: Haptics does not improve the efficiency or effectiveness of LapMentor II VR laparoscopic surgery training. The limited benefit and the significant cost of haptics suggest that haptics should not be included routinely in VR laparoscopic surgery training.

Perceptual Impairment and Psychomotor Control in Virtual Laparoscopic Surgery.

McGrath JS, Vine SJ, Brewer J, Defriend D, Masters RS.

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

Surg Endosc. 2011 Jul;25(7):2268-74. Epub 2011 Feb 27.

BACKGROUND: It is recognized that one of the major difficulties in performing laparoscopic surgery is the translation of two-dimensional video image information to a three-dimensional working area. However, research has tended to ignore the gaze and eye-hand coordination strategies employed by laparoscopic surgeons as they attempt to overcome these perceptual constraints. This study sought to examine if measures related to tool movements, gaze strategy, and eye-hand coordination (the quiet eye) differentiate between experienced and novice operators performing a two-handed manoeuvres task on a virtual reality laparoscopic surgical simulator (LAP Mentor™).

METHODS: Twenty-five right-handed surgeons were categorised as being either experienced (having led more than 60 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The 10 experienced and 15 novice surgeons completed the “two-hand manoeuvres” task from the LAP Mentor basic skills learning environment while wearing a gaze registration system. Performance, movement, gaze, and eye-hand coordination parameters were recorded and compared between groups.

RESULTS: The experienced surgeons completed the task significantly more quickly than the novices, used significantly fewer movements, and displayed shorter tool paths. 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. A more detailed analysis of a difficult subcomponent of the task revealed that experienced operators used a significantly longer aiming fixation (the quiet eye period) to guide precision grasping movements and hence needed fewer grasp attempts.

CONCLUSION: The findings of the study provide further support for the utility of examining strategic gaze behavior and eye-hand coordination measures to help further our understanding of how experienced surgeons attempt to overcome the perceptual difficulties inherent in the laparoscopic environment.

The following abstract was presented at the Annual Meeting of the ACS Accredited Educational Institutes Consortium,  April 29-30, 2011, Chicago, Illinois

Can Virtual Reality Simulator Be Used For Advanced Bariatric Surgical Training?

TM Lewis, R Aggarwal, R Kwasnicki, N Bajarethnam, K Moorthy, A Ahmed; A Darzi,

Imperial College, London, UK

The following abstract was presented at the Annual Meeting of the ACS Accredited Educational Institutes Consortium,  April 29-30, 2011, Chicago, Illinois

A Simulation Assessment Tool For Operative Laparoscopic Skill Advancement of Residents

(SOLAR): A Global Study

A Aggarwal, K Miles, A Currie, D Defriend; B Fernando, B Hobbs, D Lomanto, B Patel, A Renwick, A Darzi

Imperial College, London, UK

The following abstract was presented at the Annual Meeting of the ACS Accredited Educational Institutes Consortium, April 29-30, 2011, Chicago, Illinois

A Simulation Assessment Tool For Tubal Ligation

C J Sultana

Thomas Jefferson University, Philadelphia, Pennsylvania

Limited Value of Haptics in Virtual Reality Laparoscopic Cholecystectomy Training

Thompson JR, Leonard AC, Doarn CR, Roesch MJ, Broderick TJ.

Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267, USA.

Surg Endosc. 2011 Apr;25(4):1107-14. Epub 2010 Sep 25

BACKGROUND: Haptics is an expensive addition to virtual reality (VR) simulators, and the added value to training has not been proven. This study evaluated the benefit of haptics in VR laparoscopic surgery training for novices.

METHODS: The Simbionix LapMentor II haptic VR simulator was used in the study. Randomly, 33 laparoscopic novice students were placed in one of three groups: control, haptics-trained, or nonhaptics-trained group. The control group performed nine basic laparoscopy tasks and four cholecystectomy procedural tasks one time with haptics engaged at the default setting. The haptics group was trained to proficiency in the basic tasks and then performed each of the procedural tasks one time with haptics engaged. The nonhaptics group used the same training protocol except that haptics was disengaged. The proficiency values used were previously published expert values. Each group was assessed in the performance of 10 laparoscopic cholecystectomies (alternating with and without haptics). Performance was measured via automatically collected simulator data.

RESULTS: The three groups exhibited no differences in terms of sex, education level, hand dominance, video game experience, surgical experience, and nonsurgical simulator experience. The number of attempts required to reach proficiency did not differ between the haptics- and nonhaptics-training groups. The haptics and nonhaptics groups exhibited no difference in performance. Both training groups outperformed the control group in number of movements as well as path length of the left instrument. In addition, the nonhaptics group outperformed the control group in total time.

CONCLUSION: Haptics does not improve the efficiency or effectiveness of LapMentor II VR laparoscopic surgery training. The limited benefit and the significant cost of haptics suggest that haptics should not be included routinely in VR laparoscopic surgery training.

Psychomotor Control in a Virtual Laparoscopic Surgery Training Environment: Gaze Control Parameters Differentiate Novices from Experts

Wilson M, McGrath J, Vine S, Brewer J, Defriend D, Masters R.

School of Sport and Health Sciences, University of Exeter, St Luke’s Campus, Exeter, EX1 2LU, UK, Surg Endosc. 2010 Mar 24

BACKGROUND: Surgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision.

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.

The Role of Haptic Feedback in Laparoscopic Training Using the LAP Mentor 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 Endourology Volume: 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

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.

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.

The following abstract was presented at the poster session at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) April 22-25, 2009, Phoenix, Arizona

Concurrent Validity and Skill Dacay 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 PROCEDURE: 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.

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 LAP Mentor 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.

Pearson Correlation
LapMentor Task LM TT
and FLS
LM NIM
and FLS
LM TPL
and FLS
Ball touching task -0.575* -0.592* -.715**
Duct clipping -0.071 -0.143 -.029
Duct retraction and clipping -0.741** -0.649** -0.585**
Ball transfer -0.553* -0.796** -0.564**
Circle cutting -0.833** -0.789** -0.745**
Cautery of bands -0.233 -0.789** -0.745**
3D object manipulation -0.643** -0.711** -0.751**
Intracorporeal Suturing -0.780**

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

CONCLUSIONS: There was an excellent correlation between performance on almost all LapMentor tasks and FLS score. LapMentor number of instrument movements and total path length were slightly more robust predictors of FLS score compared with total time

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 LAP Mentor 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).

Novice Expert p-value
Total Time (sec) 523(180) 259(109) .002
Instrument Movement 553(187) 265(139) .002
Total Path Length 1058(364) 584(257) .006
Efficiency of Cautery (%) 73(12) 77(5) .4
Accuracy of Cautery (%) 51(14) 48(18) .7

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.

Challenges During the Implementation of a Laparoscopic Skills Curriculum in a Busy General Surgery Residency Program

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

BACKGROUND: This study was carried out to investigate whether eye-hand coordination skill on a virtual reality laparoscopic surgical simulator (the LAP Mentor) was able to differentiate among subjects with different laparoscopic experience and thus confirm its construct validity.

METHODS: A total of 31 surgeons, who were all right-handed, were divided into the following two groups according to their experience as an operator in laparoscopic surgery: experienced surgeons (more than 50 laparoscopic procedures) and novice surgeons (fewer than 10 laparoscopic procedures). The subjects were tested using the eye-hand coordination task of the LAP Mentor, and performance was compared between the two groups. Assessment of the laparoscopic skills was based on parameters measured by the simulator.

RESULTS: The experienced surgeons completed the task significantly faster than the novice surgeons. The experienced surgeons also achieved a lower number of movements (NOM), better economy of movement (EOM) and faster average speed of the left instrument than the novice surgeons, whereas there were no significant differences between the two groups for the NOM, EOM and average speed of the right instrument.

CONCLUSIONS: Eye-hand coordination skill of the nondominant hand, but not the dominant hand, measured using the LAP Mentor was able to differentiate between subjects with different laparoscopic experience. This study also provides evidence of construct validity for eye-hand coordination skill on the LAP Mentor.

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 Lap Mentor 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 LAP Mentor 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 LAP Mentor 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:
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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.
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Laparoscopic Skills are Improved with LAP Mentor 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

OBJECTIVES: 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.

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.