VR to OR

Effect of virtual reality training on laparoscopic surgery: randomised controlled trial.

Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, Schroeder TV, Ottesen BS. BMJ. 2009 May 14;338:b1802. doi: 10.1136/bmj.b1802.

OBJECTIVE: To assess the effect of virtual reality training on an actual laparoscopic operation. DESIGN: Prospective randomised controlled and blinded trial. SETTING: Seven gynaecological departments in the Zeeland region of Denmark. PARTICIPANTS: 24 first and second year registrars specialising in gynaecology and obstetrics. INTERVENTIONS: Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).

MAIN OUTCOME MEASURE: The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. RESULTS: The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79.

CONCLUSION: Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures. TRIAL REGISTRATION: ClinicalTrials.gov NCT00311792. .

Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.

Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky DA 3rd, Ramel S, Smith CD, Arvidsson D.

Am J Surg. 2007 Jun;193(6):797-804.

BACKGROUND: Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices.

METHODS: Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident’s first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors.

RESULTS: The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time. CONCLUSIONS: The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident’s first 10 laparoscopic cholecystectomies.

Individualized Deliberate Practice on a Virtual Reality Simulator Improves Technical Performance of Surgical Novices in the Operating Room.

Palter VN and Grantcharov TP.

Ann Surg 2014 (259) 443-448.

BACKGROUND: Training onVRsimulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR.

METHODS: This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a conventional residency training group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 3 validated assessment tools. A score of less than 60% on any component of the assessment tool resulted in the trainee practicing a specific task on the VR simulator. The DP group practiced on the simulator as per their individualized schedule. Both groups then performed another laparoscopic cholecystectomy. A blinded expert assessed the OR recordings using a validated global rating scale.

RESULTS: Although both groups had similar technical abilities preintervention [DP: median score, 13.5 (9.3–15.0); control: median score, 14.5 (9.3–17.8); P = 0.45], the DP residents had a superior technical performance postintervention [DP: median score, 17.0 (15.3–18.5); control: median score, 12.5 (7.5–14.0); P=0.03]. Of 8 DP residents, 6 practiced 5 basic VR tasks (median 1 trial to pass), and 7 of 8 practiced 2 advanced tasks (median 4 trials to pass). CONCLUSIONS: A curriculum of deliberate individualized practice on a VR simulator improves technical performance in the OR. This has implications to greatly improve the feasibility of implementing simulation-based curricula in residency training programs, rather than having them being limited to research protocols.

Development and Validation of a Comprehensive Curriculum to Teach an Advanced Minimally Invasive Procedure – A Randomized Controlled Trial.

Palter VN and Grantcharov TP.

Ann Surg 2012 (256) 1219–1226.

OBJECTIVE: This study allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator.

RESULT: Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents. Curricular-trained residents scored higher on the multiple-choice test and outperformed conventionally trained residents in 7 of 8 tasks on the simulator.

CONCLUSION: Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training.

Warm-up in a Virtual Reality Environment Improves Performance in the Operating Room.

Dan Calatayud, MD,* Sonal Arora, MBBS,† Rajesh Aggarwal, PhD,† Irina Kruglikova, MD, ‡ Svend Schulze, DSc,* Peter Funch-Jensen, DSc,‡ and Teodor Grantcharov, PhD§

(Ann Surg 2010;251: 1181–1185)

OBJECTIVE: To assess the impact of warm-up on laparoscopic performance in the operating room (OR). Background: Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR. The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP. Methods: Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR. Participants were randomized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group. After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up. All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale (from 7 to 35).

RESULTS: There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up, median 28.5 (range _ 18.5–32.0) versus median 19.25 (range _ 15–31.5), P _ 0.042. The results demonstrated excellent reliability of the assessment tool used (Cronbach’s _ _ 0.92).

CONCLUSION: This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP. The suggested program is short, easy to perform, and therefore realistic to implement in the daily life in a busy surgical department. This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR resources.

Psychomotor performance measured in a virtual environment correlates with technical skills in the operating room.

Kundhal PS, Grantcharov TP.

Surg Endosc. 2009 Mar;23(3):645-9. Epub 2008 Jul 12.

BACKGROUND: This study was conducted to validate the role of virtual reality computer simulation as an objective method for assessing laparoscopic technical skills. The authors aimed to investigate whether performance in the operating room, assessed using a modified Objective Structured Assessment of Technical Skill (OSATS), correlated with the performance parameters registered by a virtual reality laparoscopic trainer (LapSim).

METHODS: The study enrolled 10 surgical residents (3 females) with a median of 5.5 years (range, 2-6 years) since graduation who had similar limited experience in laparoscopic surgery (median, 5; range, 1-16 laparoscopic cholecystectomies). All the participants performed three repetitions of seven basic skills tasks on the LapSim laparoscopic trainer and one laparoscopic cholecystectomy in the operating room. The operating room procedure was video recorded and blindly assessed by two independent observers using a modified OSATS rating scale. Assessment in the operating room was based on three parameters: time used, error score, and economy of motion score. During the tasks on the LapSim, time, error (tissue damage and millimeters of tissue damage [tasks 2-6], error score [incomplete target areas, badly placed clips, and dropped clips [task 7]), and economy of movement parameters (path length and angular path) were registered. The correlation between time, economy, and error parameters during the simulated tasks and the operating room procedure was statistically assessed using Spearman’s test.

RESULTS: Significant correlations were demonstrated between the time used to complete the operating room procedure and time used for task 7 (r (s) = 0.74; p = 0.015). The error score demonstrated during the laparoscopic cholecystectomy correlated well with the tissue damage in three of the seven tasks (p < 0.05), the millimeters of tissue damage during two of the tasks, and the error score in task 7 (r (s) = 0.67; p = 0.034). Furthermore, statistically significant correlations were observed between the economy of motion score from the operative procedure and LapSim’s economy parameters (path length and angular path in six of the tasks) (p < 0.05).

CONCLUSIONS: The current study demonstrated significant correlations between operative performance in the operating room (assessed using a well-validated rating scale) and psychomotor performance in virtual environment assessed by a computer simulator. This provides strong evidence for the validity of the simulator system as an objective tool for assessing laparoscopic skills. Virtual reality simulation can be used in practice to assess technical skills relevant for minimally invasive surgery.

VR to OR: a review of the evidence that virtual reality simulation improves operating room performance.

Seymour NE.

World J Surg. 2008 Feb;32(2):182-8.

The use of virtual reality (VR) simulation to train surgeons has been supported by a body of experimental data derived from randomized trials of VR simulation training versus no such training. These investigations have focused on the use of VR devices to train surgeons in laparoscopic and flexible endoscopic skills, and the studies have generally demonstrated that skills acquired through courses of training in VR transfer to the clinical or animal laboratory setting, where assessments of various types have been used to measure performance. These studies, as well as the study model that describes them, and the future of randomized trials of this type are reviewed.

Curriculum-based solo virtual reality training for laparoscopic intracorporeal knot tying: objective assessment of the transfer of skill from virtual reality to reality.

Munz Y, Almoudaris AM, Moorthy K, Dosis A, Liddle AD, Darzi AW.

Am J Surg. 2007 Jun;193(6):774-83.

BACKGROUND: Very few studies have addressed the transferability of skills from virtual reality (VR) to real life. The aim of this study was to assess the feasibility and effectiveness of teaching intracorporeal knot tying (ICKT) by VR simulation only.

METHODS: Twenty novices underwent structured training of basic skills training on the Minimally Invasive Surgical Trainer simulator (Mentice AB, Gothenburg, Sweden) followed by knot tying training on the LapSim simulator (Surgical Science, Gothenburg, Sweden). They were assessed pre- and post-training on a video trainer. Assessment of performance included motion tracking and video-based checklist. Nonparametric statistical analysis was used, and P < .05 was deemed significant.

RESULTS: All participants completed a correct knot as compared with only 25% before VR training. Time to completion was 66% faster and knot quality 45% better after VR training. Significant reduction in number of movements (P = .006) and distance traveled (P < .000) by both hands after VR training.

CONCLUSIONS: Teaching ICKT by VR simulators only is feasible and effective. Furthermore, this study highlights the complementary use of different VR simulators within a structured curriculum.

Skills acquired on virtual reality laparoscopic simulators transfer into the operating room in a blinded, randomised, controlled trial.

Cosman, PH, Hugh TJ, Shearer CJ, Merrett ND, Biankin AV, Cartmill JA.

Stud Health Technol Inform. 2007; 125:76-81.

Virtual reality surgical simulators have proven value in the acquisition and assessment of laparoscopic skills. In this study, we investigated skill transfer from a virtual reality laparoscopic simulator into the operating room, using a blinded, randomised, controlled trial design. Surgical trainees using the LapSim System performed significantly better at their first real-world attempt at a laparoscopic task than their colleagues who had not received similar training, as measured independently by a number of expert surgical observers using four criteria.

Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance.

Youngblood PL, Srivastava S, Curet M, Heinrichs WL, Dev P, Wren SM.

J Am Coll Surg. 2005 Apr;200(4):546-51.

BACKGROUND: Several studies have investigated the transfer of surgical trainees’ skills acquired on surgical simulators to the operating room setting. The purpose of this study was to compare the effectiveness of two laparoscopic surgery simulators by assessing the transfer of skills learned on simulators to closely matched surgical tasks in the animal laboratory.

STUDY DESIGN: In this post-test-only Control group study design, 46 surgically naive medical student volunteers were randomly assigned to one of three groups: Tower Trainer group (n = 16), LapSim group (n = 17), and Control group (n = 13). Outcomes measures included both time and accuracy scores on three laparoscopic tasks (Task 1: Grasp and Place; Task 2: Run the Bowel; Task 3: Clip and Cut) performed on live anesthetized pigs, and a global rating of overall performance as judged by four experienced surgeons.

RESULTS: The Tower Trainer group performed significantly better than the Control group on 1 of 7 outcomes measures-Task 3: Time (p < 0.032), although the LapSim group performed significantly better than the Control group on 2 of 7 measures-Task 3: Time (p < 0.008) and Global score (p < 0.005). In comparing the two simulators, the LapSim group performed significantly better than the Tower Trainer group on 3 of 7 outcomes measures-Task 2: Time (p < 0.032), Task 2: Accuracy (p < 0.030) and Global score (p < 0.005), although the Tower Trainer group did not perform significantly better than the LapSim group on any measure.

CONCLUSIONS: This study demonstrated that naive subjects trained on a virtual-reality part-task trainer performed better on live surgical tasks in a porcine model as compared with those trained with a traditional box trainer. These findings could aid in selection of appropriate training methodologies.

The transfer of basic skills learned in a laparoscopic simulator to the operating room.

Hyltander A, Liljegren E, Rhodin PH, Lönroth H.

Surg Endosc. 2002 Sep;16(9):1324-8. Epub 2002 May 7.

BACKGROUND: The aim of the study was to evaluate whether basic surgical skills achieved by training in LapSim, a computerbased laparoscopic simulator, could be transferred to the operating room.

METHODS: For this study, 24 medical students undergoing courses in surgery were randomly assigned to train with LapSim or to serve as control subjects. After they had undergone simulator training 2 h per week for 5 weeks, their basic skills in laparoscopic surgery were assessed in a porcine model. The time to perform each task was measured, and four senior surgeons independently graded the overall performance on a 9-step differential rating scale.

RESULTS: The participants randomized to train with LapSim showed significantly better results for all tasks in both parts of the study than the untrained participants, according to the expert evaluation. Time consumption was accordingly lower in the training group in the control group.

CONCLUSIONS: The results show that basic skills achieved by systematic training with a laparoscopic simulator such as LapSim can be transferred to the operating room.

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