Research priorities in surgical simulation for the 21st century.

Stefanidis D, Arora S, Parrack DM, Hamad GG, Capella J, Grantcharov TP, Urbach DR, Scott DJ, Jones DB, and the Association for Surgical Education Simulation Committee

Am J Surg 2012, vol 203, p49–53.

BACKGROUND: Despite tremendous growth, research in surgical simulation remains uncoordinated and unfocused. The objective of this study was to develop research priorities for surgical simulation.

METHODS: By using a systematic methodology (Delphi), members of the Association for Surgical Education submitted 5 research questions on surgical simulation. An expert review panel categorized and collapsed the submitted questions and redistributed them to the membership to be ranked using a priority scale from 1 (lowest) to 5 (highest). The results were analyzed and categorized by consensus in distinct topics.

RESULTS: Sixty members submitted 226 research questions that were reduced to 74. Ratings ranged from 2.19 to 4.78. Topics included simulation effectiveness and outcomes, performance assessment and credentialing, curriculum development, team training and nontechnical skills, simulation center resources and personnel, simulator validation, and other. The highest ranked question was, “Does simulation training lead to improved quality of patient care, patient outcomes, and safety?”.

CONCLUSIONS: Research priorities for surgical simulation were developed using a systematic methodology and can be used to focus surgical simulation research in areas most likely to advance the field.

Training in surgical oncology – The role of VR simulation

Lewis TM, Aggarwal R, Rajaretnam N, Grantcharov TP, Darzi A
Surg Oncology 2011 vol 20, p134-139

There have been dramatic changes in surgical training over the past two decades which have resulted in a number of concerns for the development of future surgeons. Changes in the structure of cancer services, working hour restrictions and a commitment to patient safety has led to a reduction in training opportunities that are available to the surgeon in training. Simulation and in particular virtual reality (VR) simulation has been heralded as an effective adjunct to surgical training. Advances in VR simulation has allowed trainees to practice realistic full length procedures in a safe and controlled environment, where mistakes are permitted and can be used as learning points. There is considerable evidence to demonstrate that the VR simulation can be used to enhance technical skills and improve operating room performance. Future work should focus on the cost effectiveness and predictive validity of VR simulation, which in turn would increase the uptake of simulation and enhance surgical training.

Surgical Skills Simulation: A Shift in the Conversation

Selzer DJ and Dunnington GL
Ann Surg 2013, Vol 00, p1-2

EXCERPT FROM EDITORIAL: With the publication of the article “State of the Evidence on Simulation-Based Training for Laparoscopic Surgery: A Systematic Review,” Zendejas et al have allowed the conversation regarding the skills laboratory and laparoscopic skill acquisition to shift from a discussion of “Is it effective?” to a discussion of “How can it be most effective?” Importantly, this shift in the conversation allows a vigorous focus on critical issues such as the timing to initiate simulation, how best to coordinate the skills laboratory with clinical experience, what type of simulators should be purchased, how to use the skills laboratory to assess proficiency, and how to avoid deterioration of laparoscopic skills. Before these questions are answered, it is necessary to understand why simulation-based training in laparoscopic surgery was inevitable.

State of the evidence on simulation-based training for laparoscopic surgery: a systematic review.

Zendejas B, Brydges R, Hamstra SJ, Cook DA.

Ann Surg 2013 Vol 257(4), p586-93

OBJECTIVE: Summarize the outcomes and best practices of simulation training for laparoscopic surgery. BACKGROUND: Simulation-based training for laparoscopic surgery has become a mainstay of surgical training. Much new evidence has accrued since previous reviews were published.

METHODS: We systematically searched the literature through May 2011 for studies evaluating simulation, in comparison with no intervention or an alternate training activity, for training health professionals in laparoscopic surgery. Outcomes were classified as satisfaction, skills (in a test setting) of time (to perform the task), process (eg, performance rating), product (eg, knot strength), and behaviors when caring for patients. We used random effects to pool effect sizes.

RESULTS: From 10,903 articles screened, we identified 219 eligible studies enrolling 7138 trainees, including 91 (42%) randomized trials. For comparisons with no intervention (n = 151 studies), pooled effect size (ES) favored simulation for outcomes of knowledge (1.18; N = 9 studies), skills time (1.13; N = 89), skills process (1.23; N = 114), skills product (1.09; N = 7), behavior time (1.15; N = 7), behavior process (1.22; N = 15), and patient effects (1.28; N = 1), all P < 0.05. When compared with nonsimulation instruction (n = 3 studies), results significantly favored simulation for outcomes of skills time (ES, 0.75) and skills process (ES, 0.54). Comparisons between different simulation interventions (n = 79 studies) clarified best practices. For example, in comparison with virtual reality, box trainers have similar effects for process skills outcomes and seem to be superior for outcomes of satisfaction and skills time.

CONCLUSIONS: Simulation-based laparoscopic surgery training of health professionals has large benefits when compared with no intervention and is moderately more effective than nonsimulation instruction.

Surgical Skills Training and Simulation

Tsuda S, Scott D, Doyle J, Jones DB
Current Problems in Surgery
Volume 46, Issue 4, April 2009, Pages 271-370

No abstract available

How far will simulators be involved into training?

Laguna MP, de Reijke TM, de la Rosette JJ.
Curr Urol Rep. 2009 Mar;10(2), p97-105.

The expansion of laparoscopy and endoscopic surgery has promoted a change in surgical skills acquisition. This review aims to identify problems that modulate surgical skills acquisition and the role of simulation in the current training programs. Social, medical, and working time constraints, together with patient safety issues, lead to a decreased availability of operating room (OR) training opportunities. Systematic reviews show that there is a positive “model to model” transfer of skills more evident for virtual reality (VR) simulation, although transfer from video tower exists for naïve trainees, both of which supplement standard laparoscopic training. VR to OR positive transfer is proven for laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, although not for all parameters analyzed. A mixed model integrating both types of trainers into surgical curricula may strengthen their respective possibilities. To what extent simulation will be included in the surgical training programs depends on development of objective and finer assessment tools and proficiency-based criteria.

Virtual reality training for surgical trainees in laparoscopic surgery.

Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR.

Cochrane Database Syst Rev. 2009 Jan 21;(1)

BACKGROUND: Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. OBJECTIVES: To determine whether virtual reality training can supplement or replace conventional laparoscopic surgical training (apprenticeship) in surgical trainees with limited or no prior laparoscopic experience. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and grey literature until March 2008. SELECTION CRITERIA: We included all randomised clinical trials comparing virtual reality training versus other forms of training including video trainer training, no training, or standard laparoscopic training in surgical trainees with little or no prior laparoscopic experience. We also included trials comparing different methods of virtual reality training. DATA COLLECTION AND ANALYSIS: We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the standardised mean difference with 95% confidence intervals based on intention-to-treat analysis.

MAIN RESULTS: We included 23 trials with 612 participants. Four trials compared virtual reality versus video trainer training. Twelve trials compared virtual reality versus no training or standard laparoscopic training. Four trials compared virtual reality, video trainer training and no training, or standard laparoscopic training. Three trials compared different methods of virtual reality training. Most of the trials were of high risk of bias. In trainees without prior surgical experience, virtual reality training decreased the time taken to complete a task, increased accuracy, and decreased errors compared with no training; virtual reality group was more accurate than video trainer training group. In the participants with limited laparoscopic experience, virtual reality training reduces operating time and error better than standard in the laparoscopic training group; composite operative performance score was better in the virtual reality group than in the video trainer group.

AUTHORS’ CONCLUSIONS: Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Further research of better methodological quality and more patient-relevant outcomes are needed.

The formula for a successful laparoscopic skills curriculum.

Stefanidis D, Heniford BT.

Arch Surg. 2009 Jan;144(1):77-82; discussion 82.

Although multiple simulators have been validated as effective training tools, curriculum development is lagging, and considerable work is needed to determine the best methods for training. This article identifies the factors that influence the successful incorporation of simulator training into the resident curriculum, reviews the evidence regarding laparoscopic curriculum development in the surgical literature, and provides a formula for effective curriculum design. A successful laparoscopic skills curriculum depends on many factors including participant motivation, available resources and personnel, and trainee and faculty commitment. It should encompass goal-oriented training, sensitive and objective performance metrics, appropriate methods of instruction and feedback, deliberate, distributed, and variable practice, an amount of overtraining, maintenance training, and a cognitive component. A curriculum that follows these principles is likely to spark trainee interest, ensure their satisfaction and participation in training sessions, and lead to an effective and efficient way of acquiring new skills using simulators. A skills curriculum is a dynamic process that should be tailored to individual needs and be continuously optimized based on accumulated evidence and experience.

Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery.

Gurusamy K, Aggarwal R, Palanivelu L, Davidson BR.

Br J Surg. 2008 Sep;95(9):1088-97. Comment in:

Br J Surg. 2009 Feb;96(2):222; author reply 222-3.

BACKGROUND: Surgical training has traditionally been one of apprenticeship. The aim of this review was to determine whether virtual reality (VR) training can supplement and/or replace conventional laparoscopic training in surgical trainees with limited or no laparoscopic experience.

METHODS: Randomized clinical trials addressing this issue were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, grey literature and reference lists. Standardized mean difference was calculated with 95 per cent confidence intervals based on available case analysis.

RESULTS: Twenty-three trials (mostly with a high risk of bias) involving 622 participants were included in this review. In trainees without surgical experience, VR training decreased the time taken to complete a task, increased accuracy and decreased errors compared with no training. In the same participants, VR training was more accurate than video trainer (VT) training. In participants with limited laparoscopic experience, VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training. In these participants, the composite performance score was better in the VR group than the VT group.

CONCLUSION: VR training can supplement standard laparoscopic surgical training. It is at least as effective as video training in supplementing standard laparoscopic training.

Integrating simulation in surgery as a teaching tool and credentialing standard.

Rehrig ST, Powers K, Jones DB.
J Gastrointest Surg. 2008 Feb;12(2):222-33. Epub 2007 Nov 15.

The time-honored training methods of surgery are rapidly being replaced with new teaching tools that are being integrated into residency and recredentialing standards. Numerous factors including societal, professional, and legal have all forced surgical training programs to seek alternative methods of training residents. Learning theories that have provided the basis for open surgical skills training have been modified and culminated in the theory of automaticity and the “pretrained” laparoscopic novice. A vast array of simulators exists for training, ranging from inanimate video trainers, human patient simulators, to more recently virtual reality (VR) computer-based trainers. Currently, inanimate trainers are deployed widely throughout surgical training programs and serve as the primary platform for laparoscopic skills training. As technology evolves, VR systems have become available, allowing for more complex skills training with realistic computer-generated anatomic structures. Using the theories of crisis management and crew resource management, simulation is moving from simple skills training to whole-team training in mock operating room environments. Looking to the near future, medical training will continue to evolve to meet the changing demands of society and professional responsibility to ensure patient safety. With the advent of accredited skills-training centers endorsed by the American College of Surgeons, simulation will be the catalyst for these continuing changes.

Simulation of laparoscopic surgery – four years’ experience at the Department of Surgery of the University Hospital Marburg.

Hassan I, Osei-Agymang T, Radu G, Gerdes B, Rothmund M, Fernandex ED.
Wien Klin Wochenschr. 2008 Feb;120(3-4): 70-76.

It is well known that learning curves are longer for laparoscopic surgery compared to open surgery. Recently, virtual reality (VR) simulation was developed as alternative to conventional training. Such a new training system makes it possible to offer a wide range of repeatable surgical situations, and thus, enable assessments based on direct observation of performance. During the last four years we did several studies using a VR simulator (LapSim). After a constructive validity study – discrimination between novices and experienced laparoscopic surgeons, we were able to show that advanced residents benefit most from a three-day practical course for laparoscopic surgery, while – in a further investigation – we found contrary to training at the Pelvitrainer that novices in laparoscopic surgery have the most benefit from VR training. Minimally invasive surgery is significantly more sophisticated for the surgeon than open surgery. While Research on laparoscopic surgery has focused primarily on the development and assessment of technical skills, non technical skills such as visual-spatial perception and stress coping has received much less attention. We showed that spatial perception as well as stress coping positively correlates with virtual laparoscopic skills. A high degree of spatial perception led to faster adaption to a non-stereo environment and correlated with high level of laparoscopic skills. Furthermore, Ineffective stress-coping strategies correlate with poor virtual laparoscopic performance. VR simulation seems to be a promising tool to improve laparoscopic skills in a modern apprenticeship model. According to patient safety, the development of this instrument for surgery should be advanced professionally just as a flight simulators in aviation.

Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery.

Aggarwal R, Ward J, Balasundaram I, Sains P, Athanasiou T, Darzi A.

Ann Surg. 2007 Nov;246(5):771-9.

OBJECTIVE: The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group. SUMMARY BACKGROUND DATA: Simulator-based training has been shown to improve technical performance during real laparoscopic procedures, although research to date has not proven the persistence of this effect over subsequent cases.

MATERIAL AND METHODS: Twenty novice surgeons underwent baseline laparoscopic skills testing followed by a 1-day didactic training session. Control subjects (n = 10) performed 5 cadaveric porcine LCs each; VR-trained subjects (n = 10) completed a VR training curriculum followed by 3 porcine LCs each. A further 10 experienced laparoscopic surgeons (>100 LCs) performed 2 porcine LCs each to define benchmark levels. Technical skill assessment was by motion analysis and video-based global rating scores (out of 35).

RESULTS: There were no intergroup differences in baseline skill. The first LC revealed significant differences between control and VR groups for time (median 4590 seconds vs. 2165 seconds, P = 0.038), path length (169.2 meters vs. 86.8 meters, P = 0.009), number of movements (2446 vs. 1029, P = 0.009), and video scores (17 vs. 25, P = 0.001). The VR group, although not a control, achieved video and dexterity scores equivalent to expert levels of performance.

CONCLUSIONS: A proficiency based VR training curriculum shortens the learning curve on real laparoscopic procedures when compared with traditional training methods. This may be a more cost- and time-effective approach, and supports the need for simulator-based practice to be integrated into surgical training programs.

The benefits of virtual reality simulator training for laparoscopic surgery.

Hart R, Karthigasu K.

Curr Opin Obstet Gynecol. 2007 Aug;19(4):297-302.

PURPOSE OF REVIEW: Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS: Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon’s deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY: It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Computer-based surgical simulation is too expensive. Or is it?

Haluck RS.
Surg Endosc. 2005 Feb;19(2):159-60. Comment on: Surg Endosc. 2005 Feb;19(2):161-7.

Editorial. No abstract available.

The LapSim virtual reality simulator: promising but not yet proven

Katherine Fairhurst • Andrew Strickland •Guy Maddern
Surg Endosc (2011) 25:343–355
DOI 10.1007/s00464-010-1181-0
Received: 1 October 2009 / Accepted: 1 June 2010 / Published online: 8 July 2010
_ Springer Science+Business Media, LLC 2010

Background The acquisition of technical skills using surgical simulators is an area of active research and rapidly evolving technology. The LapSim is a virtual reality simulator that currently allows practice of basic laparoscopic skills and some procedures. To date, no reviews have been published with reference to a single virtual reality simulator. Methods A PubMed search was performed using the keyword ‘‘LapSim,’’ with further papers identified from the citations of original search articles. Results Use of the LapSim to develop surgical skills has yielded overall results, although inconsistencies exist. Data regarding the transferability of learned skills to the operative environment are encouraging as is the validation work, particularly the use of a combination of measured parameters to produce an overall comparative performance score. Conclusion Although the LapSim currently does not have any proven significant advantages over video trainers in terms of basic skills instruction and although the results of validation studies are variable, the potential for such technology to have a huge impact on surgical training is apparent. Work to determine standardized learning curves and proficiency criteria for different levels of trainees is incomplete. Moreover, defining which performance parameters measured by the LapSim accurately determine laparoscopic skill is complex. Further technological advances will undoubtedly improve the efficacy of the LapSim, and the results of large multicenter trials are anticipated.

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