Ergonomics of the Operative Field in Paediatric Minimal Access Surgery

Imperial Users onl

Virtual reality training and assessment in laparoscopic rectum surgery

Background: Virtual-reality (VR) based simulation techniques offer an efficient and low cost alternative to conventional surgery training. This article describes a VR training and assessment system in laparoscopic rectum surgery. Methods: To give a realistic visual performance of interaction between membrane tissue and surgery tools, a generalized cylinder based collision detection and a multi-layer mass-spring model are presented. A dynamic assessment model is also designed for hierarchy training evaluation. Results: With this simulator, trainees can operate on the virtual rectum with both visual and haptic sensation feedback simultaneously. The system also offers surgeons instructions in real time when improper manipulation happens. The simulator has been tested and evaluated by ten subjects. Conclusions: This prototype system has been verified by colorectal surgeons through a pilot study. They believe the visual performance and the tactile feedback are realistic. It exhibits the potential to effectively improve the surgical skills of trainee surgeons and significantly shorten their learning curve. © 2014 John Wiley & Sons, Ltd

A Review of Virtual Reality Based Training Simulators for Orthopaedic Surgery

This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 total hip replacement pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator

A review of virtual reality based training simulators for orthopaedic surgery

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordThis review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator.Wessex Academic Health Science Network (Wessex AHSN) Innovation and Wealth Creation Accelerator Fund 2014/15Bournemouth Universit

Visuo-spatial ability in colonoscopy simulator training

Visuo-spatial ability is associated with a quality of performance in a variety of surgical and medical skills. However, visuo-spatial ability is typically assessed using Visualization tests only, which led to an incomplete understanding of the involvement of visuo-spatial ability in these skills. To remedy this situation, the current study investigated the role of a broad range of visuo-spatial factors in colonoscopy simulator training. Fifteen medical trainees (no clinical experience in colonoscopy) participated in two psycho-metric test sessions to assess four visuo-spatial ability factors. Next, participants trained flexible endoscope manipulation, and navigation to the cecum on the GI Mentor II simulator, for four sessions within 1 week. Visualization, and to a lesser degree Spatial relations were the only visuo-spatial ability factors to correlate with colonoscopy simulator performance. Visualization additionally covaried with learning rate for time on task on both simulator tasks. High Visualization ability indicated faster exercise completion. Similar to other endoscopic procedures, performance in colonoscopy is positively associated with Visualization, a visuo-spatial ability factor characterized by the ability to mentally manipulate complex visuo-spatial stimuli. The complexity of the visuo-spatial mental transformations required to successfully perform colonoscopy is likely responsible for the challenging nature of this technique, and should inform training- and assessment design. Long term training studies, as well as studies investigating the nature of visuo-spatial complexity in this domain are needed to better understand the role of visuo-spatial ability in colonoscopy, and other endoscopic techniques

Training laparoscopic skills : Changes in gynecological surgery

During recent decades, gynecological surgery has changed considerably, and this development affects surgical training. In Finland, the total number of gynecological procedures has decreased by 30% during the last ten years. An increasing number of basic procedures are now done under local anesthesia at outpatient clinics where training is much more demanding than in the operating room. Laparotomies are frequently replaced by laparoscopic procedures that require more complex skills than open surgery. Furthermore, operating room efficiency causes time constraints, while patients in general have more co-morbidities and the surgical procedures needed are more complex. Thus, for trainees all these factors make training more challenging, and the traditional apprenticeship model alone no longer ensures that trainees learn the needed skills. In this dissertation study our aim was to assess developments in gynecological surgery in Finland and other Nordic countries by evaluating trends in hysterectomies. In addition, we investigated outcomes of traditional surgical training, as compared to systematic cognitive and manual pre-training on laparoscopic skills. We assessed separately the effect of pretraining on the trainee’s first operative laparoscopy, and on the other hand, on laparoscopic hysterectomy, which is the most demanding laparoscopic procedure trainees perform. In Study I, we assessed the numbers of different hysterectomies from the Nordic Medico-Statistical Committee and Finnish Institute for Health and Welfare databases. We compared outcomes of different hysterectomy methods between trainees and specialists collected from the FINHYST 2006 survey. In Finland, hysterectomy rates started to decline in 2003 and reached the rate of other Nordic countries in 2008. The rate of hysterectomy in Finland declined until 2017, and the laparoscopic method has been the most common method since 2013. In the outcome comparison, it was noted that the overall operative time was longer in trainees’ operations. In the vaginal method, blood loss was higher in the trainees’ group whereas in other hysterectomy methods or in total complication rates there were no differences between the groups. In Study II, we evaluated the effectiveness of a cognitive web-course ‘Basics in Gynecological Laparoscopy’ for trainees at various levels of experience. All trainees in Finland were invited to participate in this web-based anonymous study where the level of knowledge was evaluated before and after taking the course. Participants were allocated into three groups according to their experience. After the course, improvement in knowledge gain was detected in all three groups; the less experienced group reached the starting level of the middle group and the middle group reached the starting level of the most experienced group. In Studies III and IV, the effect of simulator training on operative skills was evaluated. Trainees with no experience in operative laparoscopy were recruited for Study III. Half of the group comprised the intervention group. They did the web-based course ‘Basics in Gynecological Laparoscopy’ and trained basic skills with a virtual reality simulator. The control group took part in the traditional training only. The first live laparoscopic salpingectomy was video-recorded and evaluated. We found no differences in the surgical outcomes between the groups. In Study IV, the participants recruited were more experienced, but had not done laparoscopic hysterectomy as a first surgeon. All participants did the basic training as the intervention group in Study III. Furthermore, the intervention group trained with the hysterectomy module in a virtual reality simulator. The intervention group performed significantly better as evaluated by the Objective Assessment of Technical Skills and Visual Analog scale. Our findings indicate that the traditional apprentice model alone is no longer sufficient in trainee education due to changes in gynecological surgery. In Study III, we did not detect differences in outcomes between the groups. However, in Study IV evaluating learning of a more advanced procedure, we demonstrated better performance after training with the procedural module in a simulator. Based on these studies, we suggest that simulator training should be mandatory, with allocated training time for the trainee and supervision time for the trainer for providing feedback. As innate skills are different, a proficiency-based curriculum results in more homogeneous skills. Less experienced trainees seem to benefit the most from simulator training, thus the training should be started in the earliest stage of training.Gynekologinen kirurgia on muuttunut huomattavasti viimeisinä vuosikymmeninä: toimenpiteiden vuosittaiset kokonaismäärät ovat huomattavasti vähentyneet, polikliinisten toimenpiteiden osuudet kasvavat, avoleikkaukset ovat pääosin korvaantuneet vaativammilla tähystysleikkauksilla ja leikkaussalin tehokkuusvaatimukset ovat nousseet. Kaikki nämä muutokset vaikuttavat gynekologiaan erikoistuvien lääkäreiden kirurgiseen koulutukseen siten, ettei perinteinen oppipoikamalli ainoana koulutusmuotona enää ole riittävä Tässä väitöskirjatutkimuksessa selvitimme gynekologisen kirurgian muutoksia Suomessa sekä muissa Pohjoismaissa käyttäen esimerkkinä kohdunpoistoleikkausten suuntauksia. Arvioimme perinteisen leikkauskoulutuksen onnistumista ja toisaalta ennen leikkaussalityöskentelyä tapahtuvan systemaattisen tiedollisen ja taidollisen koulutuksen vaikutusta tähystysleikkauksen oppimiseen. Ensimmäisessä osatyössä totesimme, että Suomessa kohdunpoistomäärät alkoivat vähentyä vuoden 2003 jälkeen ja määrät saavuttivat pohjoismaisen tason vuonna 2008. Tähystysleikkaus on yleisempi toimenpidetapa Suomessa kuin muissa Pohjoismaissa ja vuoden 2013 jälkeen se on ollut yleisin kohdunpoistotapa Suomessa. Erikoistuvien ja erikoislääkäreiden tekemien kohdunpoistoleikkausten vertailututkimuksessa todettiin, että erikoistuvien lääkäreiden tekemät leikkaukset kestivät pidempään. Emättimen kautta tehdyissä leikkauksissa oli enemmän verenvuotoa erikoistuvien lääkäreiden ryhmässä, kun taas muissa kohdunpoistotavoissa tai komplikaatioiden kokonaismäärissä ei ollut eroja ryhmien välillä. Toisessa osatyössä selvitimme ’Gynekologisen laparoskopian perusteet’ -verkkokurssin vaikuttavuutta eri kokemustason omaaville erikoistuville lääkäreille. Tietotaso tutkittiin ennen ja jälkeen kurssin läpikäymisen. Osallistujat jaettiin kolmeen ryhmään kokemustason mukaisesti, ja kaikissa kolmessa ryhmässä tietotaso nousi merkittävästi. Kurssin käytyään kokemattomin ryhmä saavutti samat pisteet kuin keskiryhmä tutkimuksen alussa. Vastaavasti keskiryhmä saavutti kokeneiden ryhmän lähtötason. Sekä kolmannessa että neljännessä osatyössä tutkimme simulaattoriharjoittelun vaikutusta leikkaustaitojen oppimiseen. Kolmannen tutkimuksen osallistujat olivat kokemattomia erikoistuvia lääkäreitä, joista puolet muodosti interventioryhmän. Interventiona oli ’Gynekologisen laparoskopian perusteet’ -verkkokurssi sekä perusharjoiteohjelma virtuaalisella simulaattorilla. Ensimmäinen tähystysteitse tehty munanjohtimen poistoleikkaus videoitiin ja arvioitiin. Tässä tutkimuksessa interventioryhmän ja kontrolliryhmän tekemien leikkausten tuloksissa ei todettu eroja. Neljänteen tutkimukseen otetut erikoistuvat lääkärit olivat kokeneempia, ja kaikki osallistujat suorittivat saman harjoitusohjelman kuin interventioryhmä kolmannessa osatyössä. Tämän tutkimuksen interventioryhmä harjoitteli lisäksi virtuaalisen simulaattorin kohdunpoisto-ohjelmalla. Interventioryhmän tekemät kohdunpoistoleikkaukset sujuivat paremmin, kun ne arvioitiin leikkaustaitojen arviointilomakkeita käyttäen. Tutkimustuloksemme mukaan oppipoikamalli yksistään ei enää turvaa riittävää koulutusta johtuen gynekologisessa kirurgiassa tapahtuneista muutoksista. Internet-pohjaisia verkkokursseja voi hyödyntää myös kirurgian opetuksessa. Simulaattoriharjoittelu vaikuttaa parantavan leikkaustaitoja, mutta koska synnynnäiset taidot yksilöiden välillä ovat erilaiset, osaamisperustainen harjoitteluohjelma johtaa tasalaatuisempiin taitoihin. Simulaattoriharjoittelun tulisi olla pakollista, ja siihen pitäisi varata työaikaa sekä erikoistuvalle lääkärille että ohjaajalle palautteen antamisen mahdollistamiseksi. Kokemattomammat erikoistuvat lääkärit tuntuisivat hyötyvän simulaattoriharjoittelusta eniten, joten systemaattinen harjoittelu pitäisi aloittaa heti erikoistumisvaiheen alussa

A comprehensive evaluation of work and simulation based assessment in otolaryngology training

Introduction: The otolaryngology curriculum requires trainees to show evidence of operative competence before completion of training. The General Medical Council recommended that structured assessment be used throughout training to monitor and guide trainee progression. Despite the reduction in operative exposure and the variation in trainee performance, a ‘one size fits all’ approach continues to be applied. The number of procedures performed remains the main indicator of competence. Objectives: To analyse the utilisation, reliability and validity of workplace-based assessments in otolaryngology training. To identify, develop and validate a series of simulation platforms suitable for incorporation into the otolaryngology curriculum. To develop a model of interchangeable workplace- and simulation-based assessment that reflects trainee’s trajectory, audit the delivery of training and set milestones for modular learning. Methods: A detailed review of the literature identified a list of procedure-specific assessment tools as well as simulators suitable to be used as assessment platforms. A simulation-integrated training programme was piloted and models were tested for feasibility, face, content and construct validity before being incorporated into the North London training programme. The outcomes of workplace- and simulation-based assessments of all core and specialty otolaryngology trainees were collated and analysed. Results: The outcomes of 6535 workplace-based assessments were analysed. The strengths and weaknesses of 4 different assessment tools are highlighted. Validated platforms utilising cadavers, animal tissue, synthetic material and virtual reality simulators were incorporated into the curriculum. 60 trainees and 40 consultants participated in the process and found it of great educational value. Conclusion: Assessment with structured feedback is integral to surgical training. Assessment using validated simulation modules can complement that undertaken in the workplace. The outcomes of structures assessments can be used to monitor and guide trainee trajectory at individual and regional level. The derived learning curves can shape and audit future otolaryngological training.Open Acces

Methods and Tools for Objective Assessment of Psychomotor Skills in Laparoscopic Surgery

Training and assessment paradigms for laparoscopic surgical skills are evolving from traditional mentor–trainee tutorship towards structured, more objective and safer programs. Accreditation of surgeons requires reaching a consensus on metrics and tasks used to assess surgeons’ psychomotor skills. Ongoing development of tracking systems and software solutions has allowed for the expansion of novel training and assessment means in laparoscopy. The current challenge is to adapt and include these systems within training programs, and to exploit their possibilities for evaluation purposes. This paper describes the state of the art in research on measuring and assessing psychomotor laparoscopic skills. It gives an overview on tracking systems as well as on metrics and advanced statistical and machine learning techniques employed for evaluation purposes. The later ones have a potential to be used as an aid in deciding on the surgical competence level, which is an important aspect when accreditation of the surgeons in particular, and patient safety in general, are considered. The prospective of these methods and tools make them complementary means for surgical assessment of motor skills, especially in the early stages of training. Successful examples such as the Fundamentals of Laparoscopic Surgery should help drive a paradigm change to structured curricula based on objective parameters. These may improve the accreditation of new surgeons, as well as optimize their already overloaded training schedules