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

Prevalence of haptic feedback in robot-mediated surgery : a systematic review of literature

© 2017 Springer-Verlag. This is a post-peer-review, pre-copyedit version of an article published in Journal of Robotic Surgery. The final authenticated version is available online at: https://doi.org/10.1007/s11701-017-0763-4With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.Peer reviewe

Video-based assistance system for training in minimally invasive surgery

In this paper, the development of an assisting system for laparoscopic surgical training is presented. With this system, we expect to facilitate the training process at the first stages of training in laparoscopic surgery and to contribute to an objective evaluation of surgical skills. To achieve this, we propose the insertion of multimedia contents and outlines of work adapted to the level of experience of trainees and the detection of the movements of the laparoscopic instrument into the monitored image. A module to track the instrument is implemented focusing on the tip of the laparoscopic tool. This tracking method does not need the presence of artificial marks or special colours to distinguish the instruments. Similarly, the system has another method based on visual tracking to localize support multimedia content in a stable position of the field of vision. Therefore, this position of the support content is adapted to the movements of the camera or the working area. Experimental results are presented to show the feasibility of the proposed system for assisting in laparoscopic surgical training

Development of a Virtual Laparoscopic Trainer using Accelerometer Augmented Tools to Assess Performance in Surgical training

Previous research suggests that virtual reality (VR) may supplement conventional training in laparoscopy. It may prove useful in the selection of surgical trainees in terms of their dexterity and spatial awareness skills in the near future. Current VR training solutions provide levels of realism and in some instances, haptic feedback, but they are cumbersome by being tethered and not ergonomically close to the actual surgical instruments for weight and freedom of use factors. In addition, they are expensive hence making them less accessible to departments than conventional box trainers. The box trainers in comparison, although more economical, lack tangible feedback and realism for handling delicate tissue structures. We have previously reported on the development of a modified digitally enhanced surgical instrument for laparoscopic training, named the Parkar Tool. This tool contains wireless accelerometer and gyroscopic sensors integrated into actual laparoscopic instruments. By design, it alleviates the need for both tethered and physically different shaped tools thereby enhancing the realism when performing surgical procedures. Additionally the software (Valhalla) has the ability to digitally record surgical motions, thereby enabling it to remotely capture surgical training data to analyse and objectively evaluate performance. We have adapted and further developed our initial single training tool method as used with a laparoscopic pyloromyotomy scenario, to an enhanced method using multiple Parkar wireless tools simultaneously, for use in several different case scenarios. This allows the use and measurement of right and left handed dexterity with the benefit of using several tasks of differing complexity. The development of a 3D tissue-surface deformations solution written in OpenGL gives us several different virtual surgical training scenario approximations to use with the instruments. The trainee can start with learning simple tasks e.g. incising tissue, grasping, squeezing and stretching tissue, to more complex procedures such as suturing, herniotomies, bowel anastomoses, as well as the original pyloromyotomy as used in the first model

Systems and technologies for objective evaluation of technical skills in laparoscopic surgery

Minimally invasive surgery is a highly demanding surgical approach regarding technical requirements for the surgeon, who must be trained in order to perform a safe surgical intervention. Traditional surgical education in minimally invasive surgery is commonly based on subjective criteria to quantify and evaluate surgical abilities, which could be potentially unsafe for the patient. Authors, surgeons and associations are increasingly demanding the development of more objective assessment tools that can accredit surgeons as technically competent. This paper describes the state of the art in objective assessment methods of surgical skills. It gives an overview on assessment systems based on structured checklists and rating scales, surgical simulators, and instrument motion analysis. As a future work, an objective and automatic assessment method of surgical skills should be standardized as a means towards proficiency-based curricula for training in laparoscopic surgery and its certification

Augmented versus Virtual Reality Laparoscopic Simulation: What Is the Difference?: A Comparison of the ProMIS Augmented Reality Laparoscopic Simulator versus LapSim Virtual Reality Laparoscopic Simulator

BACKGROUND: Virtual reality (VR) is an emerging new modality for laparoscopic skills training; however, most simulators lack realistic haptic feedback. Augmented reality (AR) is a new laparoscopic simulation system offering a combination of physical objects and VR simulation. Laparoscopic instruments are used within an hybrid mannequin on tissue or objects while using video tracking. This study was designed to assess the difference in realism, haptic feedback, and didactic value between AR and VR laparoscopic simulation. METHODS: The ProMIS AR and LapSim VR simulators were used in this study. The participants performed a basic skills task and a suturing task on both simulators, after which they filled out a questionnaire about their demographics and their opinion of both simulators scored on a 5-point Likert scale. The participants were allotted to 3 groups depending on their experience: experts, intermediates and novices. Significant differences were calculated with the paired t-test. RESULTS: There was general consensus in all groups that the ProMIS AR laparoscopic simulator is more realistic than the LapSim VR laparoscopic simulator in both the basic skills task (mean 4.22 resp. 2.18, P <0.000) as well as the suturing task (mean 4.15 resp. 1.85, P <0.000). The ProMIS is regarded as having better haptic feedback (mean 3.92 resp. 1.92, P <0.000) and as being more useful for training surgical residents (mean 4.51 resp. 2.94, P <0.000). CONCLUSIONS: In comparison with the VR simulator, the AR laparoscopic simulator was regarded by all participants as a better simulator for laparoscopic skills training on all tested feature

Training the gynecologic oncologists of the future: challenges and opportunities

Several recent advances in gynecologic cancer care have improved patient outcomes. These include national screening and vaccination programs for cervical cancer as well as neoadjuvant chemotherapy for ovarian cancer. Conversely, these advances have cumulatively reduced surgical opportunities for training creating a need to supplement existing training strategies with evidence-based adjuncts. Technologies such as virtual reality and augmented reality, if properly evaluated and validated, have transformative potential to support training. Given the changing landscape of surgical training in gynecologic oncology, we were keen to summarize the evidence underpinning current training in gynecologic oncology.In this review, we undertook a literature search of Medline, Google, Google Scholar, Embase and Scopus to gather evidence on the current state of training in gynecologic oncology and to highlight existing evidence on the best methods to teach surgical skills. Drawing from the experiences of other surgical specialties we examined the use of training adjuncts such as cadaveric dissection, animation and 3D models as well as simulation training in surgical skills acquisition. Specifically, we looked at the use of training adjuncts in gynecologic oncology training as well as the evidence behind simulation training modalities such as low fidelity box trainers, virtual and augmented reality simulation in laparoscopic training. Finally, we provided context by looking at how training curriculums varied internationally.Whereas some evidence to the reliability and validity of simulation training exists in other surgical specialties, our literature review did not find such evidence in gynecologic oncology. It is important that well conducted trials are used to ascertain the utility of simulation training modalities before integrating them into training curricula.</p

Laparoscopic Video Analysis for Training and Image Guided Surgery

Automatic analysis of Minimally Invasive Surgical video has the potential to drive new solutions for alleviating needs of safe and reproducible training programs, objective and transparent evaluation systems and navigation tools to assist surgeons and improve patient safety. Surgical video is an always available source of information, which can be used without any additional intrusive hardware in the operating room. This paper is focused on surgical video analysis methods and techniques. It describes authors' contributions in two key aspects, the 3D reconstruction of the surgical field and the segmentation and tracking of tools and organs based on laparoscopic video images. Results are given to illustrate the potential of this field of research, like the calculi of the 3D position and orientation of a tool from its 2D image, or the translation of a preoperative resection plan into a hepatectomy surgical procedure using the shading information of the image. Research efforts are required to further develop these technologies in order to harness all the valuable information available in any video-based surgery