Is it all about the money? : The effects of low and high cost simulator training scenarios in surgical training

Background: The learning process is complex and dependent on several factors such as for instance, the environment to learn, prior knowledge and distinct abilities, motivation, goal-orientation as well as the effects of instructor feedback. Medical education, in particular within surgical domains is imperative due to its influence on patient safety. The demand for training surgeons has shifted from the “master-apprentice/practice on patients”, towards a safer modality, involving simulators. The positive effects laparoscopic simulator training has on laparoscopic performance is extensive, as well as its impact on operating room performance. Nonetheless, the difference in learning effect using either low-cost or high-fidelity laparoscopic simulators were not totally clear prior to study start. Aims 1. To examine whether laparoscopic surgical training may be offered at a lower cost, with maintained equivalent level of training and effect in knowledge/learning using a low-cost laparoscopic Blackbox (Paper I). 2. To study the impact of PC-gaming experience, visuospatial ability and gender on the various parameters of the MIST-VR simulator and its effect on the score (Paper II). 3. To further investigate the Blackbox, and if different adjuncts (video analysis) could provide more information regarding the effects of training (Paper III). 4. To study the effects on time to learn laparoscopic knot- and suturing skills in novices using two different laparoscopic needle holders in a more advanced Blackbox, evaluate outcomes regarding performance, ergonomic discomfort and time to perform laparoscopic knot- and suturing skills, as well as to evaluate an objective video evaluation scoring table (OVEST) (Paper IV). Materials and Methods: The participants were medical students from the surgical semester at Karolinska Institutet, Stockholm (Studies I-III) and medical students at Athens University Medical School in Athens, Athens, Greece (Study IV). The studies were conducted at CAMST (Center for Advanced Medical Simulation and Training), Karolinska University Hospital, Stockholm (Studies I-III), and at MPLSC (Medical Physics-Lab Simulation Center), Athens University Medical School, Athens, Greece (Study IV). In conjunction with inclusion, the students (Studies I-II) performed a test (MRT-A; Mental Rotation Test – A) for the assessment of their visuospatial ability, and questionnaires including baseline questions (Studies I-IV). The simulator training/tests were done using different laparoscopic simulators; Blackbox (Studies I and III); LapMentor (Study I); MIST-VR (Studies I-III); Simball box (Study IV). The participants’ simulator performance analyzed; time to completion and economy of movement (Studies I-IV); optical flow metrics (path-length and total number of particles) as displayed by the automated video analysis software (Study III); knot- and suturing skills (Study IV). Results: Studies I and II showed, as previous studies, that the visuospatial ability correlated with the initial simulator training sessions. Study I showed no significant difference in performance between laparoscopic basic skills training regardless of simulator used; low-cost or high-fidelity laparoscopy simulator. Studies I, II and III showed discrepancies between prior PC-gaming experience and the simulator performance, as well as some gender-specific differences. Study III also showed that the use of a low-cost automated video analysis software may be feasibly comparable to the build-in software of the MIST-VR simulator. Study IV presented a shortened time to learn for novices performing laparoscopic knot- and suturing tasks in a simulated environment when using the newly designed laparoscopic needle holder compared to a conventional market needle holder. Conclusions: Laparoscopic simulator training clearly facilitates laparoscopic skills performance. Improved prerequisites of training opportunities for surgeons could potentiate patient safety, especially since enhanced surgical performance improves patient safety. Subsequently, as depicted in this thesis, there is not one single truth or solution, rather different angles and several factors that affect learning in general and surgical performance in particular. Therefore, considerations of for instance individual differences, gender, and motivation, should all be included when producing laparoscopic skills training curriculum for future surgical trainees

A Novel Haptic Simulator for Evaluating and Training Salient Force-Based Skills for Laparoscopic Surgery

Laparoscopic surgery has evolved from an \u27alternative\u27 surgical technique to currently being considered as a mainstream surgical technique. However, learning this complex technique holds unique challenges to novice surgeons due to their \u27distance\u27 from the surgical site. One of the main challenges in acquiring laparoscopic skills is the acquisition of force-based or haptic skills. The neglect of popular training methods (e.g., the Fundamentals of Laparoscopic Surgery, i.e. FLS, curriculum) in addressing this aspect of skills training has led many medical skills professionals to research new, efficient methods for haptic skills training. The overarching goal of this research was to demonstrate that a set of simple, simulator-based haptic exercises can be developed and used to train users for skilled application of forces with surgical tools. A set of salient or core haptic skills that underlie proficient laparoscopic surgery were identified, based on published time-motion studies. Low-cost, computer-based haptic training simulators were prototyped to simulate each of the identified salient haptic skills. All simulators were tested for construct validity by comparing surgeons\u27 performance on the simulators with the performance of novices with no previous laparoscopic experience. An integrated, \u27core haptic skills\u27 simulator capable of rendering the three validated haptic skills was built. To examine the efficacy of this novel salient haptic skills training simulator, novice participants were tested for training improvements in a detailed study. Results from the study demonstrated that simulator training enabled users to significantly improve force application for all three haptic tasks. Research outcomes from this project could greatly influence surgical skills simulator design, resulting in more efficient training

Visual-Motor Learning in Minimally Invasive Surgery

The purpose of this thesis was to develop an in-depth understanding of motor control in surgery. This was achieved by applying current theories of sensorimotor learning and developing a novel experimental approach. A survey of expert opinion and a review of the existing literature identified several issues related to human performance and MIS. The approach of this thesis combined existing surgical training tools with state-of-the-art technology and adapted rigorous experimental psychology techniques (grounded in the principles of sensorimotor learning) within a controlled laboratory environment. Existing technology was incorporated into surgical scenarios via the Kinematic Assessment Tool - an experimentally validated, powerful and portable system capable of providing accurate and repeatable measures of visual-motor performance. The Kinematic Assessment Tool (KAT) was first established as an appropriate means of assessing visual-motor performance, subsequently the KAT was assessed as valid when assessing MIS performance. Following this, the system was used to investigate whether the principles of ‘structural learning’ could be applied to MIS. The final experiment investigated if there is any benefit of a standardised, repeatable laparoscopic warm-up to MIS performance. These experiments demonstrated that the KAT system combined with other existing technologies, can be used to investigate visual-motor performance. The results suggested that learning the control dynamics of the surgical instruments and variability in training is beneficial when presented with novel but similar tasks. These findings are consistent with structural learning theory. This thesis should inform current thinking on MIS training and performance and the future development of simulators with more emphasis on introducing variability within tasks during training. Further investigation of the role of structural learning in MIS is required

HUMAN-ROBOT COLLABORATION IN ROBOTIC-ASSISTED SURGICAL TRAINING

Ph.DDOCTOR OF PHILOSOPH

The Design of a Haptic Device for Training and Evaluating Surgeon and Novice Laparoscopic Movement Skills

As proper levels of force application are necessary to ensure patient safety, and training hours with an expert on live subjects are difficult, enhanced computer-based training is needed to teach the next generation of surgeons. Considering the role of touch in surgery, there is a need for a device capable of discerning the haptic ability of surgical trainees. This need is amplified by minimally invasive surgical techniques where a surgeon\u27s sense of tissue properties comes not directly through their own hands but indirectly through the tools. A haptic device capable of producing a realistic range of forces and motions that can be used to test the ability of users to replicate salient forces in specific maneuvers is proposed. This device also provides the opportunity to use inexpensive haptic trainers to educate surgeons about proper force application. A novel haptic device was designed and built to provide a simplified analogy of the forces and torques felt during free tool motion and constrained pushing, sweep with laparoscopic instruments. The device is realized as a single-degree-of-freedom robotic system controlled using real-time computer hardware and software. The details of the device design and the results of testing the design against the specifications are presented. A significant achievement in the design is the use of a two-camera vision system to sense the user placement of the input device. The capability of the device as a first-order screening tool to distinguish between novices and expert surgeons is described

Performance Factors in Neurosurgical Simulation and Augmented Reality Image Guidance

Virtual reality surgical simulators have seen widespread adoption in an effort to provide safe, cost-effective and realistic practice of surgical skills. However, the majority of these simulators focus on training low-level technical skills, providing only prototypical surgical cases. For many complex procedures, this approach is deficient in representing anatomical variations that present clinically, failing to challenge users’ higher-level cognitive skills important for navigation and targeting. Surgical simulators offer the means to not only simulate any case conceivable, but to test novel approaches and examine factors that influence performance. Unfortunately, there is a void in the literature surrounding these questions. This thesis was motivated by the need to expand the role of surgical simulators to provide users with clinically relevant scenarios and evaluate human performance in relation to image guidance technologies, patient-specific anatomy, and cognitive abilities. To this end, various tools and methodologies were developed to examine cognitive abilities and knowledge, simulate procedures, and guide complex interventions all within a neurosurgical context. The first chapter provides an introduction to the material. The second chapter describes the development and evaluation of a virtual anatomical training and examination tool. The results suggest that learning occurs and that spatial reasoning ability is an important performance predictor, but subordinate to anatomical knowledge. The third chapter outlines development of automation tools to enable efficient simulation studies and data management. In the fourth chapter, subjects perform abstract targeting tasks on ellipsoid targets with and without augmented reality guidance. While the guidance tool improved accuracy, performance with the tool was strongly tied to target depth estimation – an important consideration for implementation and training with similar guidance tools. In the fifth chapter, neurosurgically experienced subjects were recruited to perform simulated ventriculostomies. Results showed anatomical variations influence performance and could impact outcome. Augmented reality guidance showed no marked improvement in performance, but exhibited a mild learning curve, indicating that additional training may be warranted. The final chapter summarizes the work presented. Our results and novel evaluative methodologies lay the groundwork for further investigation into simulators as versatile research tools to explore performance factors in simulated surgical procedures

Trends and features of virtual reality: a literature review between 2017 and 2018

Virtual Reality has greatly evolved since the 1960´s to the present. It has been implemented in multiple research and knowledge areas, the most recognized being the entertainment industry. In order to establish the state of Virtual Reality and get an idea of its prospects, 537 scientific documents have been reviewed, applying search criteria, more specifically, Virtual Reality applied to education. A bibliometric analysis was realized based on summarizing each document, as well as its keywords and trends, then proceeding to categorize each one, according to the field of application. It was found that Virtual Reality is having relevance in medicine and training area, due to the ability to simulate difficult situations and above all, specific conditions raised by instructors. The future of Virtual Reality as a tool to train professionals in multiples areas is promising.La realidad virtual ha tenido una gran evolución desde la década de 1960 hasta el día de hoy. Se ha implementado en múltiples áreas, tanto de la investigación como del conocimiento, siendo más reconocida en la industria del entretenimiento. Con el propósito de establecer el estado de la realidad virtual y obtener una idea de su futuro, 537 documentos científicos han sido revisados aplicando criterios de búsqueda específicos, como realidad virtual aplicada a la educación. Un análisis bibliométrico fue realizado, teniendo como base un resumen y descripción de cada artículo, así como sus palabras claves y tendencias, procediendo a categorizar cada documento de acuerdo con su campo de aplicación. Se encontró que la realidad virtual tiene una gran relevancia en la medicina, industria militar y en el entrenamiento de personas, debido a su capacidad de simular situaciones difíciles y, sobre todo, condiciones específicas requeridas por instructores. El futuro de la realidad virtual como herramienta de entrenamiento para los profesionales de múltiples áreas es promisori

Tendencias y características de la realidad virtual: Una revisión de la literatura

Virtual Reality has greatly evolved between 1940s and 1990s. Since then, it has been implemented in multiple research and knowledge areas, the most recognized being the entertainment industry. In order to establish the state of Virtual Reality and get an idea of its prospects, 537 scientific documents have been reviewed, applying search criteria, more specifically, Virtual Reality applied to education. A bibliometric analysis was realized based on summarizing each document, as well as its keywords and trends, then proceeding to categorize each one, according to the field of application. It was found that Virtual Reality is having relevance in medicine and training area, due to the ability to simulate difficult situations and above all, specific conditions raised by instructors. The future of Virtual Reality as a tool to train professionals in multiples areas is promising.La realidad virtual ha tenido una gran avance entre la década 1940 y 1990. Desde entonces, se ha implementado en múltiples áreas, tanto de la investigación como del conocimiento, siendo más reconocida en la industria del entretenimiento. Con el propósito de establecer el estado de la realidad virtual y obtener una idea de su futuro, 537 documentos científicos han sido revisados aplicando criterios de búsqueda específicos, como realidad virtual aplicada a la educación. Un análisis bibliométrico fue realizado, teniendo como base un resumen y descripción de cada artículo, así como sus palabras claves y tendencias, procediendo a categorizar cada documento de acuerdo con su campo de aplicación. Se encontró que la realidad virtual tiene una gran relevancia en la medicina y en el entrenamiento de personas, debido a su capacidad de simular situaciones difíciles y, sobre todo, condiciones específicas requeridas por instructores. El futuro de la realidad virtual como herramienta de entrenamiento para los profesionales de múltiples áreas es promisori

Virtual Reality Based Environment for Orthopedic Surgery (Veos)

The traditional way of teaching surgery involves students observing a �live� surgery and then gradually assisting experienced surgeons. The creation of a Virtual Reality environment for orthopedic surgery (VEOS) can be beneficial in improving the quality of training while decreasing the time needed for training. Developing such virtual environments for educational and training purposes can supplement existing approaches. In this research, the design and development of a virtual reality based environment for orthopedic surgery is described. The scope of the simulation environment is restricted to an orthopedic surgery process known as Less Invasive Stabilization System (LISS) surgery. The primary knowledge source for the LISS surgical process was Miguel A. Pirela-Cruz (Head of Orthopedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center (TTHSC)). The VEOS was designed and developed on a PC based platform. The developed VEOS was validated through interactions with surgical residents at TTHSC. Feedback from residents and our collaborator Miguel A. Pirela-Cruz was used to make necessary modifications to the surgical environment.Industrial Engineering & Managemen