The neurocognitive gains of diagnostic reasoning training using simulated interactive veterinary cases

The present longitudinal study ascertained training-associated transformations in the neural underpinnings of diagnostic reasoning, using a simulation game named “Equine Virtual Farm” (EVF). Twenty participants underwent structural, EVF/task-based and resting-state MRI and diffusion tensor imaging (DTI) before and after completing their training on diagnosing simulated veterinary cases. Comparing playing veterinarian versus seeing a colorful image across training sessions revealed the transition of brain activity from scientific creativity regions pre-training (left middle frontal and temporal gyrus) to insight problem-solving regions post-training (right cerebellum, middle cingulate and medial superior gyrus and left postcentral gyrus). Further, applying linear mixed-effects modelling on graph centrality metrics revealed the central roles of the creative semantic (inferior frontal, middle frontal and angular gyrus and parahippocampus) and reward systems (orbital gyrus, nucleus accumbens and putamen) in driving pre-training diagnostic reasoning; whereas, regions implicated in inductive reasoning (superior temporal and medial postcentral gyrus and parahippocampus) were the main post-training hubs. Lastly, resting-state and DTI analysis revealed post-training effects within the occipitotemporal semantic processing region. Altogether, these results suggest that simulation-based training transforms diagnostic reasoning in novices from regions implicated in creative semantic processing to regions implicated in improvised rule-based problem-solving

Motor learning induced neuroplasticity in minimally invasive surgery

Technical skills in surgery have become more complex and challenging to acquire since the introduction of technological aids, particularly in the arena of Minimally Invasive Surgery. Additional challenges posed by reforms to surgical careers and increased public scrutiny, have propelled identification of methods to assess and acquire MIS technical skills. Although validated objective assessments have been developed to assess motor skills requisite for MIS, they poorly understand the development of expertise. Motor skills learning, is indirectly observable, an internal process leading to relative permanent changes in the central nervous system. Advances in functional neuroimaging permit direct interrogation of evolving patterns of brain function associated with motor learning due to the property of neuroplasticity and has been used on surgeons to identify the neural correlates for technical skills acquisition and the impact of new technology. However significant gaps exist in understanding neuroplasticity underlying learning complex bimanual MIS skills. In this thesis the available evidence on applying functional neuroimaging towards assessment and enhancing operative performance in the field of surgery has been synthesized. The purpose of this thesis was to evaluate frontal lobe neuroplasticity associated with learning a complex bimanual MIS skill using functional near-infrared spectroscopy an indirect neuroimaging technique. Laparoscopic suturing and knot-tying a technically challenging bimanual skill is selected to demonstrate learning related reorganisation of cortical behaviour within the frontal lobe by shifts in activation from the prefrontal cortex (PFC) subserving attention to primary and secondary motor centres (premotor cortex, supplementary motor area and primary motor cortex) in which motor sequences are encoded and executed. In the cross-sectional study, participants of varying expertise demonstrate frontal lobe neuroplasticity commensurate with motor learning. The longitudinal study involves tracking evolution in cortical behaviour of novices in response to receipt of eight hours distributed training over a fortnight. Despite novices achieving expert like performance and stabilisation on the technical task, this study demonstrates that novices displayed persistent PFC activity. This study establishes for complex bimanual tasks, that improvements in technical performance do not accompany a reduced reliance in attention to support performance. Finally, least-squares support vector machine is used to classify expertise based on frontal lobe functional connectivity. Findings of this thesis demonstrate the value of interrogating cortical behaviour towards assessing MIS skills development and credentialing.Open Acces

Visual Perception and Cognition in Image-Guided Intervention

Surgical image visualization and interaction systems can dramatically affect the efficacy and efficiency of surgical training, planning, and interventions. This is even more profound in the case of minimally-invasive surgery where restricted access to the operative field in conjunction with limited field of view necessitate a visualization medium to provide patient-specific information at any given moment. Unfortunately, little research has been devoted to studying human factors associated with medical image displays and the need for a robust, intuitive visualization and interaction interfaces has remained largely unfulfilled to this day. Failure to engineer efficient medical solutions and design intuitive visualization interfaces is argued to be one of the major barriers to the meaningful transfer of innovative technology to the operating room. This thesis was, therefore, motivated by the need to study various cognitive and perceptual aspects of human factors in surgical image visualization systems, to increase the efficiency and effectiveness of medical interfaces, and ultimately to improve patient outcomes. To this end, we chose four different minimally-invasive interventions in the realm of surgical training, planning, training for planning, and navigation: The first chapter involves the use of stereoendoscopes to reduce morbidity in endoscopic third ventriculostomy. The results of this study suggest that, compared with conventional endoscopes, the detection of the basilar artery on the surface of the third ventricle can be facilitated with the use of stereoendoscopes, increasing the safety of targeting in third ventriculostomy procedures. In the second chapter, a contour enhancement technique is described to improve preoperative planning of arteriovenous malformation interventions. The proposed method, particularly when combined with stereopsis, is shown to increase the speed and accuracy of understanding the spatial relationship between vascular structures. In the third chapter, an augmented-reality system is proposed to facilitate the training of planning brain tumour resection. The results of our user study indicate that the proposed system improves subjects\u27 performance, particularly novices\u27, in formulating the optimal point of entry and surgical path independent of the sensorimotor tasks performed. In the last chapter, the role of fully-immersive simulation environments on the surgeons\u27 non-technical skills to perform vertebroplasty procedure is investigated. Our results suggest that while training surgeons may increase their technical skills, the introduction of crisis scenarios significantly disturbs the performance, emphasizing the need of realistic simulation environments as part of training curriculum

Visuo-motor transformations in the intraparietal sulcus mediate the acquisition of endovascular medical skill

Performing endovascular medical interventions safely and efficiently requires a diverse set of skills that need to be practised in dedicated training sessions. Here, we used multimodal magnetic resonance (MR) imaging to determine the structural and functional plasticity and core skills associated with skill acquisition. A training group learned to perform a simulator-based endovascular procedure, while a control group performed a simplified version of the task; multimodal MR images were acquired before and after training. Using a well-controlled interaction design, we found strong, multimodal evidence for the role of the intraparietal sulcus (IPS) in endovascular skill acquisition that is in line with previous work implicating the structure in simple visuo-motor and mental rotation tasks. Our results provide a unique window into the multimodal nature of rapid structural and functional plasticity of the human brain while learning a multifaceted and complex clinical skill. Further, our results provide a detailed description of the plasticity process associated with endovascular skill acquisition and highlight specific facets of skills that could enhance current medical pedagogy and be useful to explicitly target during clinical resident training

Research on real-time physics-based deformation for haptic-enabled medical simulation

This study developed a multiple effective visuo-haptic surgical engine to handle a variety of surgical manipulations in real-time. Soft tissue models are based on biomechanical experiment and continuum mechanics for greater accuracy. Such models will increase the realism of future training systems and the VR/AR/MR implementations for the operating room

Computerized Evaluatution of Microsurgery Skills Training

The style of imparting medical training has evolved, over the years. The traditional methods of teaching and practicing basic surgical skills under apprenticeship model, no longer occupy the first place in modern technically demanding advanced surgical disciplines like neurosurgery. Furthermore, the legal and ethical concerns for patient safety as well as cost-effectiveness have forced neurosurgeons to master the necessary microsurgical techniques to accomplish desired results. This has lead to increased emphasis on assessment of clinical and surgical techniques of the neurosurgeons. However, the subjective assessment of microsurgical techniques like micro-suturing under the apprenticeship model cannot be completely unbiased. A few initiatives using computer-based techniques, have been made to introduce objective evaluation of surgical skills. This thesis presents a novel approach involving computerized evaluation of different components of micro-suturing techniques, to eliminate the bias of subjective assessment. The work involved acquisition of cine clips of micro-suturing activity on synthetic material. Image processing and computer vision based techniques were then applied to these videos to assess different characteristics of micro-suturing viz. speed, dexterity and effectualness. In parallel subjective grading on these was done by a senior neurosurgeon. Further correlation and comparative study of both the assessments was done to analyze the efficacy of objective and subjective evaluation

Assessment of laparoscopic surgical skills acquired on laparoscopic virtual reality simulator compared to box trainer: an analysis of obstetrics-gynaecology residents

Background: Laparoscopic surgery requires very different set of psychomotor skills compared to open surgery, such as working in three-dimensional environment with two-dimensional view, four instead of six degrees of freedom, eye-hand coordination, depth perception and bimanual manipulation. Laparoscopic surgical training using laparoscopic simulators overcomes these inherent differences and improves efficiency of learning and patient safety. The aim of this study was to compare the effectiveness of virtual reality (VR) simulator and box-trainer and determine whether one has advantages over the other as training tool for relatively simple laparoscopic procedures. Methods: A prospective, randomized, blinded, comparative trial enrolled 20 residents in Obstetrics and Gynaecology with minimal laparoscopic experiences to participate in practical exercises with either virtual reality (LapVR) simulator (group-A), or laparoscopic Box-Trainer (group-B). The candidates acted as their own control. Subjects within one group were not allowed to practice, on the opposing trainers. Initial teaching session was given to obtain all participants familiarization with the virtual reality simulator and they carried out laparoscopic salpingotomy and laparoscopic salpingectomy for ectopic pregnancy on LapVR (pretest). Performance was recorded by LapVR for parameters of total time taken, time of cautery used, total blood loss and economy of motion. The subjects were then randomized to either group-A or group-B for series of laparoscopic exercises. The residents of group-A were practiced on LapVR in laparoscopic peg transfer, clipping and cutting and certain parameters were assessed by LapVR. The practical exercises on laparoscopic Trainer-Box were based in the tasks of “ovarian cystectomy” and “salpingotomy” for ectopic pregnancy and they were captured on DVD and scored for time and accuracy by a blinded expert investigator. After 2-day sessions lasting one and half hours each, all subjects were reassessed on the initial same procedures on LapVR (post-test). Results: Both groups showed improvement after their training tasks. Performance of two groups was comparable before and after training for both laparoscopic ectopic pregnancy procedures on LapVR. The participants’ satisfaction according to post-training questionnaire was high for the training modality as a whole and showed no differences between groups. Conclusions: Neither LapVR nor Box-Trainer simulator showed any superiority over other for training laparoscopic skills to novice learners. Laparoscopic training laboratories in laparoscopic training hospitals could include virtual reality simulators as reasonable alternative to Box-Trainer simulators for laparoscopic training of inexperienced residents in laparoscopy

Force-feedback in virtual environments

Supervised by Mandayam A. Srinivasan.Also issued as Thesis (Ph.D.)--Massachusetts Institute of Technology, Dept. of Mechanical Engineering, 2000.Includes bibliographical references (leaves 121-127).by Chih-Hao Ho