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

NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

Purpose: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians. Methods: We developed NOViSE - the first force-feedback enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom built and the behaviour of the virtual flexible endoscope is based on an established theoretical framework – the Cosserat Theory of Elastic Rods. Results: We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES Conclusions: VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype and the initial results indicate that it provides promising foundations for further development

Surgical Simulator Design and Development

With the introduction of minimally invasive surgery (MIS), it became necessary to develop training methods to learn skills outside the operating room. Several training simulators have become commercially available, but fundamental research into the requirements for effective and efficient training in MIS is still lacking. Three aspects of developing a training program are investigated here: what should be trained, how it should be trained, and how to assess the results of training. In addition, studies are presented that have investigated the role of force feedback in surgical simulators. Training should be adapted to the level of behavior: skill-based, rule-based, or knowledge-based. These levels can be used to design and structure a training program. Extra motivation for training can be created by assessment. During MIS, force feedback is reduced owing to friction in the laparoscopic instruments and within the trocar. The friction characteristics vary largely among instruments and trocars. When force feedback is incorporated into training, it should include the large variation in force feedback properties as well. Training different levels of behavior requires different training methods. Although force feedback is reduced during MIS, it is needed for tissue manipulation, and therefore force application should be trained as well

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

Robotic surgery training with commercially available simulation systems in 2011: a current review and practice pattern survey from the society of urologic robotic surgeons.

Abstract Objectives: Virtual reality (VR) simulation has the potential to standardize surgical training for robotic surgery. We sought to evaluate all commercially available VR robotic simulators. Materials and Methods: A MEDLINE(®) literature search was performed of all applicable keywords. Available VR simulators were evaluated with regard to face, content, and construct validation. Additionally, a survey was e-mailed to all members of the Endourological Society, querying the pervasiveness of VR simulators in robotic surgical training. Finally, each company was e-mailed to ask for a price quote for their respective system. Results: There are four VR robotic surgical simulators currently available: RoSS™, dV-Trainer™, SEP Robot™, and da Vinci(®) Skills Simulator™. Each system is represented in the literature and all possess varying degrees of face, content, and construct validity. Although all systems have basic skill sets with performance analysis and metrics software, most do not contain procedural components. When evaluating the results of our survey, most respondents did not possess a VR simulator although almost all believed there to be great potential for these devices in robotic surgical training. With the exception of the SEP Robot, all VR simulators are similar in price. Conclusions: VR simulators have a definite role in the future of robotic surgical training. Although the simulators target technical components of training, their largest impact will be appreciated when incorporated into a comprehensive educational curriculum

Objective Assessment of the Core Laparoscopic Skills Course

Objective. The demand for laparoscopic surgery has led to the core laparoscopic skills course (CLSC) becoming mandatory for trainees in UK. Virtual reality simulation (VR) has a great potential as a training and assessment tool of laparoscopic skills. The aim of this study was to determine the role of the CLSC in developing laparoscopic skills using the VR. Design. Prospective study. Doctors were given teaching to explain how to perform PEG transfer and clipping skills using the VR. They carried out these skills before and after the course. During the course they were trained using the Box Trainer (BT). Certain parameters assessed. Setting. Between 2008 and 2010, doctors attending the CLSC at St Georges Hospital. Participants. All doctors with minimal laparoscopic experience attending the CLSC. Results. Forty eight doctors were included. The time taken for the PEG skill improved by 52%, total left hand and right hand length by 41% and 48%. The total time in the clipping skill improved by 57%. Improvement in clips applied in the marked area was 38% and 45% in maximum vessel stretch. Conclusions. This study demonstrated that CLSC improved some aspects of the laparoscopic surgical skills. It addresses Practice-based Learning and patient care

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