Human-centered design in laparoscopic skills acquisition: Shifting paradigms in the age of technology

Minimal Access Surgery (MAS) has multi-faceted implications on the different stakeholders involved in implementation. It requires the surgeon to cope with the ergonomic and cognitive challenges required to perform a surgical procedure. It needs the surgical team to work coherently for the smooth functioning of the technologically complex operating room (OR). It needs educators and policy makers to embrace reform into the novel practices of training skills in MAS. It needs the industry to engage in research to bring out newer tools and technologies akin to training tools. This thesis explores the premise of implementation of MAS in the areas of curriculum design, implementation of training protocols, assessment tools and emerging technologies and trends that improve the learning curve and the transfer of skills from a skills lab setting to the OR. Several surgeons were included from different parts of Europe and India with expertise levels ranging from novice to expert.To study the unique requirements of individual surgeons and the detriments of performance the Laparoscopic Surgical Skills (LSS) Grade 1 Level 1 was used as a common training curriculum. First, a worldwide survey was conducted on the variety of training modalities and tools. Then, Self-assessment and the implications of “reflection-before-practice” on skills progression was studied. Automated assessment tools were devised using motion tracking software and thresholds for optimal performance were proposed. Physiological markers were studied during OR performance to determine factors that influence immersion in virtual reality surroundings and replicated in physical space using 3D projection for team training. Evolving technology in MAS requires multifaceted approach from training to customization to ensure optimal and efficient patient and ergonomic outcomes.Applied Ergonomics and Desig

Self-assessment in laparoscopic surgical skills training: Is it reliable?

Background: The concept of self-assessment has been widely acclaimed for its role in the professional development cycle and self-regulation. In the field of medical education, self-assessment has been most used to evaluate the cognitive knowledge of students. The complexity of training and evaluation in laparoscopic surgery has previously acted as a barrier in determining the benefits self-assessment has to offer in comparison with other fields of medical education. Methods: Thirty-five surgical residents who attended the 2-day Laparoscopic Surgical Skills Grade 1 Level 1 curriculum were invited to participate from The Netherlands, India and Romania. The competency assessment tool (CAT) for laparoscopic cholecystectomy was used for self- and expert-assessment and the resulting distributions assessed. Results: A comparison between the expert- and self-assessed aggregates of scores from the CAT agreed with previous studies. Uniquely to this study, the aggregates of individual sub-categories—‘use of instruments’; ‘tissue handling’; and errors ‘within the component tasks’ and the ‘end product’ from both self- and expert-assessments—were investigated. There was strong positive correlation (rs > 0.5; p < 0.001) between the expert- and self-assessment in all categories with only the ‘tissue handling’ having a weaker correlation (rs = 0.3; p = 0.04). The distribution of the mean of the differences between self-assessment and expert-assessment suggested no significant difference between the scores of experts and the residents in all categories except the ‘end product’ evaluation where the difference was significant (W = 119, p = 0.03). Conclusion: Self-assessment using the CAT form gives results that are consistently not different from expert-assessment when assessing one’s proficiency in surgical skills. Areas where there was less agreement could be explained by variations in the level of training and understanding of the assessment criteria.Applied Ergonomics and DesignIndustrial Desig

Virtual Operating Room Simulation Setup (VORSS) for Procedural Training in Minimally Invasive Surgery: a Pilot Study

Virtual reality (VR) training is widely used in several minimal invasive surgery (MIS) training curricula for procedural training. However, VR training in its current state lack immersive training environments, such as using head-mounted displays that is implemented in military or aviation training and even entertainment. The virtual operating room simulation setup (VORSS) is explored in this study to determine the effectiveness of immersive training in MIS. Twenty-eight surgeons and surgical trainees performed a laparoscopic cholecystectomy on the VORSS comprising of a head-mounted 360-degree realistic OR surrounding on a VR laparoscopic simulator. The VORSS replicated a full setup of instruments and surgical team-members as well as some of the distractions occurring during surgical procedures. Questionnaires were followed by semi-structured interviews to collect the data. Experts and novices found the VORSS to be intuitive and easy to use (p = 0.001). The outcome of the usability test, applying QUESI and NASA-TLX, reflected the usability of the VORSS (p < 0.05), at the cognitive level, which indicates a good sense of immersion and satisfaction, when performing the procedure within VORSS. The need for personalized experience within the setup was strongly noted from most of the participants. The VORSS for procedural training has the potential to become a useful tool to provide immersive training in MIS surgery. Further optimizing of the VORSS realism and introduction of distractors in the OR should result in an improvement of the system.Applied Ergonomics and DesignEducation and Research SupportHuman-Centered Desig

A software-based tool for video motion tracking in the surgical skills assessment landscape

Background: The use of motion tracking has been proved to provide an objective assessment in surgical skills training. Current systems, however, require the use of additional equipment or specialised laparoscopic instruments and cameras to extract the data. The aim of this study was to determine the possibility of using a software-based solution to extract the data. Methods: 6 expert and 23 novice participants performed a basic laparoscopic cholecystectomy procedure in the operating room. The recorded videos were analysed using Kinovea 0.8.15 and the following parameters calculated the path length, average instrument movement and number of sudden or extreme movements. Results: The analysed data showed that experts had significantly shorter path length (median 127 cm vs. 187 cm, p = 0.01), smaller average movements (median 0.40 cm vs. 0.32 cm, p = 0.002) and fewer sudden movements (median 14.00 vs. 21.61, p = 0.001) than their novice counterparts. Conclusion: The use of software-based video motion tracking of laparoscopic cholecystectomy is a simple and viable method enabling objective assessment of surgical performance. It provides clear discrimination between expert and novice performance.Applied Ergonomics and DesignIndustrial Desig

Effects of surgical flow disruptions on surgeons’ resources: a pilot study

Background: Minimally invasive surgery requires surgeons to allocate more attention and efforts than open surgery. A surgeon’s pool of resource is affected by the multiple occurrences of interruptions and distractions in the operating room. Surgical flow disruption has been addressed from a quantitative perspective. However, little is known on its impact on the surgeons’ physiological resources. Methods: Three physiological markers, heat flux (HF), energy expenditure in metabolic equivalent of tasks and galvanic skin response were recorded using body sensor monitoring during the 21 surgical operations. The three markers, respectively, represent: stress, energy mobilization and task engagement. A total of 8 surgeons with different levels of expertise (expert vs. novice) were observed performing 21 surgical procedures categorized as short versus long. Factors of distractions were time-stamped, and triangulated with physiological markers. Two cases illustrate the impact of surgical flow disruptions on the surgeons. Results: The results indicate that expert surgeons’ mental schemata are better organized than novices. Additionally, the physiological markers indicate that novice surgeons display a higher HF at the start (tendency p =.059) and at the end of procedures (p =.001) when compared to experts. However, during longer procedures, expert surgeons have higher HF at the start (p =.041) and at the end (p =.026), than at the start and end of a short procedure. Conclusion: Data collected during this pilot study showed that interruptions and disruptions affect novice and expert surgeons differently. Surgical flow disruption appears to be taxing on the surgeons’ mental, emotional and physiological resources; as a function of the length and nature of the disruptions. Several training curricula have incorporated the use of virtual reality programs to train surgeons to cope with the new technology and equipment. We recommend integrating interruptions and distractions in virtual reality training programs as these impact the surgeons’ pool of resources.Applied Ergonomics and Desig

Analysing usability and presence of a virtual reality operating room (VOR) simulator during laparoscopic surgery training

Immersive Virtual Reality (VR) laparoscopy simulation is emerging to enhance the attractiveness and realism of surgical procedural training. This study analyses the usability and presence of a Virtual Operating Room (VOR) setup via user evaluation and sets out the key elements for an immersive environment during a laparoscopic procedural training.In the VOR setup, a VR headset displayed a 360-degree computer-generated Operating Room (OR) around a VR laparoscopic simulator during laparoscopy procedures. Thirty-seven surgeons and surgical trainees performed the complete cholecystectomy task in the VOR. Questionnaires (i.e., Localized Postural Discomfort scale, Questionnaire for Intuitive Use, NASA-Task Load Index, and Presence Questionnaire) followed by a semi-structured interview were used to collect the data.The participants could intuitively adapt to the VOR and were satisfied when performing their tasks (M=3.90, IQR=0.70). The participants, particularly surgical trainees, were highly engaged to accomplish the task. Despite the higher mental workload on four subscales (p < 0.05), the surgical trainees had a lower effort of learning (4 vs 3.33, p < 0.05) compared to surgeons. The participants experienced very slight discomfort in seven body segments (0.59-1.16). In addition, they expected improvements for team interaction and personalized experience within the setup.The VOR showed potential to become a useful tool in providing immersive training during laparoscopy procedure simulation based on the usability and presence noted in the study. Future developments of user interfaces, VOR environment, team interaction and personalization should result in improvements of the system.Applied Ergonomics and Desig

Validation of Motion Tracking Software for Evaluation of Surgical Performance in Laparoscopic Cholecystectomy

Motion tracking software for assessing laparoscopic surgical proficiency has been proven to be effective in differentiating between expert and novice performances. However, with several indices that can be generated from the software, there is no set threshold that can be used to benchmark performances. The aim of this study was to identify the best possible algorithm that can be used to benchmark expert, intermediate and novice performances for objective evaluation of psychomotor skills. 12 video recordings of various surgeons were collected in a blinded fashion. Data from our previous study of 6 experts and 23 novices was also included in the analysis to determine thresholds for performance. Video recording were analyzed both by the Kinovea 0.8.15 software and a blinded expert observer using the CAT form. Multiple algorithms were tested to accurately identify expert and novice performances. ½ L + 13 A + 16 J scoring of path length, average movement and jerk index respectively resulted in identifying 23/24 performances. Comparing the algorithm to CAT assessment yielded in a linear regression coefficient R2 of 0.844. The value of motion tracking software in providing objective clinical evaluation and retrospective analysis is evident. Given the prospective use of this tool the algorithm developed in this study proves to be effective in benchmarking performances for psychomotor skills evaluation.Applied Ergonomics and DesignMedical Instruments & Bio-Inspired TechnologyHuman-Centered Desig

Competency assessment tool for laparoscopic suturing: Development and reliability evaluation

Background: Laparoscopic suturing can be technically challenging and requires extensive training to achieve competency. To date no specific and objective assessment method for laparoscopic suturing and knot tying is available that can guide training and monitor performance in these complex surgical skills. In this study we aimed to develop a laparoscopic suturing competency assessment tool (LS-CAT) and assess its inter-observer reliability. Methods: We developed a bespoke CAT tool for laparoscopic suturing through a structured, mixed methodology approach, overseen by a steering committee with experience in developing surgical assessment tools. A wide Delphi consultation with over twelve experts in laparoscopic surgery guided the development stages of the tool. Following, subjects with different levels of laparoscopic expertise were included to evaluate this tool, using a simulated laparoscopic suturing task which involved placing of two surgical knots. A research assistant video recorded and anonymised each performance. Two blinded expert surgeons assessed the anonymised videos using the developed LS-CAT. The LS-CAT scores of the two experts were compared to assess the inter-observer reliability. Lastly, we compared the subjects’ LS-CAT performance scores at the beginning and end of their learning curve. Results: This study evaluated a novel LS-CAT performance tool, comprising of four tasks. Thirty-six complete videos were analysed and evaluated with the LS-CAT, of which the scores demonstrated excellent inter-observer reliability. Cohen’s Kappa analysis revealed good to excellent levels of agreement for almost all tasks of both instrument handling and tissue handling (0.87; 0.77; 0.75; 0.86; 0.85, all with p < 0.001). Subjects performed significantly better at the end of their learning curve compared to their first attempt for all LS-CAT items (all with p < 0.001). Conclusions: We developed the LS-CAT, which is a laparoscopic suturing grading matrix, with excellent inter-rater reliability and to discriminate between experience levels. This LS-CAT has a potential for wider use to objectively assess laparoscopic suturing skills.Applied Ergonomics and Desig