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1.  Substituting Virtual Reality Trainers for Inanimate Box Trainers Does Not Decrease Laparoscopic Skills Acquisition 
Objectives:
Inanimate and virtual reality box training help in developing basic laparoscopic skills. The lack of tactile feedback and lack of reality may be a detriment when training with virtual reality trainers. This study examined the hypothesis that there is no difference in laparoscopic skills acquisition when virtual reality trainers are partially substituted for inanimate box trainers.
Methods:
Medical students without laparoscopic experience were randomized into either Group A or Group B. Group A performed tasks on the LTS 2000 (an inanimate box trainer) alone for 10 sessions. Group B performed tasks on the box trainer as well as on the MIST-VR (a virtual reality trainer) for 10 sessions. Scores for 5 inanimate box trainer exercises (time and errors) for the first and tenth sessions were compared between both groups.
Results:
No statistical differences were seen in any exercises in the first session between Group A (n=14) and Group B (n=18) in either time or errors (P=NS for all comparisons). Mean times decreased in both groups from the first session to the last session. At the last session, again both groups demonstrated no differences in any of the exercises (P=NS for all comparisons).
Conclusions:
No difference was found in laparoscopic skills acquisition when incorporating virtual reality trainers into a curriculum based on inanimate box trainers. Ideally, laparoscopic training laboratories should include both virtual reality and inanimate trainers.
PMCID: PMC3015783  PMID: 17651563
Virtual reality trainer; Laparoscopic skills acquisition; Inanimate box trainer
2.  Physical Reality Simulation for Training of Laparoscopists in the 21st Century. A Multispecialty, Multi-institutional Study 
Background:
Simulation is the most effective and safe way to train laparoscopic surgeons in an era of limited work hours, lack of funding, and increasing malpractice costs. However, the costs associated with the use of virtual reality simulators are significant, and although very technically sophisticated they still lack tactile feedback. We are proposing a physical reality simulator, the LTS 2000, as a reliable and effective alternative to virtual reality. This study was carried out to establish how reliably the simulator was able to differentiate between different levels of laparoscopic experience and to analyze the detection of skills improvement after simulation and clinical training.
Methods:
This study was carried out, between July 2002 and August 2003, in the departments of Surgery and Obstetrics and Gynecology at 2 separate institutions. We enrolled 40 individuals in the study who had experience ranging from postgraduate year-1 to full-time faculty level. Five postgraduate year-3 residents were subsequently retested after rotating on clinical services, performing advanced laparoscopic procedures to assess whether the simulator was sensitive enough to detect improvements in laparoscopic skills at the intermediate level. Six tasks were included in the test, and they were scored for speed and precision with the McGill system. Two scores were obtained: a coordination score and a suturing score combined in a total score. Other variables analyzed were handedness, specialty, number of laparoscopic procedures performed, and hours spent on the simulator.
Results:
Forty-five tests were performed. The number of subjects in each group based on level of experience was equally distributed. No difference occurred in scores between institutions, specialty, and right- or left-handed surgeons. A significant increase occurred in the coordination score and suturing score combined in the total score with increasing experience (P<0.05) at each level. Furthermore, the simulator was sensitive enough to detect a significant difference in all 3 scores between subjects who had practiced with the simulator before being tested (P<0.05). The scores of the 5 postgraduate year-3 participants doubled when tested, without reaching statistical significance due to the small sample size.
Conclusions:
Our study shows that the LTS 2000 reliably and reproducibly detects different levels of laparoscopic expertise and progression of the learning curve. LTS 2000 as a model of physical reality simulation should be considered a reliable alternative to virtual reality simulation.
PMCID: PMC3015577  PMID: 15984696
Laparoscopy; Medical training; Virtual reality simulation; Physical reality simulation
3.  A Surgical Virtual Reality Simulator Distinguishes Between Expert Gynecologic Laparoscopic Surgeons and Perinatologists 
Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skills level.
Background:
Concern regarding the quality of surgical training in obstetrics and gynecology residency programs is focusing attention on competency based education. Because open surgical skills cannot necessarily be translated into laparoscopic skills and with minimally invasive surgery becoming standard in operative gynecology, the discrepancy in training between obstetrics and gynecology will widen. Training on surgical simulators with virtual reality may improve surgical skills. However, before incorporation into training programs for gynecology residents the validity of such instruments needs to first be established. We sought to prove the construct validity of a virtual reality laparoscopic simulator, the SurgicalSimTM, by showing its ability to distinguish between surgeons with different laparoscopic experience.
Methods:
Eleven gynecologic surgeons (experts) and 11 perinatologists (controls) completed 3 tasks on the simulator, and 10 performance parameters were compared.
Results:
The experts performed faster, more efficiently, and with fewer errors, proving the construct validity of the SurgicalSim.
Conclusions:
Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skill levels. Hence, these simulators could be integrated into gynecology resident endoscopic training and utilized for objective assessment. Second, the skills required for competency in obstetrics cannot necessarily be utilized for better performance in laparoscopic gynecology.
doi:10.4293/108680811X13125733356477
PMCID: PMC3183557  PMID: 21985726
SurgicalSim; Gynecologic laparoscopy; Minimally invasive gynecology; MIS; OBGYN residency training; Competency based education; Virtual reality laparoscopic simulator; surgical education
4.  Virtual Reality and Computer-Enhanced Training Devices Equally Improve Laparoscopic Surgical Skill in Novices 
Background:
The study aim was to compare the effectiveness of virtual reality and computer-enhanced video-scopic training devices for training novice surgeons in complex laparoscopic skills.
Methods:
Third-year medical students received instruction on laparoscopic intracorporeal suturing and knot tying and then underwent a pretraining assessment of the task using a live porcine model. Students were then randomized to objectives-based training on either the virtual reality (n=8) or computer-enhanced (n=8) training devices for 4 weeks, after which the assessment was repeated.
Results:
Posttraining performance had improved compared with pretraining performance in both task completion rate (94% versus 18%; P<0.001*) and time [181±58 (SD) versus 292±24*]. Performance of the 2 groups was comparable before and after training. Of the subjects, 88% thought that haptic cues were important in simulators. Both groups agreed that their respective training systems were effective teaching tools, but computer-enhanced device trainees were more likely to rate their training as representative of reality (P<0.01).
Conclusions:
Training on virtual reality and computer-enhanced devices had equivalent effects on skills improvement in novices. Despite the perception that haptic feedback is important in laparoscopic simulation training, its absence in the virtual reality device did not impede acquisition of skill.
PMCID: PMC3015873  PMID: 18765042
Surgical education; Laparoscopic skills; Simulation training; Virtual reality
5.  Validation of a Novel Laparoscopic Adjustable Gastric Band Simulator 
Surgical endoscopy  2010;25(4):1012-1018.
Background
Morbid obesity accounts for more than 90,000 deaths per year in the United States. Laparoscopic adjustable gastric banding (LAGB) is the second most common weight loss procedure performed in the US and the most common in Europe and Australia. Simulation in surgical training is a rapidly advancing field that has been adopted by many to prepare surgeons for surgical techniques and procedures.
Study Aim
The aim of our study was to determine face, construct and content validity for a novel virtual reality laparoscopic adjustable gastric band simulator.
Methods
Twenty-eight subjects were categorized into two groups (Expert and Novice), determined by their skill level in laparoscopic surgery. Experts consisted of subjects who had at least four years of laparoscopic training and operative experience. Novices consisted of subjects with medical training, but with less than four years of laparoscopic training. The subjects performed the virtual reality laparoscopic adjustable band surgery simulator. They were automatically scored, according to various tasks. The subjects then completed a questionnaire to evaluate face and content validity.
Results
On a 5-point Likert scale (1 – lowest score, 5 – highest score), the mean score for visual realism was 4.00 ± 0.67 and the mean score for realism of the interface and tool movements was 4.07 ± 0.77 [Face Validity]. There were significant differences in the performance of the two subject groups (Expert and Novice), based on total scores (p<0.001) [Construct Validity]. Mean scores for utility of the simulator, as addressed by the Expert group, was 4.50 ± 0.71 [Content Validity].
Conclusion
We created a virtual reality laparoscopic adjustable gastric band simulator. Our initial results demonstrate excellent face, construct and content validity findings. To our knowledge, this is the first virtual reality simulator with haptic feedback for training residents and surgeons in the laparoscopic adjustable gastric banding procedure.
doi:10.1007/s00464-010-1306-5
PMCID: PMC3124630  PMID: 20734069
virtual reality; surgical training; bariatric; Obesity; LAGB; face validity; content validity; construct validity
6.  What is going on in augmented reality simulation in laparoscopic surgery? 
Surgical Endoscopy  2008;23(8):1693-1700.
Background
To prevent unnecessary errors and adverse results of laparoscopic surgery, proper training is of paramount importance. A safe way to train surgeons for laparoscopic skills is simulation. For this purpose traditional box trainers are often used, however they lack objective assessment of performance. Virtual reality laparoscopic simulators assess performance, but lack realistic haptic feedback. Augmented reality (AR) combines a virtual reality (VR) setting with real physical materials, instruments, and feedback. This article presents the current developments in augmented reality laparoscopic simulation.
Methods
Pubmed searches were performed to identify articles regarding surgical simulation and augmented reality. Identified companies manufacturing an AR laparoscopic simulator received the same questionnaire referring to the features of the simulator.
Results
Seven simulators that fitted the definition of augmented reality were identified during the literature search. Five of the approached manufacturers returned a completed questionnaire, of which one simulator appeared to be VR and was therefore not applicable for this review.
Conclusion
Several augmented reality simulators have been developed over the past few years and they are improving rapidly. We recommend the development of AR laparoscopic simulators for component tasks of procedural training. AR simulators should be implemented in current laparoscopic training curricula, in particular for laparoscopic suturing training.
doi:10.1007/s00464-008-0144-1
PMCID: PMC2710490  PMID: 18813987
Minimally invasive surgery; Training; Augmented reality; Simulation
7.  A Pilot Study of Surgical Training Using a Virtual Robotic Surgery Simulator 
Training on a virtual reality robotic simulator dry lab robotic surgery platform resulted in significant improvement in time to completion and economy of motion for novice robotic surgeons.
Background and Objectives:
Our objectives were to compare the utility of learning a suturing task on the virtual reality da Vinci Skills Simulator versus the da Vinci Surgical System dry laboratory platform and to assess user satisfaction among novice robotic surgeons.
Methods:
Medical trainees were enrolled prospectively; one group trained on the virtual reality simulator, and the other group trained on the da Vinci dry laboratory platform. Trainees received pretesting and post-testing on the dry laboratory platform. Participants then completed an anonymous online user experience and satisfaction survey.
Results:
We enrolled 20 participants. Mean pretest completion times did not significantly differ between the 2 groups. Training with either platform was associated with a similar decrease in mean time to completion (simulator platform group, 64.9 seconds [P = .04]; dry laboratory platform group, 63.9 seconds [P < .01]). Most participants (58%) preferred the virtual reality platform. The majority found the training “definitely useful” in improving robotic surgical skills (mean, 4.6) and would attend future training sessions (mean, 4.5).
Conclusion:
Training on the virtual reality robotic simulator or the dry laboratory robotic surgery platform resulted in significant improvements in time to completion and economy of motion for novice robotic surgeons. Although there was a perception that both simulators improved performance, there was a preference for the virtual reality simulator. Benefits unique to the simulator platform include autonomy of use, computerized performance feedback, and ease of setup. These features may facilitate more efficient and sophisticated simulation training above that of the conventional dry laboratory platform, without loss of efficacy.
doi:10.4293/108680813X13654754535872
PMCID: PMC3771788  PMID: 23925015
Robotic surgery; Surgical education; Surgical simulator training; Robotics; Computer simulation; Surgical procedures; Minimally invasive/education; Gynecologic surgery
8.  Preoperative Warm-Up Using a Virtual Reality Simulator 
Even more experienced laparoscopic surgeons in this report became better prepared to perform a surgical procedure doing simple exercises on a virtual reality simulator before the actual procedure.
Background and Objectives:
All modern surgical procedures require a high level of cognitive and psychomotor skills achieved using different training methods, but could be influenced by fatigue and other psychological factors. We evaluated the effect of warm-up exercises on operative laparoscopic performances.
Methods:
The surgical team operated on a consecutive series of 20 patients with gallstones. Patients were randomly allocated in 2 groups: group A to be operated on without warm-up exercises and group B to be operated on after a short-term warm-up. All the patients were operated on by the same surgical team. The full-time records of the operation were analyzed by 2 independent reviewers. A modified simplified Global Rating Score (GRS) was used to assess the surgical procedures. A training module using the Lap Mentor simulator was designed for the warm-up.
Results:
Better performances were noted by both observers in group B only regarding “Respect for tissue” scores (3.75±0.16 vs 4.43±0.20, P=.021 and 3.87±0.22 vs 4.57±0.20, P=.041) achieving significant or marginally significant differences for all categories; GRS scores for “time and motion” and “overall impression” tend to be better after warm-up, but differences failed to reach statistical significance in our series.
Conclusion:
Surgeons, even the most experienced in laparoscopic surgery, can increase specific psychomotor skills associated with a laparoscopic environment by doing simple exercises on a virtual reality simulator, just before an operation. These improvements are reflected in more accurate handling of tissue during laparoscopic cholecystectomy.
doi:10.4293/108680811X13176785204409
PMCID: PMC3340965  PMID: 22643511
Laparoscopic education; Warm-up; Computer simulation; Cholecystectomy
9.  Learning rate for laparoscopic surgical skills on MIST VR, a virtual reality simulator: quality of human-computer interface. 
Acquiring laparoscopic surgical skills involves initial learning of cognitive and motor skills followed by refinement of those skills. The successful use of a virtual reality simulator depends on the quality of the interface for the human-computer interaction and this can be determined by the initial learning rate. MIST VR, a part-task virtual reality laparoscopic simulator, provides objective assessment of psychomotor skills and can generate an overall score for performance, based upon errors made and time taken for six different tasks. This study analysed the rate of early task/instrument/computer familiarization on consecutive scores achieved by surgically experienced and naive individuals. Eleven surgeons, 18 medical students and seven non-medical personnel were tested on the simulator up to ten consecutive times, within a 2-week period. Performance data from every task and repetition were analysed to obtain individual scores of task performance. The calculation of overall score penalized errors far more heavily than total time taken, with high scores indicating poor performance. The surgeon-computer interface generated a rapid and significant early familiarization curve up to the third session on the simulator, with significant reductions in both time taken and total contact errors made. These results suggest that MIST VR represents a high quality interface. Surgeons scored consistently and significantly better than other subjects on all tasks. For surgically naive individuals, it was possible to predict the level of laparoscopic skills performance that would be attained after overcoming initial simulator learning curve, by studying their initial score. Overall scores reflected surgical experience and suggest that the simulator is measuring surgically relevant parameters. MIST VR provides a validated and much needed method for objective assessment of laparoscopic skills, for a variety of surgical disciplines.
PMCID: PMC2503263  PMID: 10615201
10.  Augmented versus Virtual Reality Laparoscopic Simulation: What Is the Difference? 
World Journal of Surgery  2007;31(4):764-772.
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 features.
doi:10.1007/s00268-006-0724-y
PMCID: PMC1913183  PMID: 17361356
11.  Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts 
Surgical Endoscopy  2010;24(10):2458-2464.
Background
Surgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision.
Methods
A total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups.
Results
The experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools.
Conclusion
The findings of the study provide support for the utility of assessing strategic gaze behaviour to better understand the way in which surgeons utilise visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed.
doi:10.1007/s00464-010-0986-1
PMCID: PMC2945464  PMID: 20333405
Eye-hand coordination; Virtual reality; Gaze strategy; Psychomotor control; Laparoscopy training
12.  Criterion-based laparoscopic training reduces total training time 
Surgical Endoscopy  2011;26(4):1095-1101.
Introduction
The benefits of criterion-based laparoscopic training over time-oriented training are unclear. The purpose of this study is to compare these types of training based on training outcome and time efficiency.
Methods
During four training sessions within 1 week (one session per day) 34 medical interns (no laparoscopic experience) practiced on two basic tasks on the Simbionix LAP Mentor virtual-reality (VR) simulator: ‘clipping and grasping’ and ‘cutting’. Group C (criterion-based) (N = 17) trained to reach predefined criteria and stopped training in each session when these criteria were met, with a maximum training time of 1 h. Group T (time-based) (N = 17) trained for a fixed time of 1 h each session. Retention of skills was assessed 1 week after training. In addition, transferability of skills was established using the Haptica ProMIS augmented-reality simulator.
Results
Both groups improved their performance significantly over the course of the training sessions (Wilcoxon signed ranks, P < 0.05). Both groups showed skill transferability and skill retention. When comparing the performance parameters of group C and group T, their performances in the first, the last and the retention training sessions did not differ significantly (Mann–Whitney U test, P > 0.05). The average number of repetitions needed to meet the criteria also did not differ between the groups. Overall, group C spent less time training on the simulator than did group T (74:48 and 120:10 min, respectively; P < 0.001). Group C performed significantly fewer repetitions of each task, overall and in session 2, 3 and 4.
Conclusions
Criterion-based training of basic laparoscopic skills can reduce the overall training time with no impact on training outcome, transferability or retention of skills. Criterion-based should be the training of choice in laparoscopic skills curricula.
doi:10.1007/s00464-011-2005-6
PMCID: PMC3310991  PMID: 22042592
Laparoscopic training; Criterion-based; Proficiency-based; LAP Mentor; Training time; Overtraining
13.  Virtual Reality Uterine Resectoscopic Simulator: Face and Construct Validation and Comparative Evaluation in an Educational Environment 
This pilot study suggests that virtual reality resectoscopic systems have the potential to measure and improve the technical skills of novices before they operate on human patients.
Background and Objectives:
Recognizing that resectoscopic simulation may have an educational role, this pilot study was designed to evaluate the face validity and educational utility of a virtual reality uterine resectoscope training system.
Methods:
A pilot prospective comparative study of novice and expert hysteroscopists' performance on a targeting exercise and myomectomy with the virtual loop electrode. At baseline, expert and novice resectoscopists each performed both exercises. Following instruction, novices practiced each exercise a total of 9 times with the 10th recorded as the training outcome. Results were compared both to baseline and to those of the experts. Data were analyzed with the paired t and Wilcoxon rank sum tests as appropriate.
Results:
At baseline, all experts touched 4 targets in a mean of 33 seconds with no perforations, compared to a mean of 2 for the 11 novices in a mean of 57 seconds (P=0.0034) with one perforation. In 3 minutes, the experts removed a mean of 97.3% of the virtual myoma, compared to 66.1% for the novices (P=0.0153). On the 10th “run,” novices touched a mean of 4 targets in a mean of 23 seconds, an improvement from baseline (P=0.0004) and improved to 89% on the myoma resection exercise (P=0.0515) 36.3% over baseline.
Conclusion:
Although this pilot study has a relatively small sample size and represents the results at one institution, it demonstrates that virtual reality resectoscopic systems have the potential to measure and improve the technical skills of novices before they operate on human patients.
doi:10.4293/108680811X13071180406312
PMCID: PMC3148859  PMID: 21902963
Resectoscope; Hysteroscope; Virtual reality; Simulator
14.  Comparison of Nintendo Wii and PlayStation2 for Enhancing Laparoscopic Skills 
The authors suggest that these video games may be an inexpensive alternative to laparoscopic training simulators.
Background and Objective:
The increase in laparoscopic surgery has led to a growing need to train residents in this skill. Virtual reality simulators and box trainers have been used as educational tools outside of the operating room, but both approaches have advantages and disadvantages. Video games have been an area of interest in the search for other modalities to train residents. Experience with the traditional single controller unit video games have been correlated with better surgical skill acquisition. In 2006, Nintendo introduced the Wii, a novel gaming modality that mimics movements in laparoscopy better than traditional games do. Our objective was to compare the Nintendo Wii and PlayStation2 for enhancing laparoscopy skills.
Methods:
The study included stratified randomization of 23 less experienced (<12 laparoscopy cases per year) and 19 more experienced (>12 per year) physicians, residents, and medical students to 30 min of Wii versus PlayStation2 in a university-affiliated hospital Department of Obstetrics and Gynecology. Pre- and posttest bead transfer and suturing scores were obtained.
Results:
Baseline characteristics were similar for both video game groups. Participants assigned to Wii and PlayStation2 both demonstrated significant improvement in bead transfer. Neither Wii nor PlayStation2 participants improved in suturing scores. The Wii group improved more in bead transfer scores when compared to the PlayStation2 group (60 points vs. 40 points, respectively), but this difference was not statistically significant.
Conclusions:
Both Wii and PlayStation2 significantly improved laparoscopic skills in bead transfer. These video games may be inexpensive alternatives to laparoscopy training simulators.
doi:10.4293/108680812X13462882737294
PMCID: PMC3558901  PMID: 23484573
Laparoscopy; Video games; Surgical; Education
15.  Effect of virtual reality training on laparoscopic surgery: randomised controlled trial 
Objective To assess the effect of virtual reality training on an actual laparoscopic operation.
Design Prospective randomised controlled and blinded trial.
Setting Seven gynaecological departments in the Zeeland region of Denmark.
Participants 24 first and second year registrars specialising in gynaecology and obstetrics.
Interventions Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls).
Main outcome measure The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes.
Results The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers’ inter-rater agreement was 0.79.
Conclusion Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures.
Trial registration ClinicalTrials.gov NCT00311792.
doi:10.1136/bmj.b1802
PMCID: PMC3273782  PMID: 19443914
16.  Comparison of Laparoscopy Training Using the Box Trainer Versus the Virtual Trainer 
The virtual reality trainer was found to be a reasonable alternative to the box trainer for laparoscopic skills training.
Background and Objectives:
To evaluate whether training on a virtual reality laparoscopic simulator improves the performance on a laparoscopic box trainer.
Methods:
Twenty-six subjects were trained using a box trainer, and 17 participants were trained using a virtual simulator. Participants in the experimental group completed 1 session of 5 exercises on the box trainer, 4 sessions on the virtual simulator, and a final session on the box trainer. Participants in the control group completed 6 sessions of 5 exercises on the box trainer alone. Exercises were monitored and scored for time and accuracy. Participants completed a self-evaluation survey after each session and a user satisfaction questionnaire at the end of the training.
Results:
No significant difference existed between the 2 groups in improvement of accuracy. Pegboard time (P=0.0110) and pattern cutting time (P=0.0229) were the only exercise parameters that improved significantly more in the control group compared with the experimental group. The experimental group developed more interest in a surgical field as a result of their experience than the control group did (70.6% vs 53.8%, respectively).
Conclusion:
The virtual simulator is a reasonable alternative to the box trainer for laparoscopic skills training.
doi:10.4293/108680810X12785289144115
PMCID: PMC3043569  PMID: 20932370
Laparoscopy; Training; Box trainer; Virtual trainer
17.  Novices Outperform Experienced Laparoscopists on Virtual Reality Laparoscopy Simulator 
Background and Objectives:
Virtual reality has been poorly studied among gynecologic surgeons. The aim of this study was to evaluate whether performance on the Minimally Invasive Surgery Trainer-Virtual Reality (MISTVR) laparoscopic trainer reflects laparoscopic experience among gynecologic surgeons and trainees.
Methods:
Twenty-six medical students, residents, and attending gynecologic surgeons completed a MIST-VR training program. A new simulated task was then presented to each participant, who repeated the task until proficiency was reached.
Results:
Attending physicians performed poorly when compared with medical students, requiring more than twice the number of attempts to reach proficiency (Mann-Whitney P<0.01). Among medical students and residents, there was an association between years of live laparoscopy experience and poor simulator performance (Spearman r P=0.01).
Conclusion:
Increased operating room experience and age were associated with worsening simulator performance. Several potential explanations for this trend are discussed, including lack of tactile and contextual feedback. Caution should be exercised when considering current virtual reality simulator technology as a measure of experience or ability among gynecologic surgeons.
PMCID: PMC3015992  PMID: 19275848
Computer simulation; Educational measurement/methods; Gynecologic surgical procedures/education; Laparoscopy; Virtual reality
18.  Suturing training in Augmented Reality: gaining proficiency in suturing skills faster 
Surgical Endoscopy  2008;23(9):2131-2137.
Background
Providing informative feedback and setting goals tends to motivate trainees to practice more extensively. Augmented Reality simulators retain the benefit of realistic haptic feedback and additionally generate objective assessment and informative feedback during the training. This study researched the performance curve of the adapted suturing module on the ProMIS Augmented Reality simulator.
Methods
Eighteen novice participants were pretrained on the MIST-VR to become acquainted with laparoscopy. Subsequently, they practiced 16 knots on the suturing module, of which the assessment scores were recorded to evaluate the gain in laparoscopic suturing skills. The scoring of the assessment method was calculated from the “time spent in the correct area” during the knot tying and the quality of the knot. Both the baseline knot and the knot at the top of the performance curve were assessed by two independent objective observers, by means of a standardized evaluation form, to objectify the gain in suturing skills.
Results
There was a statistically significant difference between the scores of the second knot (mean 72.59, standard deviation (SD) 16.28) and the top of the performance curve (mean 95.82, SD 3.05; p < 0.001, paired t-test). The scoring of the objective observers also differed significantly (mean 11.83 and 22.11, respectively; SD 3.37 and 3.89, respectively; p < 0.001) (interobserver reliability Cronbach’s alpha = 0.96). The median amount of repetitions to reach the top of the performance curve was eight, which also showed significant differences between both the assessment score (mean 88.14, SD 13.53, p < 0.001) and scoring of the objective observers of the second knot (mean 20.51, SD 4.14; p < 0.001).
Conclusions
This adapted suturing module on the ProMIS Augmented Reality laparoscopic simulator is a potent tool for gaining laparoscopic suturing skills.
doi:10.1007/s00464-008-0240-2
PMCID: PMC2730450  PMID: 19067051
Laparoscopy; Simulation; Training; Performance curve; Laparoscopic suturing
19.  Laparoscopic Warm-up Exercises Improve Performance of Senior-Level Trainees During Laparoscopic Renal Surgery 
Journal of Endourology  2012;26(5):545-550.
Abstract
Background and Purpose
Surgery is a high-stakes “performance.” Yet, unlike athletes or musicians, surgeons do not engage in routine “warm-up” exercises before “performing” in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery.
Materials and Methods
Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER (+POWER) and one without (–POWER). Subjects were randomly assigned to +POWER or −POWER for the initial case of each pairing, and all cases were performed ≥1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0.
Results
A total of 28 study cases (14+POWER, 14−POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the +POWER group (P≤0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the +POWER group for MC (P=0.04) but not iSKT (P=0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach ∝=0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores.
Conclusions
Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.
doi:10.1089/end.2011.0418
PMCID: PMC3552180  PMID: 22192095
20.  Preliminary Face and Construct Validation Study of a Virtual Basic Laparoscopic Skill Trainer 
Background
The Virtual Basic Laparoscopic Skill Trainer (VBLaST™) is a developing virtual reality-based surgical skill training system which incorporates several of the tasks of the Fundamentals of Laparoscopic Surgery (FLS) training system. This study aims to evaluate the face and construct validity of the VBLaST™.
Methods
Thirty-nine subjects were voluntarily recruited at the Beth Israel Deaconess Medical Center and classified into two groups: experts (PGY 5, fellow and practicing surgeons) and novice (PGY 1–4). They were then asked to perform three FLS tasks consisting of peg transfer, pattern cutting, and endoloop on both the VBLaST™ and the FLS system. The VBLaST™ performance scores were automatically computed, while the FLS scores were rated by a trained evaluator. Face validity was assessed using a 5-point Likert scale varying from not realistic/useful (1) to very realistic/useful (5).
Results
Face validity scores showed that the VBLaST™ was significantly realistic in portraying the three FLS tasks (3.95 ± 0.909) as well as the reality in trocar placement and tool movements (3.67 ± 0.874). Construct validity results show that VBLaST™ was able to differentiate the expert and novice group (P= 0.015). However, out of the two tasks used for evaluating VBLaST™, only the peg transfer task showed significant difference between the expert and novice group (P = 0.003). Spearman correlation coefficient analysis between the two scores showed significant correlation for the peg transfer task (Spearman coefficient 0.364, P = 0.023).
Conclusions
VBLaST™ demonstrated significant face validity and construct validity. A further set of studies, involving improvement to the current VBLaST™ system is needed to thoroughly demonstrate face and construct validity for all the tasks.
doi:10.1089/lap.2009.0030
PMCID: PMC3123729  PMID: 20201683
FLS; virtual reality; surgical training; face validity; construct validity
21.  Preliminary Face and Construct Validation Study of a Virtual Basic Laparoscopic Skill Trainer 
Abstract
Background
The Virtual Basic Laparoscopic Skill Trainer (VBLaST™) is a developing virtual-reality–based surgical skill training system that incorporates several of the tasks of the Fundamentals of Laparoscopic Surgery (FLS) training system. This study aimed to evaluate the face and construct validity of the VBLaST™ system.
Materials and Methods
Thirty-nine subjects were voluntarily recruited at the Beth Israel Deaconess Medical Center (Boston, MA) and classified into two groups: experts (PGY 5, fellow and practicing surgeons) and novice (PGY 1–4). They were then asked to perform three FLS tasks, consisting of peg transfer, pattern cutting, and endoloop, on both the VBLaST and FLS systems. The VBLaST performance scores were automatically computed, while the FLS scores were rated by a trained evaluator. Face validity was assessed using a 5-point Likert scale, varying from not realistic/useful (1) to very realistic/useful (5).
Results
Face-validity scores showed that the VBLaST system was significantly realistic in portraying the three FLS tasks (3.95 ± 0.909), as well as the reality in trocar placement and tool movements (3.67 ± 0.874). Construct-validity results show that VBLaST was able to differentiate between the expert and novice group (P = 0.015). However, of the two tasks used for evaluating VBLaST, only the peg-transfer task showed a significant difference between the expert and novice groups (P = 0.003). Spearman correlation coefficient analysis between the two scores showed significant correlation for the peg-transfer task (Spearman coefficient 0.364; P = 0.023).
Conclusions
VBLaST demonstrated significant face and construct validity. A further set of studies, involving improvement to the current VBLaST system, is needed to thoroughly demonstrate face and construct validity for all the tasks.
doi:10.1089/lap.2009.0030
PMCID: PMC3123729  PMID: 20201683
22.  Single versus multimodality training basic laparoscopic skills 
Surgical Endoscopy  2012;26(8):2172-2178.
Introduction
Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills.
Methods
Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S) (n = 18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M) (n = 18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks + one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test.
Results
Both groups improved their performance significantly (Wilcoxon signed-rank, P < 0.05). The performances of group S and group M in the additional basic task and the salpingectomy did not differ significantly (Mann–Whitney U test, P > 0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P ≤ 0.05), which can be explained by the fact that they were much more familiar with these tasks.
Conclusions
Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.
doi:10.1007/s00464-012-2184-9
PMCID: PMC3392502  PMID: 22350237
Laparoscopic training; Modality; Simulators; Virtual reality; Practice variability
23.  Virtual reality training in neurosurgery: Review of current status and future applications 
Background:
Over years, surgical training is changing and years of tradition are being challenged by legal and ethical concerns for patient safety, work hour restrictions, and the cost of operating room time. Surgical simulation and skill training offer an opportunity to teach and practice advanced techniques before attempting them on patients. Simulation training can be as straightforward as using real instruments and video equipment to manipulate simulated “tissue” in a box trainer. More advanced virtual reality (VR) simulators are now available and ready for widespread use. Early systems have demonstrated their effectiveness and discriminative ability. Newer systems enable the development of comprehensive curricula and full procedural simulations.
Methods:
A PubMed review of the literature was performed for the MESH words “Virtual reality, “Augmented Reality”, “Simulation”, “Training”, and “Neurosurgery”. Relevant articles were retrieved and reviewed. A review of the literature was performed for the history, current status of VR simulation in neurosurgery.
Results:
Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and credential surgeons as technically competent. The number of published literature discussing the application of VR simulation in neurosurgery training has evolved over the last decade from data visualization, including stereoscopic evaluation to more complex augmented reality models. With the revolution of computational analysis abilities, fully immersive VR models are currently available in neurosurgery training. Ventriculostomy catheters insertion, endoscopic and endovascular simulations are used in neurosurgical residency training centers across the world. Recent studies have shown the coloration of proficiency with those simulators and levels of experience in the real world.
Conclusion:
Fully immersive technology is starting to be applied to the practice of neurosurgery. In the near future, detailed VR neurosurgical modules will evolve to be an essential part of the curriculum of the training of neurosurgeons.
doi:10.4103/2152-7806.80117
PMCID: PMC3114314  PMID: 21697968
Haptics; simulation; training; virtual reality
24.  The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review 
Surgical Endoscopy  2009;23(6):1180-1190.
Background
Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.
Methods
A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive SurgeryAND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education.
Results
The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.
Conclusions
In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.
doi:10.1007/s00464-008-0298-x
PMCID: PMC2686803  PMID: 19118414
Haptic feedback; Minimal invasive surgery; Robotic surgery; Surgical training; Virtual reality
25.  Using Virtual Reality to Train Children Safe Street-Crossing Skills 
Background
Pedestrian injuries are among the leading causes of morbidity and mortality in middle childhood. One limitation to existing pedestrian safety interventions is that they do not provide children with repeated practice needed to develop the complex perceptual and cognitive skills required for safe street-crossing. Virtual reality (VR) offers training through repeated unsupervised practice without risk; automated feedback on success of crossings; adjustment of traffic to match children’s skill; and a fun, appealing environment for training.
Objective
Test efficacy of VR to train child pedestrians in safe street-crossing.
Setting
Birmingham, Alabama, USA.
Methods
A randomized controlled trial is underway with an expected sample of four groups of 60 children ages 7-8 (total N = 240). One group receives training in an interactive, immersive virtual pedestrian environment. A second receives pedestrian safety training via widely-used video and computer strategies. The third group receives what is judged to be the most efficacious treatment currently available, individualized behavioral training at streetside locations. The fourth group serves as a no-contact control group. All participants are exposed to a range of field- and laboratory-based measures of pedestrian skill during baseline and post-intervention visits, as well as during a six-month follow-up assessment.
Outcome Measures
Primary analyses will be conducted through linear mixed models testing change over time in the four intervention groups. Three pedestrian safety measures will serve as primary outcomes: temporal gap before initiating crossing, temporal gap remaining after crossing, and attention to traffic while waiting to cross.
Clinical Trial Registration
This study is registered at the US government website, www.clinicaltrials.gov, under the title, “Using Virtual Reality to Train Children in Pedestrian Safety”, registration number NCT00850759.
doi:10.1136/ip.2009.025288
PMCID: PMC2829738  PMID: 20179024
pedestrian; safety; injury; children; virtual reality; street-crossing

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