Novel Multi-AP Coordinated Transmission Scheme for 7th Generation WLAN 802.11be.

The demand for high-data-rate and time-sensitive applications, such as 4k/8k video streaming and real-time augmented reality (AR), virtual reality (VR), and gaming, has increased significantly. Addressing the inefficiency of distributed channel access and the fairness problem between uplink and downlink flows is crucial for the development of wireless local area network (WLAN) technologies. In this study, we propose a novel transmission scheme for IEEE 802.11be networks that addresses the fairness problem and improves the system throughput. Utilizing the concept of multi-AP coordinated OFDMA introduced in the 7th-generation WLAN IEEE 802.11be, the proposed transmission scheme allows an AP to share a granted transmission opportunity (TXOP) with nearby APs. A mathematically analysis of the throughput performance of the proposed schemes was performed using a Markov chain model. The simulation results verify that the scheme effectively improves the downlink fairness and the system throughput. Combined with the advanced multiuser (MU) features of IEEE 802.11ax, such as TUA, MU cascading sequence, and MU EDCA, the proposed scheme not only enhances downlink AP transmission, but also guarantees improved control over the medium. The scheme is carefully designed to be fully compatible with conventional IEEE 802.11 protocols, and is thus potentially universal.

Convergent validation and transfer of learning studies of a virtual reality-based pattern cutting simulator.

INTRODUCTION: Research has clearly shown the benefits of surgical simulators to train laparoscopic motor skills required for positive patient outcomes. We have developed the Virtual Basic Laparoscopic Skill Trainer (VBLaST) that simulates tasks from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. This study aims to show convergent validity of the VBLaST pattern cutting module via the CUSUM method to quantify learning curves along with motor skill transfer from simulation environments to ex vivo tissue samples. METHODS: 18 medical students at the University at Buffalo, with no prior laparoscopic surgical skills, were placed into the control, FLS training, or VBLaST training groups. Each training group performed pattern cutting trials for 12 consecutive days on their respective simulation trainers. Following a 2-week break period, the trained students performed three pattern cutting trials on each simulation platform to measure skill retention. All subjects then performed one pattern cutting task on ex vivo cadaveric peritoneal tissue. FLS and VBLaST pattern cutting scores, CUSUM scores, and transfer task completion times were reported. RESULTS: Results indicate that the FLS and VBLaST trained groups have significantly higher task performance scores than the control group in both the VBLaST and FLS environments (p < 0.05). Learning curve results indicate that three out of seven FLS training subjects and four out of six VBLaST training subjects achieved the "senior" performance level. Furthermore, both the FLS and VBLaST trained groups had significantly lower transfer task completion times on ex vivo peritoneal tissue models (p < 0.05). CONCLUSION: We characterized task performance scores for trained VBLaST and FLS subjects via CUSUM analysis of the learning curves and showed evidence that both groups have significant improvements in surgical motor skill. Furthermore, we showed that learned surgical skills in the FLS and VBLaST environments transfer not only to the different simulation environments, but also to ex vivo tissue models.

Validation of the VBLaST pattern cutting task: a learning curve study.

BACKGROUND: Mastery of laparoscopic skills is essential in surgical practice and requires considerable time and effort to achieve. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PC©) is a virtual simulator that was developed as a computerized version of the pattern cutting (PC) task in the Fundamentals of Laparoscopic Surgery (FLS) system. To establish convergent validity for the VBLaST-PC©, we assessed trainees' learning curves using the cumulative summation (CUSUM) method and compared them with those on the FLS. METHODS: Twenty-four medical students were randomly assigned to an FLS training group, a VBLaST training group, or a control group. Fifteen training sessions, 30 min in duration per session per day, were conducted over 3 weeks. All subjects completed pretest, posttest, and retention test (2 weeks after posttest) on both the FLS and VBLaST© simulators. Performance data, including time, error, FLS score, learning rate, learning plateau, and CUSUM score, were analyzed. RESULTS: The learning curve for all trained subjects demonstrated increasing performance and a performance plateau. CUSUM analyses showed that five of the seven subjects reached the intermediate proficiency level but none reached the expert proficiency level after 150 practice trials. Performance was significantly improved after simulation training, but only in the assigned simulator. No significant decay of skills after 2 weeks of disuse was observed. Control subjects did not show any learning on the FLS simulator, but improved continually in the VBLaST simulator. CONCLUSIONS: Although VBLaST©- and FLS-trained subjects demonstrated similar learning rates and plateaus, the majority of subjects required more than 150 trials to achieve proficiency. Trained subjects demonstrated improved performance in only the assigned simulator, indicating specificity of training. The virtual simulator may provide better opportunities for learning, especially with limited training exposure.

Virtual interactive suturing for the Fundamentals of Laparoscopic Surgery (FLS).

BACKGROUND: Suturing with intracorporeal knot-tying is one of the five tasks of the Fundamentals of Laparoscopic Surgery (FLS), which is a pre-requisite for board certification in general surgery. This task involves placing a short suture through two marks in a penrose drain and then tying a double-throw knot followed by two single-throw knots using two needle graspers operated by both hands. A virtual basic laparoscopic skill trainer (VBLaST©) is being developed to represent the virtual versions of the FLS tasks, including automated, real time performance measurement and feedback. In this paper, we present the development of a VBLaST suturing simulator (VBLaST-SS©). Developing such a simulator involves solving multiple challenges associated with fast collision detection, response and force feedback. METHODS: In this paper, we present a novel projection-intersection based knot detection method, which can identify the validity of different types of knots at haptic update rates. A simple and robust edge-edge based collision detection algorithm is introduced to support interactive knot tying and needle insertion operations. A bimanual hardware interface integrates actual surgical instruments with haptic devices enabling not only interactive rendering of force feedback but also realistic sensation of needle grasping, which realizes an immersive surgical suturing environment. RESULTS: Experiments on performing the FLS intracorporeal suturing task show that the simulator is able to run on a standard personal computer at interactive rates. CONCLUSIONS: VBLaST-SS© is a computer-based interactive virtual simulation system for FLS intracorporeal knot-tying suturing task that can provide real-time objective assessment for the user's performance.

Face and content validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™).

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator. METHODS: Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity. RESULTS: Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75).

Developing Modularized Virtual Reality Simulators for Natural Orifice Translumenal Endoscopic Surgery (NOTES).

Natural orifice translumenal endoscopic surgery (NOTES) procedures are rapidly being developed in diverse surgical fields. We are developing a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™) built on a modularized platform that facilitates rapid development of virtual reality (VR) NOTES simulators. Both the hardware interface and software components consist of independent reusable and customizable modules. The developed modules are integrated to build a VR-NOTES simulator for training in the hybrid transvaginal NOTES cholecystectomy. The simulator was demonstrated and evaluated by expert NOTES surgeons at the 2015 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit.

Objective Surgical Skill Differentiation for Physical and Virtual Surgical Trainers via Functional Near-Infrared Spectroscopy.

This study proposes a methodology to objectively differentiate surgical skill for physical and virtual trainers by measuring functional activation between expert and novice surgeons. Results indicate that there is a significant increase in functional activation for novices in the right lateral prefrontal cortex, and decrease in the left medial primary motor cortex, and the supplementary motor area for the physical trainer (p<0.05). Results also indicate that there is a significant lower functional activation for novices compared to experts in the left medial primary motor cortex for the virtual skills trainer (p<0.05).

Pre-clinical Training for New Notes Procedures: From Ex-vivo Models to Virtual Reality Simulators.

Natural orifice transluminal endoscopic surgery (NOTES) is a newer field of endoscopic surgery that allows for scarless treatment of pathologic entities, using novel transluminal approaches. There has been a shift of focus from a clinical and research standpoint from the development and dissemination of "first-generation" NOTES procedures to "new NOTES" procedures that traverse the mucosa of luminal structures, yet do not stray far into the peritoneal cavity. It has been a challenge to find appropriate and effective ways to train gastroenterologists and surgeons in these novel approaches. We review the importance of simulation in training and discuss available simulation options.

Graphic and haptic simulation for transvaginal cholecystectomy training in NOTES.

BACKGROUND: Natural Orifice Transluminal Endoscopic Surgery (NOTES) provides an emerging surgical technique which usually needs a long learning curve for surgeons. Virtual reality (VR) medical simulators with vision and haptic feedback can usually offer an efficient and cost-effective alternative without risk to the traditional training approaches. Under this motivation, we developed the first virtual reality simulator for transvaginal cholecystectomy in NOTES (VTEST™). METHODS: This VR-based surgical simulator aims to simulate the hybrid NOTES of cholecystectomy. We use a 6DOF haptic device and a tracking sensor to construct the core hardware component of simulator. For software, an innovative approach based on the inner-spheres is presented to deform the organs in real time. To handle the frequent collision between soft tissue and surgical instruments, an adaptive collision detection method based on GPU is designed and implemented. To give a realistic visual performance of gallbladder fat tissue removal by cautery hook, a multi-layer hexahedral model is presented to simulate the electric dissection of fat tissue. RESULTS: From the experimental results, trainees can operate in real time with high degree of stability and fidelity. A preliminary study was also performed to evaluate the realism and the usefulness of this hybrid NOTES simulator. CONCLUSIONS: This prototyped simulation system has been verified by surgeons through a pilot study. Some items of its visual performance and the utility were rated fairly high by the participants during testing. It exhibits the potential to improve the surgical skills of trainee and effectively shorten their learning curve.

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer.

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.

Optimization Model for Web Based Multimodal Interactive Simulations.

This paper presents a technique for optimizing the performance of web based multimodal interactive simulations. For such applications where visual quality and the performance of simulations directly influence user experience, overloading of hardware resources may result in unsatisfactory reduction in the quality of the simulation and user satisfaction. However, optimization of simulation performance on individual hardware platforms is not practical. Hence, we present a mixed integer programming model to optimize the performance of graphical rendering and simulation performance while satisfying application specific constraints. Our approach includes three distinct phases: identification, optimization and update. In the identification phase, the computing and rendering capabilities of the client device are evaluated using an exploratory proxy code. This data is utilized in conjunction with user specified design requirements in the optimization phase to ensure best possible computational resource allocation. The optimum solution is used for rendering (e.g. texture size, canvas resolution) and simulation parameters (e.g. simulation domain) in the update phase. Test results are presented on multiple hardware platforms with diverse computing and graphics capabilities to demonstrate the effectiveness of our approach.

Development of a Virtual Reality Simulator for Natural Orifice Translumenal Endoscopic Surgery (NOTES) Cholecystectomy Procedure.

The first virtual-reality-based simulator for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is developed called the Virtual Translumenal Endoscopic Surgery Trainer (VTESTTM). VTESTTM aims to simulate hybrid NOTES cholecystectomy procedure using a rigid scope inserted through the vaginal port. The hardware interface is designed for accurate motion tracking of the scope and laparoscopic instruments to reproduce the unique hand-eye coordination. The haptic-enabled multimodal interactive simulation includes exposing the Calot's triangle and detaching the gall bladder while performing electrosurgery. The developed VTESTTM was demonstrated and validated at NOSCAR 2013.

pWeb: A High-Performance, Parallel-Computing Framework for Web-Browser-Based Medical Simulation.

This work presents a pWeb - a new language and compiler for parallelization of client-side compute intensive web applications such as surgical simulations. The recently introduced HTML5 standard has enabled creating unprecedented applications on the web. Low performance of the web browser, however, remains the bottleneck of computationally intensive applications including visualization of complex scenes, real time physical simulations and image processing compared to native ones. The new proposed language is built upon web workers for multithreaded programming in HTML5. The language provides fundamental functionalities of parallel programming languages as well as the fork/join parallel model which is not supported by web workers. The language compiler automatically generates an equivalent parallel script that complies with the HTML5 standard. A case study on realistic rendering for surgical simulations demonstrates enhanced performance with a compact set of instructions.

Development of Extracorporeal Suturing Simulation in Virtual Basic Laparoscopic Skill Trainer (VBLaST.

This paper presents the development of extracorporeal suturing simulation in Virtual Basic Laparoscopic Skill Trainer (VBLaST©). A novel hardware interface is designed to allow the user to perform the physical action of trying a knot and seamlessly integrate the knot into the virtual simulation.

Towards virtual FLS: development of a peg transfer simulator.

BACKGROUND: Peg transfer is one of five tasks in the Fundamentals of Laparoscopic Surgery (FLS), program. This paper reports the development and validation of a Virtual Basic Laparoscopic Skill Trainer-Peg Transfer (VBLaST-PT(©) ) simulator for automatic real-time scoring and objective quantification of performance. METHODS: New techniques have been introduced in order to allow bi-manual manipulation of pegs and automatic scoring/evaluation while maintaining high quality of simulation. A preliminary face and construct validation study was performed with 22 subjects divided into two groups: experts (PGY 4-5, fellow and practicing surgeons) and novice (PGY 1-3). RESULTS: Face validation shows high scores for all aspects of the simulation. Two-tailed Mann-Whitney U-test scores showed significant differences between the two groups on completion time (P = 0.003), FLS score (P =0.002) and the VBLaST-PT© score (P = 0.006). CONCLUSIONS: VBLaST-PT(©) is a high quality virtual simulator that showed both face and construct validity.

Characterizing the learning curve of the VBLaST-PT(©) (Virtual Basic Laparoscopic Skill Trainer).

BACKGROUND: Mastering laparoscopic surgical skills requires considerable time and effort. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PT(©)) is being developed as a computerized version of the peg transfer task of the Fundamentals of Laparoscopic Surgery (FLS) system using virtual reality technology. We assessed the learning curve of trainees on the VBLaST-PT(©) using the cumulative summation (CUSUM) method and compared them with those on the FLS to establish convergent validity for the VBLaST-PT(©). METHODS: Eighteen medical students from were assigned randomly to one of three groups: control, VBLaST-training, and FLS-training. The VBLaST and the FLS groups performed a total of 150 trials of the peg-transfer task over a 3-week period, 5 days a week. Their CUSUM scores were computed based on predefined performance criteria (junior, intermediate, and senior levels). RESULTS: Of the six subjects in the VBLaST-training group, five achieved at least the "junior" level, three achieved the "intermediate" level, and one achieved the "senior" level of performance criterion by the end of the 150 trials. In comparison, for the FLS group, three students achieved the "senior" criterion and all six students achieved the "intermediate" and "junior" criteria by the 150th trials. Both the VBLaST-PT(©) and the FLS systems showed significant skill improvement and retention, albeit with system specificity as measured by transfer of learning in the retention test: The VBLaST-trained group performed better on the VBLaST-PT(©) than on FLS (p = 0.003), whereas the FLS-trained group performed better on the FLS than on VBLaST-PT(©) (p = 0.002). CONCLUSIONS: We characterized the learning curve for a virtual peg transfer task on the VBLaST-PT(©) and compared it with the FLS using CUSUM analysis. Subjects in both training groups showed significant improvement in skill performance, but the transfer of training between systems was not significant.

Pattern cutting and ligating loop simulation in Virtual Basic Laparoscopic Skill Trainer (VBLaST.

This paper presents the pattern cutting and ligating loop simulation in the Virtual Basic Laparoscopic Skill Trainer (VBLaST©). In the simulation, the gauze, tubular foam, and ligating loop thread are modeled by the mass-spring method and constraint projection for the inextensible characteristics. Discrete simulation states defined based on the tool-object interaction types are utilized to efficiently and accurately manages the physics simulation, collision processing, and haptic feedback in real-time. An automated scoring system provides quantitative measurement for evaluation of trainees' skills. The simulation results show advanced visual realism and real-time performances.

Development and validation of VBLaST-PT© : a virtual peg transfer simulator.

Peg transfer is one of the five tasks in the Fundamentals of Laparoscopic Surgery (FLS), which is now established as a standard for training minimally invasive surgery. In this paper we report development and preliminary validation of Virtual Basic Laparoscopic Skill Trainer-peg transfer (VBLaST-PT© simulator. Face validation of the VBLaST-PT© with 34 subjects revealed high scores for all aspects of simulation. A two-tailed Mann-Whitney performed on the total scores on VBLaST-PT© showed significant (p=0.001) difference between the skill groups.

Performance optimization of web-based medical simulation.

This paper presents a technique for performance optimization of multimodal interactive web-based medical simulation. A web-based simulation framework is promising for easy access and wide dissemination of medical simulation. However, the real-time performance of the simulation highly depends on hardware capability on the client side. Providing consistent simulation in different hardware is critical for reliable medical simulation. This paper proposes a non-linear mixed integer programming model to optimize the performance of visualization and physics computation while considering hardware capability and application specific constraints. The optimization model identifies and parameterizes the rendering and computing capabilities of the client hardware using an exploratory proxy code. The parameters are utilized to determine the optimized simulation conditions including texture sizes, mesh sizes and canvas resolution. The test results show that the optimization model not only achieves a desired frame per second but also resolves visual artifacts due to low performance hardware.

Face and construct validation of a virtual peg transfer simulator.

BACKGROUND: The Fundamentals of Laparoscopic Surgery (FLS) trainer box is now established as a standard for evaluating minimally invasive surgical skills. A particularly simple task in this trainer box is the peg transfer task which is aimed at testing the surgeon's bimanual dexterity, hand-eye coordination, speed, and precision. The Virtual Basic Laparoscopic Skill Trainer (VBLaST) is a virtual version of the FLS tasks which allows automatic scoring and real-time, subjective quantification of performance without the need of a human proctor. In this article we report validation studies of the VBLaST peg transfer (VBLaST-PT) simulator. METHODS: Thirty-five subjects with medical background were divided into two groups: experts (PGY 4-5, fellows, and practicing surgeons) and novices (PGY 1-3). The subjects were asked to perform the peg transfer task on both the FLS trainer box and the VBLaST-PT simulator; their performance was evaluated based on established metrics of error and time. A new length of trajectory (LOT) metric has also been introduced for offline analysis. A questionnaire was used to rate the realism of the virtual system on a 5-point Likert scale. RESULTS: Preliminary face validation of the VBLaST-PT with 34 subjects rated on a 5-point Likert scale questionnaire revealed high scores for all aspects of simulation, with 3.53 being the lowest mean score across all questions. A two-tailed Mann-Whitney test performed on the total scores showed significant (p = 0.001) difference between the groups. A similar test performed on the task time (p = 0.002) and the LOT (p = 0.004) separately showed statistically significant differences between the experts and the novices (p < 0.05). The experts appear to be traversing shorter overall trajectories in less time than the novices. CONCLUSION: VBLaST-PT showed both face and construct validity and has promise as a substitute for the FLS for training peg transfer skills.