Optical angle and visuospatial ability affect basic laparoscopic simulator task performance.

Surgical trainees show decreased performance during laparoscopic surgery when the laparoscope (camera) is not aligned with their line of sight towards the operating area. In this study we investigate the influence of visuospatial ability on laparoscopic simulator performance under such non-zero optical angles. Novices were invited to participate in a laparoscopic training session. After completing a visuospatial ability assessment, they performed a simplified laparoscopic task on an in-house developed laparoscopic simulator under eight different optical angles ranging between 0° and 315° in steps of 45°. Data-analysis showed decreased performance under all non-zero optical angles for task duration (mean difference between 1506 and 5049 ms, standard error between 499 and 507, p < .05) and for accuracy under optical angles greater than ±45° (mean difference between 1.48 and 2.11, standard error 0.32, p < .01). Performance-zones were identified for various optical angle ranges and differed for task duration and accuracy. Participants of high visuospatial ability performed significantly better under non-zero angles for accuracy compared to participants of low visuospatial ability (mean difference 0.95, standard error 0.34, p < .01), except for the 180° optical angle (no difference).

Laparoscopic simulator performance and learning curves under different optical angles.

BACKGROUND: Deviated optical angles create visuospatial and psychomotor challenges during laparoscopic procedures, resulting in delayed operative time and possibly adverse events. If it is possible to train the skills needed to work under these deviated optical angles, this could benefit procedure time and patient safety. This study investigates the influence of the optical angle on development of basic laparoscopic surgical skills. METHODS: A total of 58 medical students performed a four-session laparoscopic training course on a Virtual Reality Simulator. During each session, they performed an identical task under optical angles of 0°, 45° and - 45°. Performance parameters of task duration and damage were compared between the optical angles to investigate the effect of optical angle on performance development. The 4th session performance was compared to the 2nd session performance for each angle to determine improvement. RESULTS: Participants performed the task significantly faster under the 0° optical angle compared to the plus and minus 45° optical angles during the last three sessions (z between - 2.95 and - 2.09, p < .05). Participants improved significantly and similarly for task duration during the training course under all optical angles. At the end of the training course however significant performance differences between the zero and plus/minus 45 optical angles remained. Performance for damage did not improve and was not affected by optical angle throughout the course. CONCLUSION: Dedicated virtual reality training improves laparoscopic basic skills performance under deviated optical angles as it leads to shorter task duration, however a lasting performance impairment compared to the 0° optical angle remained. Training for performing under deviating optical angles can potentially shorter the learning curve in the operating room.

Speed versus damage: using selective feedback to modulate laparoscopic simulator performance.

BACKGROUND: Adaptive training is an approach in which training variables change with the needs and traits of individual trainees. It has potential to mitigate the effect of personality traits such as impulsiveness on surgical performance. Selective performance feedback is one way to implement adaptive training. This paper investigates whether selective feedback can direct performance of trainees of either high- or low impulsiveness. METHODS: A total of 83 inexperienced medical students of known impulsiveness performed a four-session laparoscopic training course on a Virtual Reality Simulator. They performed two identical series of tasks every session. During one series of tasks they received performance feedback on duration and during the other series they received feedback on damage. Performance parameters (duration and damage) were compared between the two series of tasks to assess whether selective performance feedback can be used to steer emphasis in performance. To assess the effectiveness of selective feedback for people of high- or low impulsiveness, the difference in performance between the two series for both duration and damage was also assessed. RESULTS: Participants were faster when given performance feedback for speed for all exercises in all sessions (average z-value = - 4.14, all p values < .05). Also, they performed better on damage control when given performance feedback for damage in all tasks and during all sessions except for one (average z-value = - 4.19, all but one p value < .05). Impulsiveness did not impact the effectiveness of selective feedback. CONCLUSION: Selective feedback on either duration or damage can be used to improve performance for the variable that the trainee receives feedback on. Trainee impulsiveness did not modulate this effect. Selective feedback can be used to steer training focus in adaptive training systems and can mitigate the negative effects of impulsiveness on damage control.

The Fun Factor: Does Serious Gaming Affect the Volume of Voluntary Laparoscopic Skills Training?

BACKGROUND: The availability of validated laparoscopic simulators has not resulted in sustainable high-volume training. We investigated whether the validated laparoscopic serious game Underground would increase voluntary training by residents. We hypothesized that by removing intrinsic barriers and extrinsic barriers, residents would spend more time on voluntary training with Underground compared to voluntary training with traditional simulators. METHODS: After 1 year, we compared amount of voluntary time spent on playing Underground to time spent on all other laparoscopic training modalities and to time spent on performing laparoscopic procedures in the OR for all surgical residents. These data were compared to resident' time spent on laparoscopic activities over the prior year before the introduction of Underground. RESULTS: From March 2016 until March 2017, 63 residents spent on average 20 min on voluntary serious gaming, 17 min on voluntary simulator training, 2 h and 44 min on mandatory laparoscopic training courses, and 14 h and 49 min on laparoscopic procedures in the OR. Voluntary activities represented 3% of laparoscopic training activities which was similar in the prior year wherein fifty residents spent on average 33 min on voluntary simulator training, 3 h and 28 min on mandatory laparoscopic training courses, and 11 h and 19 min on laparoscopic procedures. CONCLUSION: Serious gaming has not increased total voluntary training volume. Underground did not mitigate intrinsic and extrinsic barriers to voluntary training. Mandatory, scheduled training courses remain needed. Serious gaming is flexible and affordable and could be an important part of such training courses.

Construct Validity of a Serious Game for Laparoscopic Skills Training: Validation Study.

BACKGROUND: Surgical residents underutilize opportunities for traditional laparoscopic simulation training. Serious gaming may increase residents' motivation to practice laparoscopic skills. However, little is known about the effectiveness of serious gaming for laparoscopic skills training. OBJECTIVE: The aim of this study was to establish construct validity for the laparoscopic serious game Underground. METHODS: All study participants completed 2 levels of Underground. Performance for 2 novel variables (time and error) was compared between novices (n=65, prior experience <10 laparoscopic procedures), intermediates (n=26, prior experience 10-100 laparoscopic procedures), and experts (n=20, prior experience >100 laparoscopic procedures) using analysis of covariance. We corrected for gender and video game experience. RESULTS: Controlling for gender and video game experience, the effects of prior laparoscopic experience on the time variable differed significantly (F2,106=4.77, P=.01). Both experts and intermediates outperformed novices in terms of task completion speed; experts did not outperform intermediates. A similar trend was seen for the rate of gameplay errors. Both gender (F1,106=14.42, P<.001 in favor of men) and prior video game experience (F1,106=5.20, P=.03 in favor of experienced gamers) modulated the time variable. CONCLUSIONS: We established construct validity for the laparoscopic serious game Underground. Serious gaming may aid laparoscopic skills development. Previous gaming experience and gender also influenced Underground performance. The in-game performance metrics were not suitable for statistical evaluation. To unlock the full potential of serious gaming for training, a more formal approach to performance metric development is needed.

Fast or safe? The role of impulsiveness in laparoscopic simulator performance.

BACKGROUND: Little is known about the relation between impulsiveness and surgical performance even though research in similar high-risk/high-skills shows evidence of more hazardous behavior by impulsive professionals. We investigated the impact of impulsiveness on laparoscopic simulator performance. METHODS: Eighty-three subjects participated in a four-session laparoscopic training course. Based on the Eysenck Personality test, we created equal sized high- and low impulsiveness groups and compared task duration and errors on tasks for two laparoscopic simulators. RESULTS: The low impulsiveness group outperformed the high impulsiveness group on damage on the LapSim virtual reality trainer (U = 459, p < .049), and showed a trend towards better error performance on the FLS videotrainer. We found no differences on task duration. CONCLUSIONS: In surgical simulation training, high impulsiveness is associated with creating more damage, but not with faster performance. Time needed to correct errors may have obscured faster performance in the high impulsiveness group. SUMMARY FOR THE TABLE OF CONTENTS: Subjects were divided into high- and low impulsiveness groups based on the Eysenck Impulsiveness Inventory test. Performance (time and errors) were compared between groups for tasks on the LapSim virtual reality trainer and FLS videotrainer. Low impulsive subjects outperformed high impulsive subjects on errors.

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.

Peers versus Pros: Feedback using standards in simulation training.

BACKGROUND: Creating and updating expert performance-based standards for simulators is labor intensive and requires the regular availability of expert surgeons. We investigated how peer performance based standards compare to expert performance based standards. METHODS: One hundred medical students took part in a four-session laparoscopic basic skills simulator training course. Performance for the FLS videotrainer tasks were compared between students who received feedback based on either peer standards, expert standards or no feedback at all (control group). RESULTS: No difference in performance between our feedback groups was found. Compared to the control group, they were 18-36% faster but made 52% more errors for tasks on the FLS video trainer (U range [93.5-957], average p < .01). CONCLUSIONS: We demonstrated that feedback based on peer standards is equally effective as feedback based on expert standards. The found trade-off between speed and error is not desirable and warrants further investigation.

Saving robots improves laparoscopic performance: transfer of skills from a serious game to a virtual reality simulator.

BACKGROUND: Residents find it hard to commit to structural laparoscopic skills training. Serious gaming has been proposed as a solution on the premise that it is effective and more motivating than traditional simulation. We establish construct validity for the laparoscopic serious game Underground by comparing laparoscopic simulator performance for a control group and an Underground training group. METHODS: A four-session laparoscopic basic skills course is part of the medical master students surgical internship at the Radboud University Medical Centre. Four cohorts, representing 107 participants, were assigned to either the Underground group or the control group. The control group trained on the FLS video trainer and the LapSim virtual reality simulator for four sessions. The Underground group played Underground for three sessions followed by a transfer session on the FLS video trainer and the LapSim. To assess the effect of engaging in serious gameplay on performance on two validated laparoscopic simulators, initial performance on the FLS video trainer and the LapSim was compared between the control group (first session) and the Underground group (fourth session). RESULTS: We chose task duration as a proxy for laparoscopic performance. The Underground group outperformed the control group on all three LapSim tasks: Camera navigation F(1) = 12.71, p < .01; Instrument navigation F(1) = 8.04, p < .01; and Coordination F(1) = 6.36, p = .01. There was no significant effect of playing Underground for performance on the FLS video trainer Peg Transfer task, F(1) = 0.28, p = .60. CONCLUSIONS: We demonstrated skills transfer between a serious game and validated laparoscopic simulator technology. Serious gaming may become a valuable, cost-effective addition to the skillslab, if transfer to the operating room can be established. Additionally, we discuss sources of transferable skills to help explain our and previous findings.

Integrating technical and non-technical skills coaching in an acute trauma surgery team training: Is it too much?

OBJECTIVE: Research on effective integration of technical and non-technical skills in surgery team training is sparse. In a previous study we found that surgical teachers predominantly coached on technical and hardly on non-technical skills during the Definitive Surgical and Anesthetic Trauma Care (DSATC) integrated acute trauma surgery team training. This study aims to investigate whether the priming of teachers could increase the amount of non-technical skills coaching during such a training. DESIGN: Coaching activities of 12 surgical teachers were recorded on audio and video. Six teachers were primed on non-technical skills coaching prior to the training. Six others received no priming and served as controls. Blind observers reviewed the recordings of 2 training scenario's and scored whether the observed behaviors were directed on technical or non-technical skills. We compared the frequency of the non-technical skills coaching between the primed and the non-primed teachers and analyzed for differences according to the trainees' level of experience. SETTING: Surgical teachers coached trainees during the highly realistic DSATC integrated acute trauma surgery team training. Trainees performed damage control surgery in operating teams on anesthetized porcine models during 6 training scenario's. PARTICIPANTS: Twelve experienced surgical teachers participated in this study. RESULTS: Coaching on non-technical skills was limited to about 5%. The primed teachers did not coach more often on non-technical skills than the non-primed teachers. We found no differences in the frequency of non-technical skills coaching based on the trainees' level of experience. CONCLUSION: Priming experienced surgical teachers does not increase the coaching on non-technical skills. The current DSATC acute trauma surgery team training seems too complex for integrating training on technical and non-technical skills. COMPETENCIES: Patient care, Practice based learning and improvement.

Stereopsis, Visuospatial Ability, and Virtual Reality in Anatomy Learning.

A new wave of virtual reality headsets has become available. A potential benefit for the study of human anatomy is the reintroduction of stereopsis and absolute size. We report a randomized controlled trial to assess the contribution of stereopsis to anatomy learning, for students of different visuospatial ability. Sixty-three participants engaged in a one-hour session including a study phase and posttest. One group studied 3D models of the anatomy of the deep neck in full stereoptic virtual reality; one group studied those structures in virtual reality without stereoptic depth. The control group experienced an unrelated virtual reality environment. A post hoc questionnaire explored cognitive load and problem solving strategies of the participants. We found no effect of condition on learning. Visuospatial ability however did impact correct answers at F(1) = 5.63 and p = .02. No evidence was found for an impact of cognitive load on performance. Possibly, participants were able to solve the posttest items based on visuospatial information contained in the test items themselves. Additionally, the virtual anatomy may have been complex enough to discourage memory based strategies. It is important to control the amount of visuospatial information present in test items.

When experts are oceans apart: comparing expert performance values for proficiency-based laparoscopic simulator training.

BACKGROUND: Surgical training is moving away from the operating room toward simulation-based skills training facilities. This has led to the development of proficiency-based training courses in which expert performance data are used for feedback and assessment. However, few expert value data sets have been published, and no standard method for generating expert values has been adopted by the field. METHODS: To investigate the effect of different proficiency value data sets on simulator training courses, we (1) compared 2 published expert performance data sets for the LapSim laparoscopic virtual-reality simulator (by van Dongen et al. and Heinrichs et al.) and (2) assessed the effect of using either set on LapSim training data obtained from 16 local residents in surgery and gynecology. RESULTS: Across all simulator tasks, the experts consulted by van Dongen et al. performed better on motion efficiency, but not on duration or damage control. Applying both proficiency sets to training data collected during a basic skills laparoscopic simulator course, residents would have graduated on an average in 1.5 fewer sessions using the Heinrichs expert values compared with the van Dongen expert values. CONCLUSIONS: The selection of proficiency values for proficiency-based simulator training courses affects training length, skills level assessment, and training costs. Standardized, well-controlled methods are necessary to create valid and reliable expert values for use in training and research.

Coaching during a trauma surgery team training: perceptions versus structured observations.

BACKGROUND: Using the concept perception to quantify coaching skills during surgical training is questionable. This study compared the perceptions reported by the trainees and the faculty members following an emergency surgery team training with structured observations made on the basis of video registrations. METHODS: For each faculty member, we scored 45 minutes of identical scenarios to enable the quantitative assessment of the use of positive feedback, corrective feedback, as well as instruction and in particular comments containing how and why explanations. We compared the values determined from the video scores with the perceptions reported by the trainees and faculty on questionnaires. RESULTS: The trainee and faculty ratings for the coaching differed, with trainees generally giving a higher rating. While both the trainees and the faculty gave high ratings for the non-technical skills, corrective and complimenting feedback, and explanations why, the structured video observations showed lower scores in these categories. CONCLUSIONS: Both the trainees and the faculty overrated the coaching. Trainee questionnaires and faculty self-reports neither reflected the actual coaching activities nor identified coaching skill deficits.

Performance variables and professional experience in simulated laparoscopy: a two-group learning curve study.

OBJECTIVE: Virtual reality simulators are increasingly used in laparoscopy training. Such simulators allow objective assessment of performance. However, both low-level variables and overall scores generated by the simulator can be hard to interpret. We present a method to generate intermediate performance variables and show how the resulting variables can be used to investigate the development of laparoscopic skills. DESIGN: A beginner group (n = 16) and a group with intermediate laparoscopic experience (n = 9) participated in a 5-session, basic skills training course hosted by the Department of Technical Medicine at the University of Twente. Multiple simulator-generated variables were aggregated into 4 performance variables: duration, left-hand motion, right-hand motion, and damage. Differences in performance were analyzed in relation to proficiency values. RESULTS: Damage performance differentiated the most between groups and proficiency values; motion performance variables differentiated the least. The more experienced group outperformed the beginner group at damage by the end of the course. CONCLUSIONS: Differentiating between duration, left-hand motion, right-hand motion, and damage is a useful way to investigate laparoscopic performance development. Different performance variables follow different trajectories toward expertise. Valid and reliable clinical damage parameters are needed to investigate the relation of real-world damage to simulator damage.

Feedback activities of instructors during a trauma surgery course.

BACKGROUND: The aim of this study was to examine the quality and quantity of feedback and instruction from faculty members during an acute trauma surgery team training using a newly designed observational feedback instrument. METHODS: During the training, 11 operating teams, each consisting of 1 instructor coaching 2 trainees, were videotaped and audiotaped. Forty-five minutes of identical operating scenarios were reviewed and analyzed. Using a new observational feedback instrument, feedback and instruction, containing different levels of specific information related to technical and nontechnical skills, were noted. RESULTS: Instructors more often provided instruction (25.8 ± 10.6 times) than feedback (4.4 ± 3.5 times). Most feedback and instruction contained either nonspecific or less specific information and referred to technical skills. Instructors addressed communication skills more specifically. CONCLUSIONS: Coaching by faculty members predominantly contained unspecific instructions regarding technical skills. The observational feedback instrument enabled scoring of the coaching activities.

da Vinci skills simulator for assessing learning curve and criterion-based training of robotic basic skills.

OBJECTIVE: To answer 2 research questions: what are the learning curve patterns of novices on the da Vinci skills simulator parameters and what parameters are appropriate for criterion-based robotic training. MATERIALS AND METHODS: A total of 17 novices completed 2 simulator sessions within 3 days. Each training session consisted of a warming-up exercise, followed by 5 repetitions of the "ring and rail II" task. Expert participants (n = 3) performed a warming-up exercise and 3 repetitions of the "ring and rail II" task on 1 day. We analyzed all 9 parameters of the simulator. RESULTS: Significant learning occurred on 5 parameters: overall score, time to complete, instrument collision, instruments out of view, and critical errors within 1-10 repetitions (P <.05). Economy of motion and excessive instrument force only showed improvement within the first 5 repetitions. No significant learning on the parameter drops and master workspace range was found. Using the expert overall performance score (n = 3) as a criterion (overall score 90%), 9 of 17 novice participants met the criterion within 10 repetitions. CONCLUSION: Most parameters showed that basic robotic skills are learned relatively quickly using the da Vinci skills simulator, but that 10 repetitions were not sufficient for most novices to reach an expert level. Some parameters seemed inappropriate for expert-based criterion training because either no learning occurred or the novice performance was equal to expert performance.

Visuo-spatial ability in colonoscopy simulator training.

Visuo-spatial ability is associated with a quality of performance in a variety of surgical and medical skills. However, visuo-spatial ability is typically assessed using Visualization tests only, which led to an incomplete understanding of the involvement of visuo-spatial ability in these skills. To remedy this situation, the current study investigated the role of a broad range of visuo-spatial factors in colonoscopy simulator training. Fifteen medical trainees (no clinical experience in colonoscopy) participated in two psycho-metric test sessions to assess four visuo-spatial ability factors. Next, participants trained flexible endoscope manipulation, and navigation to the cecum on the GI Mentor II simulator, for four sessions within 1 week. Visualization, and to a lesser degree Spatial relations were the only visuo-spatial ability factors to correlate with colonoscopy simulator performance. Visualization additionally covaried with learning rate for time on task on both simulator tasks. High Visualization ability indicated faster exercise completion. Similar to other endoscopic procedures, performance in colonoscopy is positively associated with Visualization, a visuo-spatial ability factor characterized by the ability to mentally manipulate complex visuo-spatial stimuli. The complexity of the visuo-spatial mental transformations required to successfully perform colonoscopy is likely responsible for the challenging nature of this technique, and should inform training- and assessment design. Long term training studies, as well as studies investigating the nature of visuo-spatial complexity in this domain are needed to better understand the role of visuo-spatial ability in colonoscopy, and other endoscopic techniques.