Say, What Is on Your Mind? Surgeons' Evaluations of Realism and Usability of a Virtual Reality Vertebroplasty Simulator.

BACKGROUND: Virtual reality (VR)-based simulations offer rich opportunities for surgical skill training and assessment of surgical novices and experts. A structured evaluation and validation process of such training and assessment tools is necessary for effective surgical learning environments. OBJECTIVE: To develop and apply a classification system of surgeon-reported experience during operation of a VR vertebroplasty simulator. METHODS: A group of orthopedic, trauma surgeons and neurosurgeons (n = 13) with various levels of expertise performed on a VR vertebroplasty simulator. We established a mixed-methods design using think-aloud protocols, senior surgical expert evaluations, performance metrics, and a post-simulation questionnaire. Verbal content was systematically analyzed using structured qualitative content analysis. We established a category system for classification of surgeons' verbal evaluations during the simulation. Furthermore, we evaluated intraoperative performance metrics and explored potential associations with surgeons' characteristics and simulator evaluation. RESULTS: Overall, 244 comments on realism and usability of the vertebroplasty simulator were collected. This included positive and negative remarks, questions, and specific suggestions for improvement. Further findings included surgeons' approval of the realism and usability of the simulator and the observation that the haptic feedback of the VR patient's anatomy requires further improvement. Surgeon-reported evaluations were not associated with performance decrements. DISCUSSION: This study is the first to apply think-aloud protocols for evaluation of a surgical VR-based simulator. A novel classification approach is introduced that can be used to classify surgeons' verbalized experiences during simulator use. Our lessons learned may be valuable for future research with similar methodological approach.

Stepwise development of a simulation environment for operating room teams: the example of vertebroplasty.

BACKGROUND: Despite the growing importance of medical simulation in education, there is limited guidance available on how to develop medical simulation environments, particularly with regard to technical and non-technical skills as well as to multidisciplinary operating room (OR) team training. We introduce a cognitive task analysis (CTA) approach consisting of interviews, structured observations, and expert consensus to systematically elicit information for medical simulator development. Specifically, our objective was to introduce a guideline for development and application of a modified CTA to obtain task demands of surgical procedures for all three OR professions with comprehensive definitions of OR teams' technical and non-technical skills. METHODS: To demonstrate our methodological approach, we applied it in vertebroplasty, a minimally invasive spine procedure. We used a CTA consisting of document reviews, in situ OR observations, expert interviews, and an expert consensus panel. Interviews included five surgeons, four OR nurses, and four anesthetists. Ten procedures were observed. Data collection was carried out in five OR theaters in Germany. RESULTS: After compiling data from interviews and observations, we identified 6 procedural steps with 21 sub-steps for surgeons, 20 sub-steps for nurses, and 22 sub-steps for anesthetists. Additionally, we obtained information on 16 predefined categories of intra-operative skills and requirements for all three OR professions. Finally, simulation requirements for intra-operative demands were derived and specified in the expert panel. CONCLUSIONS: Our CTA approach is a feasible and effective way to elicit information on intra-operative demands and to define requirements of medical team simulation. Our approach contributes as a guideline to future endeavors developing simulation training of technical and non-technical skills for multidisciplinary OR teams.

Virtual reality-based simulators for spine surgery: a systematic review.

BACKGROUND CONTEXT: Virtual reality (VR)-based simulators offer numerous benefits and are very useful in assessing and training surgical skills. Virtual reality-based simulators are standard in some surgical subspecialties, but their actual use in spinal surgery remains unclear. Currently, only technical reviews of VR-based simulators are available for spinal surgery. PURPOSE: Thus, we performed a systematic review that examined the existing research on VR-based simulators in spinal procedures. We also assessed the quality of current studies evaluating VR-based training in spinal surgery. Moreover, we wanted to provide a guide for future studies evaluating VR-based simulators in this field. STUDY DESIGN AND SETTING: This is a systematic review of the current scientific literature regarding VR-based simulation in spinal surgery. METHODS: Five data sources were systematically searched to identify relevant peer-reviewed articles regarding virtual, mixed, or augmented reality-based simulators in spinal surgery. A qualitative data synthesis was performed with particular attention to evaluation approaches and outcomes. Additionally, all included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool. RESULTS: The initial review identified 476 abstracts and 63 full texts were then assessed by two reviewers. Finally, 19 studies that examined simulators for the following procedures were selected: pedicle screw placement, vertebroplasty, posterior cervical laminectomy and foraminotomy, lumbar puncture, facet joint injection, and spinal needle insertion and placement. These studies had a low-to-medium methodological quality with a MERSQI mean score of 11.47 out of 18 (standard deviation=1.81). CONCLUSIONS: This review described the current state and applications of VR-based simulator training and assessment approaches in spinal procedures. Limitations, strengths, and future advancements of VR-based simulators for training and assessment in spinal surgery were explored. Higher-quality studies with patient-related outcome measures are needed. To establish further adaptation of VR-based simulators in spinal surgery, future evaluations need to improve the study quality, apply long-term study designs, and examine non-technical skills, as well as multidisciplinary team training.

Intra-operative disruptions, surgeon's mental workload, and technical performance in a full-scale simulated procedure.

BACKGROUND AND AIM: Surgical flow disruptions occur frequently and jeopardize perioperative care and surgical performance. So far, insights into subjective and cognitive implications of intra-operative disruptions for surgeons and inherent consequences for performance are inconsistent. This study aimed to investigate the effect of surgical flow disruption on surgeon's intra-operative workload and technical performance. METHODS: In a full-scale OR simulation, 19 surgeons were randomly allocated to either of the two disruption scenarios (telephone call vs. patient discomfort). Using a mixed virtual reality simulator with a computerized, high-fidelity mannequin, all surgeons were trained in performing a vertebroplasty procedure and subsequently performed such a procedure under experimental conditions. Standardized measures on subjective workload and technical performance (trocar positioning deviation from expert-defined standard, number, and duration of X-ray acquisitions) were collected. RESULTS: Intra-operative workload during simulated disruption scenarios was significantly higher compared to training sessions (p < .01). Surgeons in the telephone call scenario experienced significantly more distraction compared to their colleagues in the patient discomfort scenario (p < .05). However, workload tended to be increased in surgeons who coped with distractions due to patient discomfort. Technical performance was not significantly different between both disruption scenarios. We found a significant association between surgeons' intra-operative workload and technical performance such that surgeons with increased mental workload tended to perform worse (ß = .55, p = .04). CONCLUSIONS: Surgical flow disruptions affect surgeons' intra-operative workload. Increased mental workload was associated with inferior technical performance. Our simulation-based findings emphasize the need to establish smooth surgical flow which is characterized by a low level of process deviations and disruptions.

Vertebroplasty Performance on Simulator for 19 Surgeons Using Hierarchical Task Analysis.

We present a unique simulator-based methodology for assessing both technical and nontechnical (cognitive) skills for surgical trainees while immersed in a complete medical simulation environment. Further, we have included two crisis scenarios which allow for the evaluation of the effect of cognitive strategy selection on the low-level surgical skills. Training these mixed-mode scenarios can thereby be evaluated on our platform, allowing for improved assessment and a stronger foundation for credentialing, with the potential to reduce the occurrence of adverse events in the operating room. Scientific evaluation and validation of our work is conducted together with 19 junior surgeons in order to achieve the following goals: 1) to provide a qualitative measure of usability, 2) to assess vertebroplasty technical performance of the surgeon, and 3) to explore the relationship between mental workload and surgical performance during crisis. Our results indicate that: 1) the surgeons scored the face validity of our modeled simulation environment very highly ( 4.68 ±0.48, using a 5-point Likert scale), 2) surgeon training enabled completion of tasks more quickly, and 3) the introduction of crisis scenarios negatively affected the surgeons' objective performance. Taken together, our results underscore the need to develop realistic simulation environments that prepare young residents to respond to emergent events in the operating room.

Desired-View--controlled positioning of angiographic C-arms.

We present the idea of a user interface concept, which resolves the challenges involved in the control of angiographic C-arms for their constant repositioning during interventions by either the surgeons or the surgical staff. Our aim is to shift the paradigm of interventional image acquisition workflow from the traditional control device interfaces to 'desired-view' control. This allows the physicians to only communicate the desired outcome of imaging, based on simulated X-rays from pre-operative CT or CTA data, while the system takes care of computing the positioning of the imaging device relative to the patient's anatomy through inverse kinematics and CT to patient registration. Together with our clinical partners, we evaluate the new technique using 5 patient CTA and their corresponding intraoperative X-ray angiography datasets.

Task and crisis analysis during surgical training.

PURPOSE: To design a surgical training environment based on task and crisis analysis of the surgical workflow. METHOD: The environment consists of: (1) real surgical instruments that are augmented with realistic haptic feedback and VR capabilities, (2) human sensory channels such as tactile, auditory and visual in real time, and (3) the ability to facilitate deliberate exposure to adverse events enabling mediation of error recovery strategies. VALIDATION: Five surgeons were immersed in our medical simulation environment through task and crisis scenarios of a typical vertebroplasty workflow. RESULTS: Based on a five-point Likert-scale survey, the face validity of our simulation environment was confirmed by investigating surgeon behavior and workflow response. CONCLUSIONS: The result of the conducted user-study corroborates our unique medical simulation concept of combining VR and human multisensory responses into surgical workflow.