Amine Chellali

Effects of sleep hours and fatigue on performance in laparoscopic surgery simulators

AbstractBackground Studies on a virtual reality simulator have demonstrated that sleep-deprived residents make more errors. Work-hour restrictions were implemented, among other reasons, to ensure enough sleep time for residents. The objective of this study was to assess the effects of sleep time, perceived fatigue, and experience on surgical performance. We hypothesized that performance would decrease with less sleep and fatigue, and that experienced surgeons would perform better than less experienced surgeons despite sleep deprivation and fatigue. MethodsTwenty-two surgical residents and attendings performed a peg transfer task on two simulators: the Fundamentals of Laparoscopic Skills (FLS) trainer and the Virtual Basic Laparoscopic Surgical Trainer (VBLaST©), a virtual version of the FLS. Participants also completed questionnaires to assess their fatigue level and recent sleep hours. Each subject performed ten trials on each simulator in a counterbalanced order. Performance was measured using the FLS normalized scores and analyzed using a multiple regression model.ResultsThe multiple regression analysis showed that sleep hours and perceived fatigue were not covariates. No correlation was found between experience level and sleep hours or fatigue. Sleep hours and fatigue did not appear to affect performance. Expertise level was the only significant determinant of performance in both FLS and VBLaST©.ConclusionsRestricting resident work hours was expected to result in less fatigue and better clinical performance. In our study, peg transfer task performance was not affected by sleep hours. Experience level was a significant indicator of performance. Further examination of the complex relationship between sleep hour, fatigue, and clinical performance is needed to support the practice of work-hour restriction for surgical residents.

Learning to see the body: supporting instructional practices in laparoscopic surgical procedures

Learning the practices and the performance of physically manipulating instruments in minimally invasive surgeries is an impetus for the development of surgical training simulators. However, an often-overlooked aspect of surgical training is learning how to see the body through the various imaging mechanisms. With this study, we address the ways in which surgeons demonstrate and instruct residents in seeing the body during minimally invasive surgical procedures. Drawing on observations and analysis of video recordings of minimally invasive surgical operations, we examine how particular anatomy and movement within the body to see and conceptualize that anatomy are made visible by the instructive practices of the surgeon. We use these findings to discuss further directions for minimally invasive surgical training through mechanisms for making the body visible during situated surgical training and surgical training simulation systems.

Effects of Experience and Workplace Culture in Human-Robot Team Interaction in Robotic Surgery: A Case Study

Robots are being used in the operating room to aid in surgery, prompting changes to workflow and adaptive behavior by the users. This case study presents a methodology for examining human-robot team interaction in a complex environment, along with the results of its application in a study of the effects of experience and workplace culture, for human-robot team interaction in the operating room. The analysis of verbal and non-verbal events in robotic surgery in two different surgical teams (one in the US and one in France) revealed differences in workflow, timeline, roles, and communication patterns as a function of experience and workplace culture. Longer preparation times and more verbal exchanges related to uncertainty in use of the robotic equipment were found for the French team, who also happened to be less experienced. This study offers an effective method for studying human-robot team interaction and has implications for the future design and training of teamwork with robotic systems in other complex work environments.

Preliminary evaluation of the pattern cutting and the ligating loop virtual laparoscopic trainers.

IntroductionThe Fundamentals of Laparoscopic Surgery (FLS) trainer is currently the standard for training and evaluating basic laparoscopic skills. However, its manual scoring system is time-consuming and subjective. The Virtual Basic Laparoscopic Skill Trainer (VBLaST©) is the virtual version of the FLS trainer which allows automatic and real time assessment of skill performance, as well as force feedback. In this study, the VBLaST© pattern cutting (VBLaST-PC©) and ligating loop (VBLaST-LL©) tasks were evaluated as part of a validation study. We hypothesized that performance would be similar on the FLS and VBLaST© trainers, and that subjects with more experience would perform better than those with less experience on both trainers.MethodsFifty-five subjects with varying surgical experience were recruited at the Learning Center during the 2013 SAGES annual meeting and were divided into two groups: experts (PGY 5, surgical fellows and surgical attendings) and novices (PGY 1-4). They were asked to perform the PC or the ligating loop task on the FLS and the VBLaST© trainers. Their performance scores for each trainer were calculated and compared.ResultsThere were no significant differences between the FLS and VBLaST© scores for either the PC or the ligating loop task. Experts’ scores were significantly higher than the scores for novices on both trainers.ConclusionThis study showed that the subjects’ performance on the VBLaST© trainer was similar to the FLS performance for both tasks. Both the VBLaST-PC© and the VBLaST-LL© tasks permitted discrimination between the novice and expert groups. Although concurrent and discriminant validity has been established, further studies to establish convergent and predictive validity are needed. Once validated as a training system for laparoscopic skills, the system is expected to overcome the current limitations of the FLS trainer.

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.

The Impact of New Instruments on Surgical Performance in Natural Orifice Translumenal Endoscopic Surgery

Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a recent emerging technique for performing general surgery procedures such as cholecystectomy (gallbladder removal). However, the advantages of NOTES over conventional laparoscopic surgery, the current gold standard, are still questionable. The aim of this study was to show the impact of introducing new surgical instruments in the NOTES technique on surgical performance in a cholecystectomy as compared to conventional laparoscopic surgery. A set of videos from real cholecystectomy cases performed using these two different techniques were analyzed. Hierarchical task decomposition and timeline analysis were conducted for each technique. A comparison to show variations between the two techniques at the task level is presented to highlight the technical issues, and their effects on performance, associated with the use of current endoscopic tools in the NOTES technique. The results show a longer procedural time in the NOTES technique than in the laparoscopic technique with the highest increase in surgical time for dissection tasks. The tools used for dissection were also shown to be inadequate for the task based on the motion analysis. Using this systematic method of analysis, new surgical techniques can be assessed based on performance measures, while areas of design improvement in surgical tools can be identified and related to the performance assessment.

Haptic Communication for a 2D Pointing Task in a Virtual Environment

This paper examines the properties of haptic communication between two human operators using kinesthetic haptic devices in a collaborative task in a virtual environment. Twenty subjects, divided into 10 dyads, participated in a 2D pointing task. Each dyad consisted of a supervisor and an acting agent. The supervisor’s role was to guide the acting agent towards a target in the virtual environment through either verbal or haptic communication only. Verbal communication was found to be the most efficient means of communication, but collaboration was also effective using haptic communication. Several different haptic communication strategies were observed, all with equal effectiveness as measured by task completion time. These strategies followed the same pattern as the verbal strategies. These results suggest that haptic communication in a virtual environment is possible, allowing for future designs of haptically enhanced collaborative work in virtual environments.

Classic3D and Single3D: Two unimanual techniques for constrained 3D manipulations on tablet PCs

Standard 3D widgets are used for object manipulation in desktop CAD applications but are less suited for use on touchscreens. We propose two 3D constrained manipulation techniques for Tablet PCs. Using finger identification, the dominant hands index, middle and ring fingers are mapped with the X, Y and Z axes. Users can then trigger different manipulation tasks using specific chording gestures. A user study to assess usability and efficiency permitted to identify the gestures that are the most suitable for each manipulation task. Some design recommendations for an efficient 3D constrained manipulations technique are presented.

Preliminary evaluation of a virtual needle insertion training system

Inserting a needle to perform a biopsy requires a high haptic sensitivity. The traditional learning methods based on observation and training on real patients are questionable. In this paper, we present a preliminary evaluation of a VR trainer for needle insertion tasks. The system aims to replicate an existing physical setup while overcoming some of its limitations. Results permit to validate some design choices and suggest some UI improvements.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

BackgroundNOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.MethodsVideos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.ResultsAt least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.ConclusionAs pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods—combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.