Marlies P. Schijven

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

BackgroundVirtual 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.MethodsA 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.ResultsThe results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.ConclusionsIn 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.

Systematic review of serious games for medical education and surgical skills training

The application of digital games for training medical professionals is on the rise. So‐called ‘serious’ games form training tools that provide a challenging simulated environment, ideal for future surgical training. Ultimately, serious games are directed at reducing medical error and subsequent healthcare costs. The aim was to review current serious games for training medical professionals and to evaluate the validity testing of such games.

Consensus guidelines for validation of virtual reality surgical simulators

Abstract.The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ).

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer

The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3-28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.66-7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58-16.38) compared with those > or = 65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.

Training and learning robotic surgery, time for a more structured approach: a systematic review

Please cite this paper as: Schreuder H, Wolswijk R, Zweemer R, Schijven M, Verheijen R. Training and learning robotic surgery, time for a more structured approach: a systematic review. BJOG 2012;119:137–149.

Augmented versus virtual reality laparoscopic simulation : What is the difference? A comparison of the ProMIS augmented reality laparoscopic simulator versus LapSim virtual reality laparoscopic simulator

BackgroundVirtual 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.MethodsThe 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.ResultsThere 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).ConclusionsIn 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.

Construct validity: Experts and novices performing on the Xitact LS500 laparoscopy simulator

Background: This study was undertaken to establish construct validity of the Xitact LS500, a virtual reality laparoscopic cholecystectomy simulator. The primary research statement is: “The clip-and-cut task on the Xitact LS500 virtual reality laparoscopic cholecystectomy simulator mimics the surgical procedure of the clipping and cutting of the cystic duct and artery during the laparoscopic cholecystectomy adequately.” Methods: According to the level of experience of the surgeon, an “expert group opinion” was formed resulting from 37 surgeons having performed over 100 laparoscopic cholecystectomies, and a “novice group opinion” was formed resulting of 37 surgeons having no experience at all with performing laparoscopic cholecystectomy. Participants received an instructed hands-on “tour” on the Xitact simulator and performed three formal simulation runs. Results: The “novice group” is younger and more surgeons are female. Performance scores in the “expert” group are significantly higher on the second (p value 0.011) and third (p value 0.005) run, compared to the novices’ scores. Experts are significantly faster on completion of all three runs. There is an increase in score over runs in both groups, which is statistically significant in the “expert group.” Less than one-third of surgeons in either group are able to correctly predict their performance score as generated by Xitact. Both “experts” and “novices” feel it is useful to train with Xitact LS500 in the surgical curriculum. Conclusions: Three hypotheses, formulated to operationalize the primary research statement, could be answered affirmatively. Although further validation studies are needed, the Xitact LS500 simulator seems to be able to discriminate between expert and novice surgeons in this research setting, and thus the construct for this setting is considered to be valid.

Construct validity of the LapSim: Can the LapSim virtual reality simulator distinguish between novices and experts?

BackgroundVirtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden).MethodsForty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer.ResultsThe higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters.ConclusionsOur results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

The learning curve on the Xitact LS 500 laparoscopy simulator: profiles of performance

Background: This study assesses the acquisition of skill and the learning curve associated with the performance of the clip-and-cut task on the Xitact LS 500 virtual reality (VR) simulator in laparoscopic cholecystectomy.Methods: A group of 33 residents and interns with no previous laparoscopic experience participated in the study. All participants received a 1-h familiarization tour on the simulator. Thirty participants completed a full course of 30 simulation runs over 3 days (10 runs per day). The outcome parameters were a previously validated sum-score and time to complete performance. Results: Group demographics were similar. Of the participants who completed the full study, 16.7% appeared to have such a high level of innate psychomotor abilities that they were considered proficient in the task immediately after the initial familiarization tour. Most participants (63.3%) had a moderate level of innate abilities, and their performance improved through repetitive VR training. In our study, 20% of the participants had such a low level of innate abilities that they were unable to achieve an acceptable performance in our minimal-access surgery (MAS) simulation.Conclusions: Learning curves cannot be assessed by examining the repetitive training of only one person. There seem to be four different performance profiles, reflecting the fact that some people are more adept than others to be trained by MAS procedural VR simulation. For participants receptive to training—63.3% in this study—proficiency in the task occurs after ~25 simulative runs.

European consensus on a competency-based virtual reality training program for basic endoscopic surgical psychomotor skills

BackgroundVirtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program.MethodsA consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the t test for equality of means.ResultsConsensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference.ConclusionsA European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.