Neal E. Seymour

Virtual Reality Training Improves Operating Room Performance: Results of a Randomized, Double-Blinded Study

ObjectiveTo demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. Summary Background DataThe use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. MethodsSixteen surgical residents (PGY 1–4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). ResultsNo differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P < .007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P < .04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case;P < .008, Mann-Whitney test). ConclusionsThe use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.

VR to OR: A Review of the Evidence that Virtual Reality Simulation Improves Operating Room Performance

The use of virtual reality (VR) simulation to train surgeons has been supported by a body of experimental data derived from randomized trials of VR simulation training versus no such training. These investigations have focused on the use of VR devices to train surgeons in laparoscopic and flexible endoscopic skills, and the studies have generally demonstrated that skills acquired through courses of training in VR transfer to the clinical or animal laboratory setting, where assessments of various types have been used to measure performance. These studies, as well as the study model that describes them, and the future of randomized trials of this type are reviewed.

Boot Camp: Educational Outcomes After 4 Successive Years of Preparatory Simulation- Based Training at Onset of Internship

PURPOSE Preparatory training for new trainees beginning residency has been used by a variety of programs across the country. To improve the clinical orientation process for our new postgraduate year (PGY)-1 residents, we developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. We define our surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. We report educational results of 4 successive years of Boot Camp training. Results were analyzed to determine if performance evidenced at onset of training was predictive of later educational outcomes. METHODS Learners were PGY-1 residents, in both categorical and preliminary positions, at our medium-sized surgical residency program. Over a 4-year period, from July 2007 to July 2010, all 30 PGY-1 residents starting surgical residency at our institution underwent specific preparatory didactic and skills training over a 9-week period. This consisted of mandatory weekly 1-hour and 3-hour sessions in the Simulation Center, representing a 4-fold increase in time in simulation laboratory training compared with the remainder of the year. Training occurred in 8 procedural skills areas (instrument use, knot-tying, suturing, laparoscopic skills, airway management, cardiopulmonary resuscitation, central venous catheter, and chest tube insertion) and in simulated patient care (shock, surgical emergencies, and respiratory, cardiac, and trauma management) using a variety of high- and low-tech simulation platforms. Faculty and senior residents served as instructors. All educational activities were structured to include preparatory materials, pretraining briefing sessions, and immediate in-training or post-training review and debriefing. Baseline cognitive skills were assessed with written tests on basic patient management. Post-Boot Camp tests similarly evaluated cognitive skills. Technical skills were assessed using a variety of task-specific instruments, and expressed as a mean score for all activities for each resident. All measurements were expressed as percent (%) best possible score. Cognitive and technical performance in Boot Camp was compared with subsequent clinical and core curriculum evaluations including weekly quiz scores, annual American Board of Surgery In-Training Examination (ABSITE) scores, program in-training evaluations (New Innovations, Uniontown, Ohio), and operative assessment instrument scores (OP-Rate, Baystate Medical Center, Springfield, Massachusetts) for the remainder of the PGY-1 year. RESULTS Performance data were available for 30 PGY-1 residents over 4 years. Baseline cognitive skills were lower for the first year of Boot Camp as compared with subsequent years (71 ± 13, 83 ± 9, 84 ± 11, and 86 ± 6, respectively; p = 0.028, analysis of variance; ANOVA). Performance improved between pretests and final testing (81 ± 11 vs 89 ± 7; p < 0.001 paired t test). There was statistically significant correlation between Boot Camp final cognitive test results and American Board of Surgery In-Training Examination scores (p = 0.01; n = 22), but not quite significant for weekly curriculum quiz scores (p = 0.055; n = 22) and New Innovations cognitive assessments (p = 0.09; n = 25). Statistically significant correlation was also noted between Boot Camp mean overall skills and New Innovations technical skills assessments (p = 0.002; n = 25) and OP-Rate assessments (p = 0.01; n = 12). CONCLUSIONS Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents correlate with subjective and objective clinical performance evaluations. This concurrent correlation with multiple traditional evaluation methods used to express competency in our residency program supports the use of Boot Camp performance measures as needs assessment tools as well as adjuncts to cumulative resident evaluation data.

Pancreatic polypeptide administration improves abnormal glucose metabolism in patients with chronic pancreatitis

Chronic pancreatitis (CP) is associated with lowered plasma levels and a blunted nutrient-induced release of pancreatic polypeptide (PP). To investigate the possible role of PP on glucose metabolism, we studied male patients with documented CP (n = 5) and obesity-matched control subjects (NL) (n = 6). Hepatic glucose production (HGP) and overall glucose disposal rates were determined by [3-3H]glucose infusion during a hyperinsulinemic-euglycemic clamp during three separate admissions. Basal rates of HGP were higher in CP patients. In response to an infusion of insulin (60 pmol.m-2.min-1), HGP fell 91 +/- 5% in NL subjects but only 68 +/- 8% in CP subjects (P < 0.05). One month later, the clamp was repeated during the final 2 h of an 8-h infusion of bovine PP (2 pmol.kg-1.min-1). HGP before the insulin infusion and its subsequent suppression (NL: 83 +/- 5%; CP: 86 +/- 15%) were nearly identical between groups. In follow-up studies 1 month after the PP infusion, HGP both basally and in response to insulin alone were similar to the first study. During oral glucose tolerance tests (OGTT) performed 18 h after the PP infusion, subjects with normal (n = 7) baseline OGTT responses showed no effect. All patients with diabetic (n = 3) or nondiagnostic (n = 1) OGTT responses, however, demonstrated lowered mean plasma glucose levels (approximately -2.3 mmol/L; range: -0.6 to -7.2 mmol/L). OGTTs repeated 1 month after the PP treatment showed a return to pretreatment responses. We conclude that chronic pancreatitis accompanied by PP deficiency is associated with partial hepatic resistance both in the basal state and in response to hyperinsulinemia. This impairment is reversed after iv PP administration. PP deficiency may therefore play a role in the development of pancreatogenic diabetes caused by pancreatic injury.

Prospective, Randomized Assessment of Transfer of Training (ToT) and Transfer Effectiveness Ratio (TER) of Virtual Reality Simulation Training for Laparoscopic Skill Acquisition

Objectives:We assessed the effectiveness of ToT from VR laparoscopic simulation training in 2 studies. In a second study, we also assessed the TER. ToT is a detectable performance improvement between equivalent groups, and TER is the observed percentage performance differences between 2 matched groups carrying out the same task but with 1 group pretrained on VR simulation. Concordance between simulated and in-vivo procedure performance was also assessed. Design:Prospective, randomized, and blinded. Participants:In Study 1, experienced laparoscopic surgeons (n = 195) and in Study 2 laparoscopic novices (n = 30) were randomized to either train on VR simulation before completing an equivalent real-world task or complete the real-world task only. Results:Experienced laparoscopic surgeons and novices who trained on the simulator performed significantly better than their controls, thus demonstrating ToT. Their performance showed a TER between 7% and 42% from the virtual to the real tasks. Simulation training impacted most on procedural error reduction in both studies (32- 42%). The correlation observed between the VR and real-world task performance was r > 0·96 (Study 2). Conclusions:VR simulation training offers a powerful and effective platform for training safer skills.

Laparoscopic treatment of fulminant ulcerative colitis.

Background: The complexity and risks of the surgical treatment of ulcerative colitis are greater in patients with fulminant disease. Subtotal colectomy is frequently offered to such patients to control acute disease and restore immunological and nutritional status prior to a restorative procedure. The role of laparoscopy in this setting is poorly defined. Methods: The records of 18 patients with poorly controlled fulminant colitis on aggressive immunosuppressive therapy who underwent laparoscopic subtotal colectomy were reviewed. Results: Postoperative complications occurred in six patients (33%). Postoperative length of stay was 5.0 ± 0.3 days vs 8.8 ± 1.8 days (p<0.05) for a group of six patients who had undergone open subtotal colectomy for the same indications. Systemic steroids were withdrawn in all patients, and 17 patients subsequently underwent proctectomy and pelvic pouch construction. Conclusions: The relatively high morbidity rate in these patients is likely related to their compromised status at the time of surgery. Laparoscopic subtotal colectomy in patients with fulminant ulcerative colitis allows for earlier hospital discharge, facilitates subsequent pelvic pouch, construction, and provides an excellent alternative to conventional two- and three-stage surgical treatment.

Laparoscopic versus open incisional hernia repair: a single-institution analysis of hospital resource utilization for 884 consecutive cases.

BackgroundTo analyze hospital resource utilization for laparoscopic vs open incisional hernia repair including the postoperative period.MethodsProspectively collected administrative data for incisional hernia repairs were examined. A total of 884 incisional hernia repairs were examined for trends in type of approach over time. Starting October 2001, detailed records were available, and examined for operating room (OR) time, cost data, length of stay (LOS), and 30-day postoperative hospital encounters.ResultsOf the total, 469 incisional hernias were approached laparoscopically (53%) and 415 open (47%). Laparoscopic repair had shorter LOS (1 ± 0.2 days vs 2 ± 0.6 days), longer OR time (149 ± 4 min vs 89 ± 4 min), higher supply costs (

Establishing a simulation center for surgical skills : what to do and how to do it

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Analysis of errors in laparoscopic surgical procedures.

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Surgical Resident Performance on a Virtual Reality Simulator Correlates with Operating Room Performance

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