Victoria A. Roach

Application of Stereoscopic Visualization on Surgical Skill Acquisition in Novices

OBJECTIVE The use of stereoscopic imaging can provide additional depth cues that may increase trainee performance on surgical tasks, but it has yet to be evaluated using a validated surgical skill system. This study examines the influence of monoscopic vs stereoscopic visualization in novice trainees performing the McGill Inanimate System for Training and Evaluation of Laparoscopic Skill (MISTELS) tasks, a validated laparoscopic skill-evaluation system, predicting a difference in performance based on visualization modality. DESIGN A total of 31 first- and second-year medical students at the University of Western Ontario were selected, each performed the MISTELS battery of tasks (circle cutting, peg transfer, ligated loop Placement, intracorporeal knot tying, and extracorporeal knot tying) using either monoscopic or stereoscopic visualization displays. Performance was evaluated in accordance with the MISTELS protocol. Participant visual spatial ability and manual dexterity skills were also analyzed and compared with performance. p values less than 0.05 were considered significant. RESULTS For ligated loop placement, extracorporeal knot tying, and intracorporeal knot tying, no significant difference was found between monoscopic and stereoscopic visualization on task performance (p > 0.05). Monoscopic visualization was shown to produce significantly better performance in the peg transfer task alone (p = 0.001). Qualitatively, 57.1% of participants believed their performance was aided by stereoscopic visualization and 68.8% believed that future learners would benefit from its implementation into surgical education. Most participants rated the peg transfer task to be the least difficult task (60%) and rated the intracorporeal knot-tying task to be the most difficult (65.9%). CONCLUSIONS These results suggest that the intrinsic difficulty of the MISTELS tasks may exceed a novice users skill. No benefit with additional 3-dimensional cues in naïve surgical trainees was found. Additional visual cues in stereoscopic visualization may only serve to increase cognitive load and potentially decrease skill acquisition and learning.

Is three‐dimensional videography the cutting edge of surgical skill acquisition?

The process of learning new surgical technical skills is vital to the career of a surgeon. The acquisition of these new skills is influenced greatly by visual‐spatial ability (VSA) and may be difficult for some learners to rapidly assimilate. In many cases, the role of VSA on the acquisition of a novel technical skill has been explored; however, none have probed the impact of a three‐dimensional (3D) video learning module on the acquisition of new surgical skills. The first aim of this study is to capture spatially complex surgical translational flaps using 3D videography and incorporate the footage into a self‐contained e‐learning module designed in line with the principles of cognitive load theory. The second aim is to assess the efficacy of 3D video as a medium to support the acquisition of complex surgical skills in novice surgeons as evaluated using a global ratings scale. It is hypothesized that the addition of depth in 3D viewing will augment the learners innate visual spatial abilities, thereby enhancing skill acquisition compared to two‐dimensional viewing of the same procedure. Despite growing literature suggesting that 3D correlates directly to enhanced skill acquisition, this study did not differentiate significant results contributing to increased surgical performance. This topic will continue to be explored using more sensitive scales of measurement and more complex “open procedures” capitalizing on the importance of depth perception in surgical manipulation. Anat Sci Educ.

Comparison of 3D reconstructive technologies used for morphometric research and the translation of knowledge using a decision matrix

The use of three‐dimensional (3D) models for education, pre‐operative assessment, presurgical planning, and measurement have become more prevalent. With the increase in prevalence of 3D models there has also been an increase in 3D reconstructive software programs that are used to create these models. These software programs differ in reconstruction concepts, operating system requirements, user features, cost, and no one program has emerged as the standard. The purpose of this study was to conduct a systematic comparison of three widely available 3D reconstructive software programs, Amira®, OsiriX, and Mimics®, with respect to the softwares ability to be used in two broad themes: morphometric research and education to translate morphological knowledge. Cost, system requirements, and inherent features of each program were compared. A novel concept selection tool, a decision matrix, was used to objectify comparisons of usability of the interface, quality of the output, and efficiency of the tools. Findings indicate that Mimics was the best‐suited program for construction of 3D anatomical models and morphometric analysis, but for creating a learning tool the results were less clear. OsiriX was very user‐friendly; however, it had limited capabilities. Conversely, although Amira had endless potential and could create complex dynamic videos, it had a challenging interface. These results provide a resource for morphometric researchers and educators to assist the selection of appropriate reconstruction programs when starting a new 3D modeling project. Anat Sci Educ 6: 393–403.

Head to Head: The Role of Academic Competition in Undergraduate Anatomical Education.

Competition is a key element in many educational games and is often adopted by educators in an effort to motivate and excite their students. Yet, the use of academic competition in educational institutions remains the subject of much debate. Opponents argue that academic competition causes an increase in student anxiety and divides their attention. However, if the contexts of academic competition are defined, could the inclusion of a game‐like competition in a university course be a viable and beneficial method of engaging students? Students (n = 67) were recruited from an undergraduate human anatomy course at Western University. Using a crossover design, students were exposed to a competitive tournament either at the time of their first term test or second term test. The anatomical knowledge of participating students was assessed prior to the start of the study using a baseline anatomy test. Following treatment with an online competitive anatomy tournament, students term test grades and final course grades were analyzed. Both the second term test scores (F(2,64) = 3.743, P = 0.029) and overall course grades (F(2,64) = 3.356, P = 0.041) were found to be significantly different (P < 0.05) for individuals in the competitive group when compared to their non‐competing peers. As suggested by the literature where organized competition in the classroom correlates to improved academic performance, this study uncovered significant results pertaining to increased academic performance resulting from participating in tournament‐based competition. In light of these positive results, further exploration of the effects of academic competition on student performance across age brackets and disciplines is warranted. Anat Sci Educ 8: 404–412.

Spatial Visualization Ability and Laparoscopic Skills in Novice Learners: Evaluating Stereoscopic versus Monoscopic Visualizations.

Elevated spatial visualization ability (Vz) is thought to influence surgical skill acquisition and performance. Current research suggests that stereo visualization technology and its association with skill performance may confer perceptual advantages. This is of particular interest in laparoscopic skill training, where stereo visualization may confer learning advantages to novices of variant Vz. This study explored laparoscopic skill performance scores in novices with variable spatial ability utilizing stereoscopic and traditional monoscopic visualization paradigms. Utilizing the McGill Inanimate System for Teaching and Evaluating Laparoscopic Skills (MISTELS) scoring protocol it was hypothesized that individuals with high spatial visualization ability (HVz) would achieve higher overall and individual MISTELS task scores as compared to low spatial visualization ability (LVz) counterparts. Further, we also hypothesized that a difference would exist between HVz and LVz individual scores based on the viewing modality employed. No significant difference was observed between HVz and LVz individuals for MISTELS tasks scores, overall or individually under both viewing modalities, despite higher average MISTELS scores for HVz individuals. The lack of difference between scores obtained under the stereo modality suggested that the additional depth that is conferred by the stereoscopic visualization may act to enhance performance for individuals with LVz, potentially equilibrating their performance with their HVz peers. Further experimentation is required to better ascertain the effects of stereo visualization in individuals of high and low Vz, though it appears stereoscopic visualizations could serve as a prosthetic to enhance skill performance. Anat Sci Educ 7: 295–301.

The eye of the beholder: Can patterns in eye movement reveal aptitudes for spatial reasoning?

Mental rotation ability (MRA) is linked to academic success in the spatially complex Science, Technology, Engineering, Medicine, and Mathematics (STEMM) disciplines, and anatomical sciences. Mental rotation literature suggests that MRA may manifest in the movement of the eyes. Quantification of eye movement data may serve to distinguish MRA across individuals, and serve as a consideration when designing visualizations for instruction. It is hypothesized that high‐MRA individuals will demonstrate fewer eye fixations, conduct shorter average fixation durations (AFD), and demonstrate shorter response times, than low‐MRA individuals. Additionally, individuals with different levels of MRA will attend to different features of the block‐figures presented in the electronic mental rotations test (EMRT). All participants (n = 23) completed the EMRT while metrics of eye movement were collected. The test required participants view pairs of three‐dimensional (3D) shapes, and identify if the pair is rotated but identical, or two different structures. Temporal analysis revealed no significant correlations between response time, average fixation durations, or number of fixations and mental rotation ability. Further analysis of within‐participant variability yielded a significant correlation for response time variability, but no correlation between AFD variability and variability in the number of fixations. Additional analysis of salience revealed that during problem solving, individuals of differing MRA attended to different features of the block images; suggesting that eye movements directed at salient features may contribute to differences in mental rotations ability, and may ultimately serve to predict success in anatomy. Anat Sci Educ 9: 357–366.

Different perspectives: Spatial ability influences where individuals look on a timed spatial test

Learning in anatomy can be both spatially and visually complex. Pedagogical investigations have begun exploration as to how spatial ability may mitigate learning. Emerging hypotheses suggests individuals with higher spatial reasoning may attend to images differently than those who are lacking. To elucidate attentional patterns associated with different spatial ability, eye movements were measured in individuals completing a timed electronic mental rotation test (EMRT). The EMRT was based on the line drawings of Shepherd and Metzler. Individuals deduced whether image pairs were rotations (same) or mirror images (different). It was hypothesized that individuals with high spatial ability (HSA) would demonstrate shorter average fixation durations during problem solving and attend to different features of the EMRT than low spatial ability (LSA) counterparts. Moreover, question response accuracy would be associated with fewer fixations and shorter average response times, regardless of spatial reasoning ability. Average fixation duration in the HSA group was shorter than LSA (F(1,8) = 7.99; P = 0.022). Importantly, HSA and LSA individuals looked to different regions of the EMRT images (Fisher Exact Test: 12.47; P = 0.018); attending to the same locations only 34% of the time. Correctly answered questions were characterized by fewer fixations per question (F(1, 8) = 18.12; P = 0.003) and shorter average response times (F(1, 8) = 23.89; P = 0.001). The results indicate that spatial ability may influence visual attention to salient areas of images and this may be key to problem solving processes for low spatial individuals. Anat Sci Educ 10: 224–234.

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program

OBJECTIVE A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices. DESIGN Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency. RESULTS Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol. CONCLUSIONS An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.

Time Limits in Testing: An Analysis of Eye Movements and Visual Attention in Spatial Problem Solving.

Individuals with an aptitude for interpreting spatial information (high mental rotation ability: HMRA) typically master anatomy with more ease, and more quickly, than those with low mental rotation ability (LMRA). This article explores how visual attention differs with time limits on spatial reasoning tests. Participants were assorted to two groups based on their mental rotation ability scores and their eye movements were collected during these tests. Analysis of salience during testing revealed similarities between MRA groups in untimed conditions but significant differences between the groups in the timed one. Question‐by‐question analyses demonstrate that HMRA individuals were more consistent across the two timing conditions (κ = 0.25), than the LMRA (κ = 0.013). It is clear that the groups respond to time limits differently and their apprehension of images during spatial problem solving differs significantly. Without time restrictions, salience analysis suggests LMRA individuals attended to similar aspects of the images as HMRA and their test scores rose concomitantly. Under timed conditions however, LMRA diverge from HMRA attention patterns, adopting inflexible approaches to visual search and attaining lower test scores. With this in mind, anatomical educators may wish to revisit some evaluations and teaching approaches in their own practice. Although examinations need to evaluate understanding of anatomical relationships, the addition of time limits may induce an unforeseen interaction of spatial reasoning and anatomical knowledge. Anat Sci Educ 10: 528–537.

Guiding low spatial ability individuals through visual cueing: The dual importance of where and when to look: Guiding the Learner through Visual Cueing

Research suggests that spatial ability may predict success in complex disciplines including anatomy, where mastery requires a firm understanding of the intricate relationships occurring along the course of veins, arteries, and nerves, as they traverse through and around bones, muscles, and organs. Debate exists on the malleability of spatial ability, and some suggest that spatial ability can be enhanced through training. It is hypothesized that spatial ability can be trained in low‐performing individuals through visual guidance. To address this, training was completed through a visual guidance protocol. This protocol was based on eye‐movement patterns of high‐performing individuals, collected via eye‐tracking as they completed an Electronic Mental Rotations Test (EMRT). The effects of guidance were evaluated using 33 individuals with low mental rotation ability, in a counterbalanced crossover design. Individuals were placed in one of two treatment groups (late or early guidance) and completed both a guided, and an unguided EMRT. A third group (no guidance/control) completed two unguided EMRTs. All groups demonstrated an increase in EMRT scores on their second test (P < 0.001); however, an interaction was observed between treatment and test iteration (P = 0.024). The effect of guidance on scores was contingent on when the guidance was applied. When guidance was applied early, scores were significantly greater than expected (P = 0.028). These findings suggest that by guiding individuals with low mental rotation ability “where” to look early in training, better search approaches may be adopted, yielding improvements in spatial reasoning scores. It is proposed that visual guidance may be applied in spatial fields, such as STEMM (science, technology, engineering, mathematics and medicine), surgery, and anatomy to improve students interpretation of visual content. Anat Sci Educ.