Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality (MIST VR). Proving the effectiveness of virtual reality simulation for training in laparoscopic surgery. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills. Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Training in laparoscopic suturing skills using a new computer-based virtual reality simulator (MIST-VR) provides results comparable to those with an established pelvic trainer system. Skills acquired on virtual reality laparoscopic simulators transfer into the operating room in a blinded, randomised, controlled trial. Skill transfer from virtual reality to a real laparoscopic task. A comparison between randomly alternating imaging, normal laparoscopic imaging, and virtual reality training in laparoscopic psychomotor skill acquisition. Does training in a virtual reality simulator improve surgical performance? The transfer of basic skills learned in a laparoscopic simulator to the operating room. Transfer validity of laparoscopic knot-tying training on a VR simulator to a realistic environment: a randomized controlled trial. Laparoscopic virtual reality and box trainers: is one superior to the other? Virtual-reality training improves angled telescope skills in novice laparoscopists. Randomized controlled trial of virtual reality simulator training: transfer to live patients. Virtual reality colonoscopy simulation: a compulsory practice for the future colonoscopist?
The "fulcrum effect" of the body wall on surgical instrument manipulation is a major hurdle for novice endoscopic surgeons. Virtual reality training has not previously been evaluated as a means to overcome this problem.
                16 participants with no experience of endoscopy were required to make multiple defined incisions under laparoscopic laboratory conditions within 2-minute periods. Half of the subjects were randomized to receive initial training on the Minimally Invasive Surgical Trainer, Virtual Reality (MIST VR) computer programme.
                Participants with MIST VR training made significantly more correct incisions (P = 0.0001) than the control group on test trial 1, and even after extended practice by both groups (P = 0.0001). They were also significantly more likely to actively use both hands to perform the endoscopic evaluation task (P = 0.01).
                Virtual reality training represents a potential, viable solution for junior endoscopists, for overcoming the "fulcrum effect", in a replicable, safe learning environment which allows objective and reliable quantification of skill levels by trainers. The aim of this study was to compare learning curves for laparoscopic cholecystectomy (LC) after training on a proficiency based virtual reality (VR) curriculum with that of a traditionally trained group.
                Simulator-based training has been shown to improve technical performance during real laparoscopic procedures, although research to date has not proven the persistence of this effect over subsequent cases.
                Twenty novice surgeons underwent baseline laparoscopic skills testing followed by a 1-day didactic training session. Control subjects (n = 10) performed 5 cadaveric porcine LCs each; VR-trained subjects (n = 10) completed a VR training curriculum followed by 3 porcine LCs each. A further 10 experienced laparoscopic surgeons (>100 LCs) performed 2 porcine LCs each to define benchmark levels. Technical skill assessment was by motion analysis and video-based global rating scores (out of 35).
                There were no intergroup differences in baseline skill. The first LC revealed significant differences between control and VR groups for time (median 4590 seconds vs. 2165 seconds, P = 0.038), path length (169.2 meters vs. 86.8 meters, P = 0.009), number of movements (2446 vs. 1029, P = 0.009), and video scores (17 vs. 25, P = 0.001). The VR group, although not a control, achieved video and dexterity scores equivalent to expert levels of performance.
                A proficiency based VR training curriculum shortens the learning curve on real laparoscopic procedures when compared with traditional training methods. This may be a more cost- and time-effective approach, and supports the need for simulator-based practice to be integrated into surgical training programs. This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy.
                Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR.
                No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores.
                Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.
                Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment.
                The 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.
                Sixteen 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).
                No 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).
                The 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. Training on a video trainer or computer-based minimally invasive surgery trainer leads to improved benchtop laparoscopic skill. Recently, improved operative performance from practice on a video trainer was reported. The purpose of this study was three fold: (a) to compare psychomotor skill improvement after training on a virtual reality (VR) system with that after training on a video-trainer, (VT) (b) to evaluate whether skills learned on the one training system are transferable to the other, and (c) to evaluate whether VR or VT training improves operative performance. For the study, 50 junior surgery residents completed baseline skill testing on both the VR and VT systems. These subjects then were randomized to either a VR or VT structured training group. After practice, the subjects were tested again on their VR and VT skills. To assess the effect of practice on operative performance, all second-year residents (n = 19) were evaluated on their operative performance during a laparoscopic cholecystectomy before and after skill training. Data are expressed as percentage of improvement in mean score/time. Analysis was performed by Student's paired t-test. The VR training group showed improvement of 54% on the VR posttest, as compared with 55% improvement by the VT group. The VR training group improved more on the VT posttest tasks (36%) than the VT training group improved on the VR posttest tasks (17%) (p <0.05). Operative performance improved only in the VR training group (p <0.05). Psychomotor skills improve after training on both VR and VT, and skills may be transferable. Furthermore, training on a minimally invasive surgery trainer, virtual reality system may improve operative performance during laparoscopic cholecystectomy. Laparoscopic surgery requires a different set of skills than traditional open surgery. The acquisition of basic laparoscopic skills may help novices when learning laparoscopic procedures. This study tested the hypothesis that the combination of virtual reality and box trainers leads to better basic laparoscopic skill acquisition than either method alone or no training.
                A randomized control trial involving preclinical medical students with no prior operative experience was performed. The students were grouped according to four training methods: virtual reality training, inanimate box training, a combination of both, and no training (control). The pre- and posttraining scores for four skills in the porcine laboratory were the metrics chosen for this study.
                A total of 65 students participated in this study. There were no differences among any of the pretraining scores (p > 0.05). The posttraining times differed between the four groups. Post hoc analyses showed statistically significant differences (p < 0.05) between the participants trained with both trainers and the control subjects.
                Our data demonstrate that the combination of virtual reality training and inanimate box training leads to better laparoscopic skill acquisition than either training method alone or no training at all. Optimal preclinical laparoscopic training should incorporate both virtual reality trainers and inanimate box trainers. Virtual reality (VR) training has been shown previously to improve intraoperative performance during part of a laparoscopic cholecystectomy. The aim of this study was to assess the effect of proficiency-based VR training on the outcome of the first 10 entire cholecystectomies performed by novices.
                Thirteen laparoscopically inexperienced residents were randomized to either (1) VR training until a predefined expert level of performance was reached, or (2) the control group. Videotapes of each resident's first 10 procedures were reviewed independently in a blinded fashion and scored for predefined errors.
                The VR-trained group consistently made significantly fewer errors (P = .0037). On the other hand, residents in the control group made, on average, 3 times as many errors and used 58% longer surgical time.
                The results of this study show that training on the VR simulator to a level of proficiency significantly improves intraoperative performance during a resident's first 10 laparoscopic cholecystectomies. We hypothesized that the Minimally Invasive Surgery Trainer (MIST-VR; VP Medical R, London, U.K.) would be as effective as the Yale Laparoscopic Skills Course in improving laparoscopic intracorporeal suturing skills.
                Each student made six attempts to tie a knot laparoscopically. Students were then randomized to train on the MIST-VR for five sessions (six skills/session) or the Yale Skills for five sessions (three skills/session) over 5 days. On completion of training, all students were evaluated by a test consisting of six attempts to tie a laparoscopic knot.
                The percentage improvement in knot tying time did not differ significantly in the pelvic trainer group (30 +/- 21%) (from 443 +/- 135 to 311 +/- 137 seconds) and the MIST-VR group (39 +/- 21%) (from 409 +/- 109 to 256 +/- 140 seconds) (P = 0.308).
                The MIST-VR is equivalent to the Yale Skills Course for training in the advanced laparoscopic skill of intracorporeal suturing. Virtual reality surgical simulators have proven value in the acquisition and assessment of laparoscopic skills. In this study, we investigated skill transfer from a virtual reality laparoscopic simulator into the operating room, using a blinded, randomised, controlled trial design. Surgical trainees using the LapSim System performed significantly better at their first real-world attempt at a laparoscopic task than their colleagues who had not received similar training, as measured independently by a number of expert surgical observers using four criteria. To validate the usefulness of virtual reality surgical simulators, we investigated the transfer of skills achieved by their use to real tasks.
                Thirty medical students underwent a pretest using a real laparoscopic trainer. They were then randomized to the following three groups: group I received no training; group II received training using the Minimal Invasive Surgical Trainer in Virtual Reality (MIST-VR); and group III received training using conventional training exercises. Each group then underwent a posttest. Using the Imperial College Surgical Assessment Device (ICSAD), scores were generated for time taken, distance traveled, number of movements made, and speed of instrument movement.
                Significant changes between the MIST-VR group (group II) and the conventionally trained group (group III), were observed in the speed of movement of the left hand and the numbers of movements taken by each hand, when compared to the untrained group (group I).
                The training of novices using MIST-VR yields quantifiable changes in skill that are transferable to a simple real task and are similar to the results achieved with conventional training. To evaluate virtual reality as a laparoscopic training device in helping surgeons to automate to the "fulcrum effect" by comparing it to time-matched training programs using randomly alternating images (ie, y-axis inverted and normal laparoscopic) and normal laparoscopic viewing conditions.
                Twenty-four participants (16 females and 8 males), were randomly assigned to minimally invasive surgery virtual reality (MIST VR), randomly alternating (between y-axis inverted and normal laparoscopic images), and normal laparoscopic imaging condition. Participants were requested to perform a 2-minute laparoscopic cutting task before and after training.
                In the test trial participants who trained on the MIST VR performed significantly better than those in the normal laparoscopic and randomly alternating imaging conditions.
                The results show that virtual reality training may provide faster skill acquisition with particular reference to automation of the fulcrum effect. MIST VR provides a new way of training laparoscopic psychomotor surgical skills. The development of computerized surgical simulators in a virtual reality environment demands models for proper validation. Recent investigations have shown that a virtual reality simulator (MIST-VR) is a reliable tool for the assessment of laparoscopic psychomotor skills and that it improves the automation of the so-called fulcrum effect. Therefore, we set out to determine whether training with the MIST-VR would improve the surgical performance of surgically inexperienced medical students and to see if results obtained in the simulator would correlate with surgical performance.
                A total of 29 medical students were randomized into two groups. One group received preoperative MIST-VR training. Both groups then performed a simulated laparoscopic appendectomy in a pig. The operations were videotaped and examined by three independent observers.
                There was no significant difference in performance between the two groups. The performance with the MIST-VR correlated with the results in surgery.
                A method that can measure surgical skill, based on the scoring of independent observers who view videotaped performances, seems to be reliable. MIST-VR did not improve the surgical skills of the subjects, but the results with MIST-VR did predict surgical outcome. The aim of the study was to evaluate whether basic surgical skills achieved by training in LapSim, a computerbased laparoscopic simulator, could be transferred to the operating room.
                For this study, 24 medical students undergoing courses in surgery were randomly assigned to train with LapSim or to serve as control subjects. After they had undergone simulator training 2 h per week for 5 weeks, their basic skills in laparoscopic surgery were assessed in a porcine model. The time to perform each task was measured, and four senior surgeons independently graded the overall performance on a 9-step differential rating scale.
                The participants randomized to train with LapSim showed significantly better results for all tasks in both parts of the study than the untrained participants, according to the expert evaluation. Time consumption was accordingly lower in the training group in the control group.
                The results show that basic skills achieved by systematic training with a laparoscopic simulator such as LapSim can be transferred to the operating room. Laparoscopic suturing is one of the most difficult tasks in endoscopic surgery, requiring extensive training. The aim of this study was to determine the transfer validity of knot-tying training on a virtual-reality (VR) simulator to a realistic laparoscopic environment.
                Twenty surgical trainees underwent basic eye-hand coordination training on a VR simulator (SIMENDO, DelltaTech, Delft, The Netherlands) until predefined performance criteria were met. Then, they were randomized into two groups. Group A (the experimental group) received additional training with the knot-tying module on the simulator, during which they had to tie a double laparoscopic knot ten times. Group B (controls) did not receive additional manual training. Within a week the participants tied a double knot in the abdominal cavity of an anaesthetized porcine model. Their performance was captured on digital video and coded. Objective analysis parameters were: time taken to tie the knot and number of predefined errors made. Subjective assessments were also made by two laparoscopic surgeons using a global rating list with a five-point Likert scale.
                Trainees in group A (n = 9) were significantly faster than the controls (n = 10), with a median of 262 versus 374 seconds (p = 0.034). Group A made a significantly lower number of errors than the controls (median of 24 versus 36 errors, p = 0.030). Subjective assessments by the laparoscopic experts did not show any significant differences in economy of movement and erroneous behavior between the two groups.
                Surgical trainees who received knot-tying training on the VR simulator were faster and made fewer errors than the controls. The VR module is a useful tool to train laparoscopic knot-tying. Opportunities arose to improve simulator-based instruction that might enhance future training. Virtual reality (VR) simulators now have the potential to replace traditional methods of laparoscopic training. The aim of this study was to compare the VR simulator with the classical box trainer and determine whether one has advantages over the other.
                Twenty four novices were tested to determine their baseline laparoscopic skills and then randomized into the following three group: LapSim, box trainer, and no training (control). After 3 weekly training sessions lasting 30-min each, all subjects were reassessed. Assessment included motion analysis and error scores. Nonparametric tests were applied, and p < 0.05 was deemed significant.
                Both trained groups made significant improvements in all parameters measured ( p < 0.05). Compared to the controls, the box trainer group performed significantly better on most of the parameters, whereas the LapSim group performed significantly better on some parameters. There were no significant differences between the LapSim and box trainer groups.
                LapSim is effective in teaching skills that are transferable to a real laparoscopic task. However, there appear to be no substantial advantages of one system over the other. Based on prior success of virtual-reality (VR) trainers in imparting surgical skills, a randomized and controlled study was designed to determine whether VR training improves angled-telescope operative performance.
                Third-year medical students received instruction on the use of an angled laparoscope and subsequently underwent performance assessment of angled telescope navigational tasks in an anesthetized porcine model. Subjects were then randomized to objective-based training with an angled-telescope simulator (EndoTower; Verefi Technologies, Elizabethtown, PA) versus no training, followed by reassessment of performance.
                Initially, there were no significant differences between VR-trained (n = 9) and control (n = 10) groups. After training, object visualization, scope orientation, and horizon error scores were significantly better in VR-trained than control groups; subject-matched improvement in orientation score was 50.9% versus 10.8% (P < .05).
                VR training in angled laparoscope use improves operative performance of novices. These data support growing evidence that VR training is highly effective in improving surgical skills outside of the clinical setting. New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients.
                A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments.
                In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance.
                Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement. As for any manual procedure, the learning curves for medical interventions can have undesirable phases, occurring mostly in the early experience of applying a technique. There have been impressive advances in endoscopic procedures during recent years, and there is an emerging trend that the number of procedures is increasing in parallel with these. In addition, the introduction of screening programs for colorectal cancer will also increase the numbers of procedures needed. Recent developments in medical simulation seem promising with regard to the possibility of "training out" undesirable parts of the learning curve outside the operating room. The aim of this study was to investigate whether the use of the AccuTouch flexible endoscopy simulator improves the early part of the learning curve in colonoscopy training.
                12 endoscopy trainees, 10 surgeons and two medical gastroenterologists, all with experience in gastroscopy but with no specific colonoscopy experience, were randomly assigned to either simulator training or to a control group. They all received the same theoretical study package and the training group practiced with the AccuTouch colonoscopy simulator until a predefined expert level of performance was reached. All trainees performed their first ten individual colonoscopies described in detail in a separate protocol.
                Trainees in the simulator-trained group performed significantly better (P=0.0011) and managed to reach the cecum in 52% of their cases (vs. 19% in the control group), and were 4.53 times more likely to succeed compared with the controls. Additionally, there was a significantly shorter procedure time and less patient discomfort in the hands of the simulator-trained group.
                Skills acquired using the AccuTouch simulator transfer well into the clinical colonoscopy environment. The results of this trial clearly support the plan to integrate simulator training into endoscopic education curricula.
Virtual reality training can supplement standard laparoscopic surgical training of apprenticeship and is at least as effective as video trainer training in supplementing standard laparoscopic training. Further research of better methodological quality and more patient-relevant outcomes are needed.