Studies: Surgery: Endoscopic

Ahmad, Asyia; Alnoah, Zaid; Kochman, Michael L.; Krevsky, Benjamin; Peikin, Steven R.; Mercogliano, Giancarlo; Bailey, Marie; Boynton, Robert and Reynolds, James C. Philadelphia GI Training Group; Philadelphia, PA, Camden, NJ, Wynnewood, PA. Endoscopic simulator enhances training of colonoscopy in a randomized, prospective, blinded trial. Gastrointestinal Endoscopy April 2003, 57(5): S1499.

The aim of this single blind, randomized, prospective, multi-center study was to determine the impact of using an endoscopic simulator (AccuTouch Endoscopy Simulator, Immersion Medical, Gaithersburg, MD) for the acquisition of skills to perform colonoscopy. Conclusion: The use of this endoscopic simulator enhanced the performance of colonoscopies by GI fellows within the first two months of training.

Anon. New endoscopy simulator helps train for needle aspiration. Laparoscopic Surgery Update. 2001;9(6):69.

Trainees need to perform a certain number of endoscopic procedures to achieve competence. Training on simulators is advantageous because it reduces the number of potentially life-threatening critical mistakes. The change in medical practice that limits education time and patient availability, and the increase in medical legal awareness, have contributed to the greater use of simulators in medical training and education. Simulators are of three types: mechanical, animal, and computer based. Progress in computer technology is expected to promote computer-based simulators. At present, the computer-based simulator is helpful in teaching upper and lower gastrointestinal endoscopy, for diagnostic and some therapeutic procedures. It has been used at workshops and live demonstrations performed during endoscopic meetings. It is predicted that with further technological improvement, training on simulators will become obligatory before performing on humans.

Bro-Nielsen M. Tasto JL. Cunningham R. Merril GL. PreOp endoscopic simulator: a PC-based immersive training system for bronchoscopy. Studies in Health Technology & Informatics. 62:76-82, 1999.

The high cost of simulators that offer adequate realism for training has been a major challenge for the simulation community. The cost of the computers alone has been too high for most training institutions to afford. We have met this challenge by developing the PreOp Endoscopic Simulator, our second generation of low-cost medical simulators. The PreOp system integrates multimedia, 3D graphics simulation, and force feedback technology on a PC. This paper discusses the challenges of this project and the trade-offs and solutions that we developed to overcome them. We discuss our process of analyzing and prioritizing the medical tasks necessary to correctly perform flexible bronchoscopy. In addition, we illustrate how we blended together simulation and multimedia technology to ensure adequate immersion and training efficacy, while keeping the system cost to a minimum.

Caversaccio M, Eichenberger A, Hausler R. Virtual simulator as a training tool for endonasal surgery. Am J Rhinol;2003;17(5):283-90. Department of Otorhinolaryngology, Head, and Neck Surgery, Inselspital, University of Bern, Switzerland.

BACKGROUND: Virtual simulation could be an important tool for medical and surgical training as well as education. The efficacy of a simulator for endoscopic nasal procedures in a training program was evaluated. METHODS: The simulator is a medical and scientific tool for visualizing and interacting with three-dimensional volumetric data. Twenty endonasal operations with chronic rhinosinusitis were simulated by two 3rd-year residents and proctored by the senior surgeon 1 day before the actual surgery was performed with an endoscope and computer-aided surgery. A questionnaire was established. RESULTS: The surgical simulator may provide a better understanding of the morphology of the paranasal sinuses with a minor impact on performance of endoscopy by junior residents. Disadvantages identified were time consumption, absence of force feedback, and subtle handling of the joysticks. CONCLUSION: The virtual simulator allows the nonendoscopically nasal trained surgeon to understand and practice endonasal surgery using real-patient data but failed to make an impact on operating room performance. Furthermore, the simulator's effectiveness was limited by the absence of force feedback, subtle handling of the joysticks, and considerable time consumption.

Cisler JJ. Martin JA. Logistical considerations for endoscopy simulators. Gastrointestinal Endoscopy Clinics of North America. 16(3):565-75, 2006 Jul.

A variety of endoscopy simulators have been produced during the last several decades. Multiple factors have influenced the types of simulators that have been developed and the ongoing evolution of existing models. Realistic simulation is only one issue in providing simulation-based training in GI endoscopy. Details such as cost, technologic limitations, management and availability of training facilities, personnel, animal welfare and the procurement, handling, and disposal of animal parts are all major factors when considering the options available among existing endoscopy simulators. Table 1 summarizes the logistical factors for the different types of endoscopy simulator. These considerations clearly are of major importance in simulator design and development and in the conceptualization and organization of simulator-based curricula and courses.

Clark JA. Volchok JA. Hazey JW. Sadighi PJ. Fanelli RD. Initial experience using an endoscopic simulator to train surgical residents in flexible endoscopy in a community medical center residency program. Current Surgery 2005;62(1):59-63.

INTRODUCTION: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins. METHODS: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed. RESULTS: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%. CONCLUSIONS: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

Datta VK, Mandalia M, Mackay SD and Darzi AW. Academic Surgical Unit, Imperial College School of Medicine, St. Mary's Hospital, London, UK. Evaluation and validation of a virtual reality based flexible sigmoidoscopy trainer. Gut 2001, supl I, 48: A1-A124. PDF: http://www.immersion.com/medical/docs/gut_study.pdf.

The results show that the AccuTouch® Endoscopy Simulator (formerly called PreOp™) is a valid discriminator of flexible sigmoidoscopic experience.

Di Giulio E, Fregonese D, Casetti T, Cestari R, Chilovi F, D'Ambra G, Di Matteo G, Ficano L & Delle Fave G. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial. Gastrointestinal Endoscopy 2004;60(2):196-200.

Dumay ACM. Jense GJ. Endoscopic surgery simulation in a virtual enviroment. Computers in Biology & Medicine. Vol. 25(2)(pp 139-148), 1995.

The minimally invasive nature of endoscopic surgery allows operations to be performed on patients through small incisions, often under local anaesthesia. Patient recovery times and cosmetic detriment are thus greatly reduced, while overall quality of care is improved. Presently, surgeons are trained to perform endosurgical procedures in a number of ways: practising with surgical training devices, using animal models and assisting experienced surgeons. In this paper, the focus is on answering the key question: 'Can virtual environment technology assist surgeons in training and maintaining endoscopic surgery skills'? Initial developments towards surgical simulators have clearly demonstrated the great potential of virtual environment technology for surgical training purposes. Breakthroughs towards surgery are expected within the next 5 to 10 years.

Edmond CV Jr. Impact of the endoscopic sinus surgical simulator on operating room performance. Laryngoscope 2002;112(7 Pt 1):1148-58.

OBJECTIVES/HYPOTHESIS: The aim of this study is to evaluate an endoscopic sinus surgical simulator (ESS) as a training device and to introduce a methodology to assess its impact on actual operating room performance. STUDY DESIGN: Prospective evaluation of the endoscopic sinus surgical simulator as a trainer. METHODS: Ten junior and senior ear, nose and throat residents served as subjects, some of whom had prior training with the simulator. The evaluation team collected several measures, which were analyzed for a statistical correlation, including simulator scores, operating room performance rating, ratings of videotaped operating room procedures, and surgical competency rating. RESULTS: These findings suggest the ESS simulator positively affects initial operating room performance across all measures as judged by senior surgeons rating anonymous videotapes of those procedures. The two simulation-trained residents were rated consistently better than the other two residents across all measures. These differences approached statistical significance for two items: anterior ethmoidectomy (P =.06; P CONCLUSIONS: The endoscopic sinus surgical simulator is a valid training device and appears to positively impact operating room performance among junior otolaryngology residents.

Garuda, Sanjay; Keshavarzian, Ali; Losurdo, John; Brown, Michael D.; Rush Presbyterian St. Luke's Medical Center, Chicago, IL. Efficacy of a computer-assisted endoscopic simulator in training residents in flexible sigmoidoscopy. Presented as a poster abstract at the 2002 ACG.

Use of a simulator (AccuTouch Endoscopy Simulator, Immersion Medical, Gaithersburg, MD) reduced the number of procedures required to reach competency.

Gerson LB. Van Dam J. Technology review: the use of simulators for training in GI endoscopy. Gastrointestinal Endoscopy. 2004 Dec; 60(6): 992-1001. (23 ref)

Gessner CE. Jowell PS. Baillie J. Novel methods for endoscopic training. [Review] [54 refs] Gastrointestinal Endoscopy Clinics of North America. 5(2):323-36, 1995 Apr.

The development of past, present, and future endoscopic training methods is described. A historical perspective of endoscopy training guidelines and devices is used to demonstrate support for the use of novel endoscopic training techniques. Computer simulation of endoscopy, interactive learning, and virtual reality applications in endoscopy and surgery are reviewed. The goals of endoscopic simulation and challenges facing investigators in this field are discussed, with an emphasis on current and future research.

Grantcharov TP. Kristiansen VB. Bendix J. Bardram L. Rosenberg J. Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. British Journal of Surgery 2004;91(2):146-50.

BACKGROUND: This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Greenwald D. Cohen J. Evolution of endoscopy simulators and their application. Gastrointestinal Endoscopy Clinics of North America. 2006 Jul; 16(3): 389-406. (52 ref)

Significant advances already have been made in the use of simulators for teaching and training in GI endoscopy. Indeed, during the past decade the evolution and improvement of these devices is readily apparent with each passing year. Doubtless, these advances have led to the increased availability and popularity of simulator-based hands-on workshops. Simulator-based skills assessment remains a relatively undeveloped field, awaiting increased realism and the development and validation of proper tests. Still, static models, ex vivo artificial models, ex vivo animal models, and computer simulators collectively represent a substantial and powerful tool for education and training in GI endoscopy. It is easy to foresee a day when hands-on training using simulators will be readily available outside the gastroenterology fellowship setting. With the progression of technology and the continuous introduction of new devices and procedures will come a parallel, compelling need for hands-on, simulator-based experience with all such new tools and techniques.

Hochberger J. Matthes K. Maiss J. Koebnick C. Hahn EG. Cohen J. Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone.[see comment]. Gastrointestinal Endoscopy 2005;61(2):204-15.

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS: Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS: Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS: compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.

Long V. Kalloo AN. AccuTouch Endoscopy Simulator: development, applications and early experience. Gastrointestinal Endoscopy Clinics of North America 2006;16(3):479-87.

These studies suggest that there are several potential advantages to use of the AccuTouch simulators, including (1) improvement of the endoscopic training of trainees before patient contact, (2) possible evaluation for procedural competency, and (3) possible cost savings, increasing the productivity of faculty while the trainees are developing competency using the trainers. Other potential advantages might include the training of endoscopists in new diagnostic and therapeutic techniques and even new devices before patient contact. With continued improvement in software and hardware, endoscopic simulators will become an integral part of endoscopic training programs.

Manyak MJ. Santangelo K. Hahn J. Kaufman R. Carleton T. Hua XC. Walsh RJ. Virtual reality surgical simulation for lower urinary tract endoscopy and procedures. Journal of Endourology. 16(3):185-90, 2002 Apr.

BACKGROUND AND PURPOSE: To provide a realistic experience of lower urinary tract endoscopic procedures, we have developed and continue to expand a computer-based surgical simulator that incorporates a surgical tool interface with anatomic detail and haptic feedback. METHODS: Surface-based geometric data for the lower urinary tract were generated from the National Library of Medicine Visible Human dataset. The three-dimensional texture map of the surface geometry was developed from recorded endoscopic video procedures. Geometry and associated texture maps were rendered in real time using the Silicon Graphics Extreme Impacts program. The surgical interface device incorporated all normal ranges of motion and resistance that occur within an actual operative environment. The hands-on endoscopic device attached to the interface device was provided by Circon-ACMI, Inc. Urologic residents evaluated the program for correlation with actual endoscopic procedures. RESULTS: Texture-mapped digitized images provided a close anatomic similarity to actual videoendoscopic images. Virtual endoscopy of the lower urinary tract was reproducible and closely simulated actual visual and tactile endoscopic experience. CONCLUSIONS: Virtual reality surgical simulation is feasible for a variety of lower urinary tract procedures. This system coordinates visual perception with appropriate haptic feedback in both longitudinal and rotational axes. These types of procedures may be incorporated into future educational experiences for urologists to introduce new techniques and to provide documentation of surgical experience.

Maiss J. Wiesnet J. Proeschel A. Matthes K. Prat F. Cohen J. Chaussade S. Sautereau D. Naegel A. Krauss N. Peters A. Hahn EG. Hochberger J. Objective benefit of a 1-day training course in endoscopic hemostasis using the "compactEASIE" endoscopy simulator. Endoscopy 2005;37(6):552-8.

BACKGROUND AND STUDY AIMS: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 as a training model for interventional endoscopy. Objective evidence of the benefits of training with this model has not previously been published. As part of two long-term projects, the benefits of a 1-day training course with the "compactEASIE" simulator were evaluated. MATERIALS AND METHODS: Fourteen American and 18 French gastroenterology fellows were enrolled. These fellows were participants in the intensive groups performing training in endoscopic hemostasis, with a total number of 28 fellows in New York and 36 in France. Gastrointestinal endoscopy faculty members in New York and France evaluated and timed the fellows in four disciplines to establish baseline skills (manual skills; injection and coagulation; Hemoclip application; and variceal ligation) with the compactEASIE simulator. The trainees were reevaluated after an intensive 1-day course (with two or three fellows and one instructor per station), also including preparation and assistance for each procedure. The assessment (overall and parts) was done by expert tutors using an ordinal scale ranging from 1 to 10 (1 = poorest, 10 = best), recording also mistakes and performance time. The compactEASIE simulator, equipped with an upper gastrointestinal organ package and an artificial blood perfusion system, was used as the training tool. RESULTS: A highly significant improvement ( P CONCLUSIONS: A 1-day training course on endoscopic hemostasis using the compactEASIE simulator is capable of improving the performance of hemostasis procedures. Long-term effects of repeated training sessions are currently subject of collaborative studies in New York and France.

Matthes K. Cohen J. Kochman ML. Cerulli MA. Vora KC. Hochberger J. Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop. Gastrointestinal Endoscopy 2005;62(6):921-7.

BACKGROUND: The efficacy of an intensive hands-on training in endoscopic hemostasis on the compactEASIE simulator has been previously demonstrated in a randomized prospective trial. In the current study, we evaluated how quickly and effectively new tutors, without simulator training experience, are able to acquire teaching skills in endoscopic hemostasis. METHODS: Five tutors with prior Erlangen Active Simulator for Interventional Endoscopy (EASIE) teaching experience instructed 7 endoscopists without prior EASIE experience on how to teach when using the model. These new tutors then independently conducted a workshop for 8 fellows in 4 hemostasis techniques. Results were compared with a historical control trained similarly by experienced tutors. Two one-day workshops in endoscopic hemostasis on the compactEASIE ex vivo endoscopy simulator were conducted in a category A hospital in New York City, New York. Skill scores at the end of training were compared with baseline skills assessments, and qualitative ratings of the new tutors were obtained from both the trainees and the experienced tutors. RESULTS: Significant improvement was achieved by the fellows in all 4 skills areas. Both the expert tutors and the trainees consistently rated the teaching skill of the new tutors highly. Fellows' skill acquisition using new tutors was of similar magnitude to that achieved in the prior EASIE trial using experienced trainers teaching the fellows. CONCLUSIONS: It is feasible to conduct an effective EASIE train-the-trainer course in one day. Tutors trained in this manner are able to provide a similar educational experience with objective improvement in trainee skill to experts who have conducted many hands-on workshops.

Panait L. Rafiq A. Tomulescu V. Boanca C. Popescu I. Carbonell A. Merrell RC. Telementoring versus on-site mentoring in virtual reality-based surgical training. Surgical Endoscopy. 20(1):113-8, 2006 Jan.

BACKGROUND: Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training. METHODS: In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured. RESULTS: Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p CONCLUSIONS: Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.

Rolfsson G. Nordgren A. Bindzau S. Hagstrom JP. McLaughlin J. Thurfjell L. Training and assessment of laparoscopic skills using a haptic simulator. Studies in Health Technology & Informatics. 85:409-11, 2002.

Surgical simulation is a promising technique for training of laparoscopic surgery. Computer based simulation provides not only a cost effective alternative to traditional training but also a way to assess the surgeons performance. In this paper, we present a haptic simulator that allows for training and assessment of basic laparoscopic skills. The skills trained are modeled around a cholecystectomy procedure and include bi-manual dissection, clips setting, catheter insertion and cutting. The system uses accurate anatomic models of the organs involved in the procedure. This combined with effective methods for soft tissue deformation and haptic feedback, giving the surgeon a precise feeling of the interaction between organs and surgical instruments, provides a realistic training environment. The system has been designed with procedural training in mind and by putting together the individual tasks it will be possible to train on performing a complete cholecystectomy procedure.

Rotnes JS. Kaasa J. Westgaard G. Eriksen EM. Hvidsten PO. Strom K. Sorhus V. Halbwachs Y. Haug E. Grimnes M. Fontenelle H. Ekeberg T. Thomassen JB. Elle OJ. Fosse E. A tutorial platform suitable for surgical simulator training (SimMentor). Studies in Health Technology & Informatics. 85:419-25, 2002.

BACKGROUND: The introduction of simulators in surgical training entails the need to develop pedagogic platforms adapted to the potentials and limitations provided by the information technology. As a solution to the technical challenges in treating all possible interaction events and to obtain a suitable pedagogic approach, we have developed a pedagogic platform for surgical training, SimMentor. METHODS: In SimMentor the procedure to be practiced is divided into a number of natural phases. The trainee will practice on one phase at a time, however he can select the sequence of phases arbitrarily. A phase is taught by letting the trainee alternate freely between 2 modes: 1: A 3-dimensional animated guidance designed for learning the objectives and challenges in a procedure. 2: An interactive training session through the instrument manipulator device designed for training motoric responses based on visual and tactile responses produced by the simulator. The two modes are interfaced with the same virtual reality platform, thus SimMentor allows a seamless transition between the modes. RESULTS: We have developed a prototype simulator for robotic assisted endoscopic CABG (Coronary Artery Bypass Grafting) procedure by first focusing on the anastomosis part of the operation. Tissue, suture and instrument models have been developed and integrated with a simulated model of a beating heart comprises the elements in the simulator engine that is used in construction a training platform for learning different methods for performing a coronary anastomosis procedure. CONCLUSION: The platform is designed for integrating the following features: 1) practical approach to handle interactivity events with flexible-objects 3D simulators, 2) methods for quantitative evaluations of performance, 3) didactic presentations, 4) effective ways of producing diversity of clinical and pathological training scenarios.

Satava RM. Laparoscopic surgery, robots, and surgical simulation: moral and ethical issues. [Review] [11 refs] Seminars in Laparoscopic Surgery. 9(4):230-8, 2002 Dec.

Schijven MP. Jakimowicz JJ. Introducing the Xitact LS500 laparoscopy simulator: toward a revolution in surgical education. [Review] [19 refs] Surgical Technology International. 11:32-6, 2003.

Minimal invasive surgery has become the primary technique-of-choice for uncomplicated, symptomatic cholelithiasis. Skills needed for performing laparoscopic cholecystectomy cannot be extrapolated directly from the open surgical technique. An obvious need exists for a valid, objective, and repetitive teaching and training setting for minimally invasive surgery. The surgical skills laboratory may have an important role in acquisition of such skills. New technologies, such as virtual-reality surgical simulation, provide objective, trainee-friendly methods of training. Both surgeons and residents believe it is important to train residents in minimally invasive surgical techniques, using virtual-reality surgical simulation within the context of the surgical skills laboratory. This article highlights the features of one of the most promising technical novelties in the area of surgical virtual- reality simulation, the Xitact LS500 laparoscopy simulator.

Sedlack RE. Simulators in training: defining the optimal role for various simulation models in the training environment. Gastrointestinal Endoscopy Clinics of North America. 2006 Jul; 16(3): 553-63. (28 ref)

Clearly, the potential applications for simulation training in endoscopy are vast. Endoscopy models may serve as a platform to introduce new skills, to maintain proficiency, or even to assess competency. As these applications are explored fully, the strengths and weaknesses of specific devices will dictate their roles. Educators must ensure that these roles are founded on reliable research but remain mindful that simulators are only tools to augment clinical training, with the goal of benefiting both student and patient, and are not a replacement for patient-based experience.

Sedlack, Robert E. and Kolars, Joseph C. Department of Gastroenterology, Mayo Clinic, Rochester, MN. Colonoscopy curriculum development and performance-based assessment criteria on a computer-based endoscopy simulator. Academic Medicine 2002; 77(7): 750-751. PDF: http://www.immersion.com/medical/docs/colonoscopycurriculum.pdf.

Using the commercially available computer-based colonoscopy simulator (AccuTouch Endoscopy Simulator, Immersion Medical, Gaithersburg, MD), the authors concluded that simulator-based training would be most beneficial in the early stages of colonoscopy training. Trainees at the Mayo Clinic must now complete 9 hours of simulator training involving approximately 25 virtual procedures and then demonstrate certain performance standards on the simulator before advancing to live-patient colonoscopies.

Sedlack, Robert E. and Kolars, Joseph C. Department of Gastroenterology, Mayo Clinic, Rochester, MN. The effects of computer simulator training on patient-based sigmoidoscopy by residents. Gastrointestinal Endoscopy April 2003, 57(5): S1495.

For the first time, computer-based sigmoidoscopy simulator training demonstrates a direct patient benefit- reduced discomfort during flexible sigmoidoscopy. Study performed on an AccuTouch Endoscopy Simulator (Immersion Medical, Gaithersburg, MD).

Sedlack RE. Kolars JC. Alexander JA. Computer simulation training enhances patient comfort during endoscopy. Clinical Gastroenterology & Hepatology 2004;2(4):348-52.

BACKGROUND & AIMS: Computer-based endoscopy simulator (CBES) training's impact on patient-based outcomes has never been examined. This study examines whether the endoscopy skills of trainees are improved and patient discomfort is reduced as a result of CBES training. METHODS: From July 2001-June 2002, 38 residents received either 1 week of patient-based training (PBT) alone in flexible sigmoidoscopy (FS) or 3 hours of simulator-based training (SBT) before a week of training in FS. Patients completed questionnaires grading the discomfort experienced during endoscopy (1, no pain; 10, worst pain of life). In addition, residents' performance was graded by the supervising staff and themselves with 8 performance parameters by using a 1-10 Likert scale (1, strongly agree; 5, neutral; 10, strongly disagree). RESULTS: Nineteen SBT and 19 PBT residents performed 150 and 175 FS, respectively. During this same period, staff completed 585 FS. The median patient discomfort score for SBT residents was significantly less than for PBT residents, 3 (25%-75% interquartile range [IQR], 2-5) vs. 4 (IQR, 2-6) (P CONCLUSIONS: Increased patient comfort resulted from simulation training, demonstrating that CBES training has a direct benefit to the patient. Although no measurable impact on residents' performance skills was observed, we do demonstrate that residents perceive themselves as having acquired greater endoscopic skills in contrast to staff evaluations.

Seymour NE. Gallagher AG. Roman SA. O'Brien MK. Bansal VK. Andersen DK. Satava RM. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Annals of Surgery 2002;236(4):458-63; discussion 2002 Oct.:463-4.

OBJECTIVE: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. SUMMARY BACKGROUND DATA: 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. METHODS: 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). RESULTS: 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 CONCLUSIONS: 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.

Strom P. Kjellin A. Hedman L. Johnson E. Wredmark T. Fellander-Tsai L. Validation and learning in the Procedicus KSA virtual reality surgical simulator. Surgical Endoscopy 2003;17(2):227-31.

BACKGROUND: Advanced simulator training within medicine is a rapidly growing field. Virtual reality simulators are being introduced as cost-saving educational tools, which also lead to increased patient safety. METHODS: Fifteen medical students were included in the study. For 10 medical students performance was monitored, before and after 1 h of training, in two endoscopic simulators (the Procedicus KSA with haptic feedback and anatomical graphics and the established MIST simulator without this haptic feedback and graphics). Five medical students performed 50 tests in the Procedicus KSA in order to analyze learning curves. One of these five medical students performed multiple training sessions during 2 weeks and performed more than 300 tests. RESULTS: There was a significant improvement after 1 h of training regarding time, movement economy, and total score. The results in the two simulators were highly correlated. CONCLUSION: Our results show that the use of surgical simulators as a pedagogical tool in medical student training is encouraging. It shows rapid learning curves and our suggestion is to introduce endoscopic simulator training in undergraduate medical education during the course in surgery when motivation is high and before the development of "negative stereotypes" and incorrect practices.

Tasto JL, Verstreken K, Brown JM, Bauer JJ. PreOp endoscopy simulator: from bronchoscopy to ureteroscopy. Stud Health Technol Inform. 2000;70:344-9. HT Medical Systems, Inc., Gaithersburg, Maryland 20878, USA.

The high cost of virtual reality simulators has posed a major obstacle to the widespread adoption of simulators for medical training. HT Medical broke through this cost barrier by developing the PreOp Flexible Bronchoscopy simulator, a realistic training simulation system that integrates force feedback, multimedia, and 3D graphics on a PC. We are currently extending the PreOp platform so that it can simulate other endoscopic procedures. This paper discusses our efforts to extend the platform to simulate flexible sigmoidoscopy and ureteroscopy.

Tsai CL, Heinrichs WL. Acquisition of Eye-hand Coordination Skills for Videoendoscopic Surgery. The Journal of the American Association of Gynecological Laparoscopists 1994 Aug;1(4, Part 2):S37. Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford Endoscopy Center for Training and Technology, 750 Welch Road, Stanford, CA 94305.

Evaluation of eye-hand coordination skills in relation to experiential human factors may lead to improved instruction for videoendoscopic surgical skills acquisition. Twenty-nine subjects (medical students or residents in surgical specialties) volunteered to perform three exercises of increasing complexity in an "inanimate" trainer system that simulated the eye-hand coordination tasks inherent in a laboratory videoendoscopic surgical environment. Fourteen subjects participated in a biweekly practice program of 4 weeks duration using an inanimate trainer. Fifteen subjects had no practice on the laparoscopic trainer during the 4 weeks. Both groups were tested after demonstration on three exercises at the beginning and end of a 4 week period and all performed the procedures in solitude. Both groups of subjects increased performance levels (time and accuracy) over the four weeks, but improvement was significantly greater for the practicing subjects. After eight sessions, convergence of performance levels was observed, but plateauing of performance levels was not evident, even with the simple paradigms evaluated. To investigate what factors contribute to learning, subjects were assessed with respect to their surgical experiences, personality, and self-evaluated motor skills. Subjects with prior endoscopic surgical experience, interest in mechanical activities (as measured by the Strong Interest Inventory), or regular engagement in video game play tended to be more skillful initially, but demonstrated less improvement in performance levels after practice than subjects who had lower levels of experience, interest, or video game play. Manual dexterity (as measured by the Purdue Pegboard Manual Dexterity Test) was positively related to the degree of observed improvement. We conclude that "inanimate" videoendoscopic paradigms offer relatively inexpensive and useful training exercises for acquiring basic eye-hand coordination skills. Relevance for animate laboratory skills requirements are probable but can only be inferred. Subjects with manual dexterity skills used in video games may perform better initially in the inanimate videoendoscopic situation but this advantage is shortlived.

Uribe JI. Ralph WM Jr. Glaser AY. Fried MP. Learning curves, acquisition, and retention of skills trained with the endoscopic sinus surgery simulator. American Journal of Rhinology 2004;18(2):87-92.

BACKGROUND: As an initial step in evaluating the effectiveness of training otolaryngology residents on an endoscopic sinus surgery simulator (ES3), we have assessed the ability of the ES3 to train persons inexperienced in sinus surgery (medical students) to perform certain simulated procedural tasks needed in endoscopic sinus surgery (ESS). METHODS: A total of 26 medical students were enrolled and trained on the ES3 following a preset protocol in the three levels of difficulty and complexity (novice, intermediate, and advanced modes). RESULTS: In the novice mode (three-dimensional abstract images are used to teach the use of endoscopic surgical equipment), medical students displayed a steep learning curve within three to five trials on the simulator and after an additional four to five trials, they reached a plateau in their learning curves to within 90% of that of experienced sinus surgeons. In the intermediate mode (ESS is performed on a simulated patient with teaching aids), medical students were able to reach a plateau in their learning curves to within 80% of that of experienced surgeons. This performance was sustained in the advanced mode (simulated sinus surgery without teaching aids). We observed that medical students, who had novice or intermediate mode training interrupted with an interval of 11-60 days, were able to resume their training without deviation from their prior learning curves. CONCLUSION: Intensive, proctored training on the ES3 can train inexperienced persons to perform simulated ESS within a reasonable approximation of the performance of experienced sinus surgeons on the ES3 and the training that an inexperienced person receives on the simulator is not short term but is retained over a period of at least 2 months.

Watterson JD. Beiko DT. Kuan JK. Denstedt JD. Randomized prospective blinded study validating acquistion of ureteroscopy skills using computer based virtual reality endourological simulator. Journal of Urology 2002;168(5):1928-32.

PURPOSE: Surgical simulation has emerged in the last decade as a potential tool for aiding acquisition of technical skills, including anesthesia protocols, trauma management, cardiac catheterization and laparoscopy. We evaluate and validate the use of a computer based ureteroscopy simulator (URO Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic skills. MATERIALS AND METHODS: We assessed 20 novice trainees for the ability to perform basic ureteroscopic tasks on a computer based ureteroscopy simulator. Participants were randomized to receive individualized mentored instruction or no additional training, and subsequently underwent post-testing. Pre-training and post-training improvement in performance was assessed by objective simulator based measurements. Subjective overall performance was rated using a validated endourological global rating scale by an observer blinded to subject training status. RESULTS: Demographics and pre-test scores were similar between groups. Post-testing revealed a significant effect of training on objective and subjective measurements. Spearman rank correlation demonstrated a significant association between objective simulator based measurements and the endourological global rating scale. CONCLUSIONS: Use of a computer based ureteroscopy simulator resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. Results of this study demonstrate the use of a virtual reality ureteroscopy simulator in endourological training. Correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the ureteroscopy simulator for the assessment of ureteroscopic skills.

Wilhelm DM. Ogan K. Roehrborn CG. Cadeddu JA. Pearle MS. Assessment of basic endoscopic performance using a virtual reality simulator.[see comment]. Journal of the American College of Surgeons 2002;195(5):675-81.

BACKGROUND: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. STUDY DESIGN: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). RESULTS: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p CONCLUSIONS: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.

Studies: Endoscopic diagnostic and surgical simulators (37)