Updated: 8 Jan. 2007.
Aboud E, Suarez CE, Al-Mefty O, Yasargil MG. New alternative to animal models for surgical training. ATLA 2004;32 Suppl 1:501-508.
[Waste organ perfusion simulators.]
Allen SW & Chambers JN. Computer-assisted instruction of fundamental surgical motor skills. Journal of Veterinary Medical Education 1997;24(1):2-5.
A computer-assisted learning program, "The Surgical Techniques Auto-Tutorial Program," was developed for use as an introductory training tool of fundamental surgical motor skills such as instrument handling and knot tying. The program was well received by veterinary medical students. Although computer-assisted instruction was as effective as traditional methods in helping the students develop and retain some skill, direct instructor contact was necessary for the retention of other skills such as knot tying. It is concluded that when followed by instructor contact laboratories allowing feedback and reinforcement of operative skills, computer-assisted instruction was found to be a helpful introductory training tool for the development of fundamental surgical motor skills.
Anon. Still more on Tufts' student
surgery program. Journal of the American Veterinary Medical Association
1990 Apr 01;196(7):1002-1003, 1006.
At the Veterinary Surgery Clinic of the University of Zurich models were
developed in cooperation with a surgery professor from the United States. These
models allow to practice manual dexterity of the students in basic surgical
techniques. Additionally, proper assisting in these basic surgical techniques
can also be practiced using these models. A further advantage represents the
facts that these models do not have a scent because they are manufactured from a
special polyurethane facilitating easy transport of these models to allow
additional practicing at the students leisure at home. The result of this
education, which was initiated three years ago, is better manual dexterity in
surgical techniques, a dexterity which is achieved without sacrificing
laboratory animals. This represents a big advantage for the students and later
the veterinarian.
Awwad AM. A training card for microsurgery. Microsurgery 1984;5:160.
Bate M. 2000. Practical experience with DASIE (Dog Abdominal Surrogate Instructional Exercise). In Bate M. (Ed.). Australian Veterinarians in Ethics, Research & Teaching (AVERT) Proceedings of the Annual Conference held at Rendezvous Observation City, Perth, 27 – 28 June 2000; Artarmon, NSW, Australia: AVERT. 2001:51 - 56.
Good article on the usefulness of the DASIE, advantages and disadvantages, and its use in teaching animal experimenters basic surgical skills at the University of Newcastle, NSW, Australia. Has 5 great photos of the DASIE in use.
Bauer, M.S., N. Glickman, L. Glickman, J.P. Toombs & P. Bill. Evaluation of the effectiveness of a cadaver laboratory during a fourth-year veterinary surgery rotation. Journal of Veterinary Medical Education 1992. 19(2): 77–84.
Learning outcomes were similar between two groups of fourth-year veterinary students, one who were taught surgery using a terminal and cadaver laboratory format, the other taught using survival laboratories.
Bauer MS, Glickman N, Salisbury SK, Toombs JP, Prostredny JM. Surgical vs terminal animal laboratories to teach small animal surgery. Journal of Veterinary Medical Education 1992;19(2):54-58.
Bernardo A. Preul MC. Zabramski JM. Spetzler RF. A three-dimensional interactive virtual dissection model to simulate transpetrous surgical avenues.[see comment]. Neurosurgery. 52(3):499-505; discussion 504-5, 2003 Mar.
OBJECTIVE: This project involves the development of a three-dimensional surgical simulator called interactive virtual dissection, which is designed to teach surgeons the visuospatial skills required to navigate through a transpetrosal approach. METHODS: A robotically controlled microscope is used for surgical planning and data collection. The spatial anatomic data are recorded from sequentially deeper cadaveric head dissections as a series of superimposed anatomic pictures in stereoscopic digital format. The sequential series of images are then merged to form the final virtual representation. RESULTS: The current three-dimensional virtual reality simulator allows the user to drill the petrous bone progressively deeper and to identify crucial structures much like an experienced surgeon drilling the petrous bone. The program allows surgeons and trainees to manipulate the virtual "surgical field" by interacting with the surgical anatomy. The interactive system functions on a desktop computer. CONCLUSION: The ability to visualize and understand anatomic spatial relationships is crucial in surgical planning, as is a surgeon's confidence in performing the surgery. The virtual reality simulator does not replace the need for practicing surgery on cadavers. However, it is designed to facilitate, via stereoscopic projection, learning how to manipulate a drill in complicated or unfamiliar surgical approaches (e.g., a transpetrosal approach).
Bijleveld K. Audiovisual aids in the teaching of veterinary surgery. Tijdschrift voor Diergeneeskunde. 98(20):955-6, 1973 Oct 15.
Block GI. Student's opinion on surgery alternative program. Journal of the American Veterinary Medical Association 1990 Jul 01;197(1):12-13, 16.
Bowman, K. F. Tate, L. P. Bristol, D. G. Morbidity and mortality associated with survival surgery in a large animal surgery teaching laboratory. [Abstract only. Conference paper] Veterinary Surgery. 1992. 21: 5, 385.
Buyukmihci N. 2002. Non-violence in surgical training. Unpublished. www.avar.org.
This excellent essay by Veterinary Professor Buyukmihci argues that it is possible to teach veterinary surgery without harmful animal usage; suggests possible means of doing so; and examines the use of cadavers and of pound dogs. Additional useful information and quotations are given in the reference list.
Carpenter LG, Piermattei DL, Salman MD,
Orton EC, Nelson AW, Smeak DD, Jennings PB Jr, Taylor RA. A comparison of
surgical training with live anesthetized dogs and cadavers. Veterinary
Surgery 1991 Nov-Dec;20(6):373-378.Department of Clinical Sciences, College
of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort
Collins, USA.
Cadavers were compared with live anesthetized dogs for their effectiveness as
models for surgical training of veterinary medical students. One group of
students was trained using cadavers, and a peer group was trained using live
anesthetized dogs. Both groups then performed an intestinal anastomosis using a
live subject. The time to completion of the procedure was recorded. The
anastomoses and celiotomy closures were evaluated. Each anastomosis was isolated
and pressure tested. Reviewers blindly scored each surgical team's performance
based on actual inspection of the surgical site and on viewing videotapes of the
procedure. The participants' attitudes toward the use of live animals in
teaching and research were documented before and after training. No
statistically significant differences could be detected between the two groups.
The results suggest that some substitution of cadavers for live dogs in surgical
training might be feasible.
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.
Chaer RA. Derubertis BG. Lin SC. Bush HL. Karwowski JK. Birk D. Morrissey NJ. Faries PL. McKinsey JF. Kent KC. Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study. Annals of Surgery 2006;244(3):343-52.
OBJECTIVES: Surgical simulation has been shown to enhance the training of general surgery residents. Since catheter-based techniques have become an important part of the vascular surgeon's armamentarium, we explored whether simulation might impact the acquisition of catheter skills by surgical residents. METHODS: Twenty general surgery residents received didactic training in the techniques of catheter intervention. Residents were then randomized with 10 receiving additional training with the Procedicus, computer-based, haptic simulator. All 20 residents then participated in 2 consecutive mentored catheter-based interventions for lower extremity occlusive disease in an OR/angiography suite. Resident performance was graded by attending surgeons blinded to the resident's training status, using 18 procedural steps as well as a global rating scale. RESULTS: There were no differences between the 2 resident groups with regard to demographics or scores on a visuospatial test administered at study outset. Overall, residents exposed to simulation scored higher than controls during the first angio/OR intervention: procedural steps (simulation/control) (50 +/- 6 vs. 33 +/- 9, P = 0.0015); global rating scale (30 +/- 7 vs. 19 +/- 5, P = 0.0052). The advantage provided by simulator training persisted with the second intervention (53 +/- 6 vs. 36 +/- 7, P = 0.0006); global rating scale (33 +/- 6 vs. 21 +/- 6, P = 0.0015). Moreover, simulation training, particularly for the second intervention, led to enhancement in almost all of the individual measures of performance. CONCLUSION: Simulation is a valid tool for instructing surgical residents and fellows in basic endovascular techniques and should be incorporated into surgical training programs. Moreover, simulators may also benefit the large number of vascular surgeons who seek retraining in catheter-based intervention.
Champion HR. Gallagher AG. Surgical simulation - a 'good idea whose time has come'. British Journal of Surgery. 90(7):767-8, 2003 Jul.
Chou B. Handa VL. Simulators and virtual reality in surgical education. Obstetrics and Gynecology Clinics of North America. 2006 Jun; 33(2): 283-96. (36 ref)
This article explores the pros and cons of virtual reality simulators, their abilities to train and assess surgical skills, and their potential future applications. Computer-based virtual reality simulators and more conventional box trainers are compared and contrasted. The virtual reality simulator provides objective assessment of surgical skills and immediate feedback further to enhance training. With this ability to provide standardized, unbiased assessment of surgical skills, the virtual reality trainer has the potential to be a tool for selecting, instructing, certifying, and recertifying gynecologists.
Crosby NL, Clapson JB, Buncke HJ, Newlin L. Advanced non-animal microsurgical exercises. Microsurgery 1995;16(9):655-658.
Cuschieri A. Training and simulation. [Journal: Review] Minimally Invasive Therapy & Allied Technologies: Mitat. Vol. 10(2)(pp 67-74), 2001.
Surgical training is a complex process that continues throughout the professional careers of surgeons. Significant changes in training have taken place during the past two decades, stimulated by the introduction of endoscopic surgery. Simulation is used increasingly for both training and assessment of surgeons in addition to the well-established apprenticeship systems. Currently, surgical and medical simulation is undertaken within the confines of skills laboratories. As virtual-reality simulators improve, skills laboratories will transform into virtual-reality simulation centres. Surgical simulation ensures that the learning curve is completed without jeopardising the outcome of patients, or using live animals.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11371295&dopt=Abstract.
In the last academic year, a training
period in a surgical skills laboratory, using plastic models, was included as a
part of the 'Cirurgia 3' ('Surgery 3', 6th year) programme of Faculdade Medicina
Lisboa. To evaluate the training period, a structured, anonymous questionnaire
was administered at the end, seeking students' responses on their satisfaction
in attending the course. A global view of the answers points out students'
favourable opinion of the laboratory-training period: concerning students'
perceived goals for attending the course, a high degree of satisfaction was
reported (globally 73% of computed scores were rated as 'good' or 'very good');
the teaching/learning environment and the delivered content got 90% 'very good'
and 'good' ratings; teaching staff performance got the highest percentage of
rating scores 'very good' and 'good' (95%). These ratings were dependent on
variables that are unlikely to be a reflection only of glamour and seduction
(clear explanations and clear demonstration of each component of the skill) and
were less dependent on other variables such as 'enthusiasm for teaching' and
'relationship with students', which could be expected to be influenced by the
charisma of the tutors. Helping students learn and train in surgical skills in a
laboratory is challenging and our results affirm that the environment and the
content were valuable for the understanding of the subject, while sessions
planning and appropriate teaching technique are essential when practical skills
are to be taught and learned.
Dennis MB. Alternative training methods II: Incorporating inanimate surgical models. Lab Animal 1999;28(5):32-36.
DeYoung DJ, Richardson DC. Teaching the principles of internal fixation of fractures with plastic bone models. Journal of Veterinary Medical Education 1987;14:30-31.
Dunayer E. More on Tufts' student surgery program. Journal of the American Veterinary Medical Association 1990 Jan 15;196(2):184.
Fanua SP, Kim J, Shaw Wilgis EF. Alternative model for teaching microsurgery. Microsurgery 2001;21(8):379-382.
Describes the use of medical grading tubes and surgical gloves to practice suturing, end-to-end, end-to-side and side-to-side anastomoses and free graft placement.
France L. Lenoir J. Angelidis A. Meseure P. Cani MP. Faure F. Chaillou C. A layered model of a virtual human intestine for surgery simulation. Medical Image Analysis. 9(2):123-32, 2005 Apr.
In this paper, we propose a new approach to simulate the small intestine in a context of laparoscopic surgery. The ultimate aim of this work is to simulate the training of a basic surgical gesture in real-time: moving aside the intestine to reach hidden areas of the abdomen. The main problem posed by this kind of simulation is animating the intestine. The problem comes from the nature of the intestine: a very long tube which is not isotropically elastic, and is contained in a volume that is small when compared to the intestine's length. It coils extensively and collides with itself in many places. To do this, we use a layered model to animate the intestine. The intestine's axis is animated as a linear mechanical component. A specific sphere-based model handles contacts and self-collisions. A skinning model is used to create the intestine's volume around the axis. This paper discusses and compares three different representations for skinning the intestine: a parametric surface model and two implicit surface models. The first implicit surface model uses point skeletons while the second uses local convolution surfaces. Using these models, we obtained good-looking results in real-time. Some videos of this work can be found in the online version at doi: 10.1016/j.media.2004.11.006 and at www-imagis.imag.fr/Publications/2004/FLAMCFC04.
Gallagher AG. Ritter EM. Champion H. Higgins G. Fried MP. Moses G. Smith CD. Satava RM. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Annals of Surgery. 241(2):364-72, 2005 Feb.
SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.
Goncharenko I. Emotob H. Matsumoto S. Mishima H. Tanaka S. Kanou Y. Fujii T. Sugou N. Mito T. Shibata I. Realistic Virtual Endoscopy of the ventricle system and haptic-based surgical simulator of hydrocefalus treatment. Studies in Health Technology & Informatics. 94:93-5, 2003.
New methods and software tools for automatic extraction of the ventricle system from magnetic resonance imagery (MRI) data, ventricle part classification, and realistic texturing are proposed to support Virtual Endoscopy (VE). Volume- and surface-based medical atlases are intensively used as templates in the methods. The processed ventricle-related surfaces are then utilized in a haptic-based system, which provides a surgeon with several basic functions simulating "virtual treatment" of hydrocephalus.
Greenfield CL, Johnson AL, Shaeffer D & Hungerford LL. Comparison of surgical skills of students trained with models or live animals. Veterinary Surgery 1994;23(5):402.
Greenfield CL, Johnson AL, Smith CW, Marretta SM, Farmer JA, Klippert L. Integrating Alternative Models into the Existing Surgical Curriculum. Journal of Veterinary Medical Education 1994;21(1):23-27.
Guenego, L. Cazieux, A. Place of audiovisual techniques in education. Favourable results of an experiment in the Surgery Department of the Toulouse Veterinary School. [French] [Journal article] Revue de Medecine Veterinaire. 1992. 143: 2, 107-111. 5 ref.
Hart L, Anderson D, Zasloff R. Alternatives to the use of live animals in veterinary school curricula. Humane Innovations and Alternatives 1993;7:499–503.
Hikichi T. Yoshida A. Igarashi S. Mukai N. Harada M. Muroi K. Terada T. Vitreous surgery simulator. Archives of Ophthalmology. 118(12):1679-81, 2000 Dec.
OBJECTIVE: To reduce the surgical risks to patients and expose surgeons to surgical experience and complications, we have developed a practical system of vitreous surgery using virtual-reality technology. METHODS: The system is composed of high-resolution color stereo binoculars, haptic devices, foot switches, and a high-speed graphics computer. To simulate vitreous surgery, we created several virtual patient eyes with retinal diseases such as preretinal membranes and subretinal neovascular tissue at the fovea. RESULTS: The simulator provided the trainees with an operating environment similar to an actual one, and allowed them to learn to maneuver surgical instruments and remove proliferative tissue on the retina, under the retina, or both. This system allowed surgeons to avoid iatrogenic complications through visual signs such as retinal hemorrhage when the instrument contacted the retinal surface. CONCLUSIONS: This simulator may not only be suitable for residents to learn ocular surgical techniques but may also allow veteran surgeons to develop new surgical methods and skills.
Holmberg D, Cockshutt J. A non-animal alternative for teaching introductory surgery. Humane Innovations and Alternatives. Date unknown:635–636.
Describes the use of the Dog Abdominal Surrogate for Instructional Exercises (DASIE).
Holmburg, D. L. Cockshutt. J. R. Basher, A. W. P. Use of an abdominal surrogate for teaching small animal surgery. [Abstract only. Conference paper] Veterinary Surgery. 1992. 21: 5, 386.
Holmberg DL, Cockshutt JR & Basher AWP. Use of a dog abdominal surrogate for teaching surgery. Journal of Veterinary Medical Education 1993;20(2):61-2.
The DASIE (dog abdominal surrogate for instructional exercises) was well received by students. It was considered to be an effective, low stress method of preparing for live animal surgery. Its use has reduced the need for animals in teaching abdominal surgery. This follows the philosophical trend of today's society in its demands for non-living teaching models. The use, is therefore suggested, of an abdominal surrogate as an aesthetically acceptable alternative to live animal or cadaver surgery for some introductory surgical laboratory classes.
Howe LM. Boothe HW Jr. Hartsfield SM. Student assessment of the educational
benefits of using a CD-ROM for instruction of basic surgical skills.
Journal of Veterinary
Medical Education
2005. 32(1):138-43.
Jennings P. Alternatives to the use of living animals in the student surgery laboratory. Journal of Veterinary Medical Education 1986;13(1):14–16.
Johnson AL, Farmer JA. Evaluation of traditional and alternative models in psychomotor laboratories for veterinary surgery. Journal of Veterinary Medical Education 1989;16(1):11–14.
Inanimate models effectively taught basic psychomotor skills, and had the advantage over live animals that they could be used repeatedly, enhancing the acquisition of motor proficiency.
Johnson A, Farmer J. Teaching veterinary surgery in the operating room. Journal of Veterinary Medical Education 1990;17(1):10–12.
Johnson A, Greenfield C, Klippert L, Hungerford L, Farmer J, Siegel A. Frequency of procedure and proficiency expected of new veterinary school graduates with regard to small animal surgical procedures in private practice. Journal of the American Veterinary Medical Association Special Report 1993 Apr 01;202(7):1068–1071.
Johnson AL, Harari J, Lincoln J, Farmer JA, Korvick D. Bone models of pathologic conditions used for teaching veterinary orthopedic surgery. Journal of Veterinary Medical Education 1990;17:13-15.
Kahler S. Will recovery surgery courses survive? Journal of the American Veterinary Medical Association 2000;216(8):1201, 1204.
Kaufman T, Hurwitz DJ, Ballantyne DL. The foliage leaf in microvascular surgery. Microsurgery 1984;5:57-58.
Kuppersmith RB. Johnston R. Jones SB. Jenkins HA. Virtual reality surgical simulation and otolaryngology. Archives of Otolaryngology -- Head & Neck Surgery. 122(12):1297-8, 1996 Dec.
Large-scale flight simulation was pioneered in the 1940s to help meet the training requirements and demand for pilots in World War II. Flight simulators have been effective for training, evaluating, and certifying military and commercial pilots. Accurate scenarios have been developed that allow pilots in training to gain experience without the risk and expense of learning while in flight. The research in aviation simulation suggests a transfer effectiveness ratio of 0.48. This means that 1 hour in the simulator saves a half hour in the air. Because of the successful use of flight simulation as a training technique, computer-based simulators are now used in a variety of domains.
Larsson A. Intracorporeal suturing and knot tying in surgical simulation. Studies in Health Technology & Informatics. 81:266-71, 2001.
Intracorporeal suturing and knot tying is one of the most difficult tasks to perform during minimally invasive surgery. To master these tasks the student requires extensive training in a real or simulated environment. Realistic simulation of suturing and knot tying is a challenging task, the dynamic behaviors of the needle and thread are complicated to calculate efficiently in real time. We present our approach to simulated training of intracorporeal suturing and knot tying as well as our method for performance assessment. Different algorithms for physical modeling of suture thread dynamics are examined and evaluated.
Leow F. Tufts develops alternative program for teaching surgery. Journal of the American Veterinary Medical Association 1989 Oct 01;195(7):868-870.
Lentz GM, Mandel LS, Lee D, Gardella C, Melville J, Goff BA. Testing surgical skills of obstetric and gynecologic residents in a bench laboratory setting: validity and reliability. American Journal of Obstetrics and Gynecology 2001 Jun;184(7):1462-1470.
Leskovsky P. Harders M. Szekely G. A web-based repository of surgical simulator projects. Studies in Health Technology & Informatics. 119:311-5, 2006.
The use of computer-based surgical simulators for training of prospective surgeons has been a topic of research for more than a decade. As a result, a large number of academic projects have been carried out, and a growing number of commercial products are available on the market. Keeping track of all these endeavors for established groups as well as for newly started projects can be quite arduous. Gathering information on existing methods, already traveled research paths, and problems encountered is a time consuming task. To alleviate this situation, we have established a modifiable online repository of existing projects. It contains detailed information about a large number of simulator projects gathered from web pages, papers and personal communication. The database is modifiable (with password protected sections) and also allows for a simple statistical analysis of the collected data. For further information, the surgical repository web page can be found at www.virtualsurgery.vision.ee.ethz.ch.
Letterie GS. How virtual reality may enhance training in obstetrics and gynecology. [Review] [28 refs] American Journal of Obstetrics & Gynecology. 187(3 Suppl):S37-40, 2002 Sep.
OBJECTIVE: Contemporary training in obstetrics and gynecology is aimed at the acquisition of a complex set of skills oriented to both the technical and personal aspects of patient care. The ability to create clinical simulations through virtual reality (VR) may facilitate the accomplishment of these goals. The purpose of this paper is 2-fold: (1) to review the circumstances and equipment in industry, science, and education in which VR has been successfully applied, and (2) to explore the possible role of VR for training in obstetrics and gynecology and to suggest innovative and unique approaches to enhancing this training.Material And Methods: Qualitative assessment of the literature describing successful applications of VR in industry, law enforcement, military, and medicine from 1995 to 2000. Articles were identified through a computer-based search using Medline, Current Contents, and cross referencing bibliographies of articles identified through the search. RESULTS: One hundred and fifty-four articles were reviewed. This review of contemporary literature suggests that VR has been successfully used to simulate person-to-person interactions for training in psychiatry and the social sciences in a variety of circumstances by using real-time simulations of personal interactions, and to launch 3-dimensional trainers for surgical simulation. These successful applications and simulations suggest that this technology may be helpful and should be evaluated as an educational modality in obstetrics and gynecology in two areas: (1) counseling in circumstances ranging from routine preoperative informed consent to intervention in more acute circumstances such as domestic violence or rape, and (2) training in basic and advanced surgical skills for both medical students and residents. CONCLUSION: Virtual reality is an untested, but potentially useful, modality for training in obstetrics and gynecology. On the basis of successful applications in other nonmedical and medical areas, VR may have a role in teaching essential elements of counseling and surgical skill acquisition.
Li Y. Brodlie K. Phillips N. Web-based VR training simulator for percutaneous rhizotomy. Studies in Health Technology & Informatics 2000;70:175-81.
Virtual Reality offers great potential for surgical training--yet is typically limited by the dedicated and expensive equipment required. Web-based VR has the potential to offer a much cheaper alternative, in which simulations of fundamental techniques are downloaded from a server to run within a web browser. The equipment requirement is modest--an Internet-connected PC or small workstation--and the simulation can be accessed worldwide. In a collaboration between computer scientists and neurosurgeons, we have studied the use of web-based VR to train neurosurgeons in Percutaneous Rhizotomy--a treatment for the intractable facial pain which occurs in trigeminal neuralgia. This involves the insertion of a needle so as to puncture the foramen ovale, and lesion the nerve. Our simulation uses VRML to provide a 3D visualization environment, but the work immediately exposes a key limitation of VRML for surgical simulation. VRML does not support collision detection between objects--only between viewpoint and object. Thus collision between needle and skull cannot be detected and fed back to the trainee. We have developed a novel solution in which the training simulation has linked views: a normal view, plus a view as seen from the tip of the needle. Collision detection is captured in the needle view, and fed back to the viewer. A happy consequence of this approach has been the chance to aid the trainee with this additional view from needle tip, which helps locate the foramen ovale. The technology to achieve this is Java software communicating with the VRML worlds through the External Authoring Interface (EAI). The training simulator is available on the Web, with accompanying tutorial on its use. A major advantage of web-based VR is that the techniques generalize to a whole range of surgical simulations. Thus we have been able to use exactly the same approach as described above for neurosurgery, to develop a shoulder arthroscopy simulator--where again collision detection, and the view from the scope, are fundamental.
Loew FM. Tufts develops alternative program
for teaching surgery. Journal of the American Veterinary Medical Association
1989 Oct 01;195(7):868-870.
Marescaux J, Mutter D, Soler L, Vix M & Leroy J. [The Virtual University applied to telesurgery: from tele-education to tele-manipulation]. [French] Bulletin de l Academie Nationale de Medecine 1999;183(3):509-21. Discussion 521-2.
The advent of new computer technologies appears as a revolution of surgical teaching, as well as the planning and realisation of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of miniaturised camera constitutes the greatest alteration that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution was announces further changes: the development of telecommunication devices applied to medicine (tele-education, teletraining, telementoring, teleproctoring and tele-accreditation) constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of telepresence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery of Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realisation of international multi-site video conferences between surgeons. The WEBS project created the first Virtual University concept placing surgical techniques at the surgeon's disposal through Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows to develop the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University frame and to conceive teaching on a world level, offering to the practitioner unimaginable possibilities of formation, training and planning of surgical procedures.
Marescaux J, Mutter D, Soler L, Vix M & Leroy J. [The virtual university applied to telesurgery: from tele-education to telemanipulation]. [French] Chirurgie 1999;124(3):232-9.
The advent of new computer technologies can appear as a revolution in surgical teaching, as well as in the planing and realization of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of a miniaturized camera, constitutes the greatest change that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution also predicts further changes: the development of telecommunication devices applied to medicine (tele-education, tele-training, tele-mentoring, tele-proctoring and tele-accreditation), constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of tele-presence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery at Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realization of international multi-site video conferences between surgeons. The WEBS project created the first virtual university concept by placing surgical techniques at the surgeon's disposal through the Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows the development of the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University framework, and to conceive teaching on a world-wide level, offering the practitioner unimaginable possibilities of formation, training and the planning of surgical procedures.
Montgomery K. Burgess L. Dev P. Heinrichs L. Project hydra--a new paradigm of internet-based surgical simulation. Studies in Health Technology & Informatics 2006; 119:399-403.
Computer-based surgical simulation systems have produced tremendous benefits and demonstrated validity as a better method for many areas of surgical skills acquisition. However, despite these benefits, broad proliferation of these systems has continued to be elusive. While in large part this lag in adoption of this technology is due to social factors (organizational momentum, curriculum integration difficulties, etc), the cost of computer-based simulation systems has certainly remained a major deterrent toward broad deployment. Instead, what if it were possible to eliminate the cost of the large computer completely from the system, yet provide a much more extensive and detailed simulation than currently available? Finally, what if a simulation with even greater detail over a wider anatomical area were possible? This is the genesis of Project Hydra- a shared simulation supercomputer were made available for free and all that is required to access it is a low-end Internet-connected computer and, optionally, interaction/haptics devices as needed for the particular task. This would enable supercomputer-class simulation at every desktop with much greater fidelity than any user could individually afford and provide an online community for simulation research and application. Further, Internet-based simulation provides for many other benefits as well. By the user merely plugging optional, additional hardware into their existing, low-end PC and using the Internet as a means of simulation dissemination, distribution, and delivery means that the user can have immediate access to simulation updates/upgrades and download/access new content (didactic curriculum and cases). Further, this ease of access and use could lead to accelerated adoption and use of simulation within the medical curriculum and this access is provided anywhere in the world 24 x 7. In addition, once connected, a server-based simulation system would be a natural point for performing easy, automated clinical studies of surgical performance and skills.
Montgomery K. Thonier G. Stephanides M. Schendel S. Virtual reality based surgical assistance and training system for long duration space missions. Studies in Health Technology & Informatics. 81:315-21, 2001.
Access to medical care during long duration space missions is extremely important. Numerous unanticipated medical problems will need to be addressed promptly and efficiently. Although telemedicine provides a convenient tool for remote diagnosis and treatment, it is impractical due to the long delay between data transmission and reception to Earth. While a well-trained surgeon-internist-astronaut would be an essential addition to the crew, the vast number of potential medical problems necessitate instant access to computerized, skill-enhancing and diagnostic tools. A functional prototype of a virtual reality based surgical training and assistance tool was created at our center, using low-power, small, lightweight components that would be easy to transport on a space mission. The system consists of a tracked, head-mounted display, a computer system, and a number of tracked surgical instruments. The software provides a real-time surgical simulation system with integrated monitoring and information retrieval and a voice input/output subsystem. Initial medical content for the system has been created, comprising craniofacial, hand, inner ear, and general anatomy, as well as information on a number of surgical procedures and techniques. One surgical specialty in particular, microsurgery, was provided as a full simulation due to its long training requirements, significant impact on result due to experience, and likelihood for need. However, the system is easily adapted to realistically simulate a large number of other surgical procedures. By providing a general system for surgical simulation and assistance, the astronaut-surgeon can maintain their skills, acquire new specialty skills, and use tools for computer-based surgical planning and assistance to minimize overall crew and mission risk.
Montgomery K. Sorokin A. Lionetti G. Schendel S. A surgical simulator for cleft lip planning and repair. Studies in Health Technology & Informatics 2003;94:204-9.
The objective of this project was to develop a computer-based surgical simulation system for cleft lip planning and repair. This system allows the user to interact with a virtual patient to perform the traditional steps of cleft-lip repair. The system interfaces to force-feedback (haptic) devices to track the user's motion and provide feedback during the procedure, while performing real-time soft-tissue simulation. An eleven-day old unilateral cleft-lip and palate patient was previously CT scanned for ancillary diagnostic purposes using standard imaging protocols and 1mm slices. High-resolution 3D meshes were automatically generated from this data using the ROVE software created in our lab. The resulting 3D meshes of bone and soft-tissue were instilled with physical properties of soft tissues for purposes of simulation. Once these preprocessing steps were completed, the patient's bone and soft-tissue data are presented on the computer screen in stereo and the user can freely view, rotate, and otherwise interact with the patient's data in real-time. The user is prompted to select anatomical landmarks on the patient data for preoperative planning purposes, then their locations are compared against that of a "gold standard" and a score, derived from their deviation from that standard and time required, is generated. The user can then move a haptic stylus and guide the motion of the virtual cutting tool. The soft tissues can thus be incised using this virtual cutting tool, moved using virtual forceps, and fused in order to perform any of the major procedures for cleft-lip repair. Real-time soft tissue deformation of the mesh realistically simulates normal tissues and haptic-rate (>1kHz) force-feedback is provided. The surgical result of the procedure can then be immediately visualized and the entire training process can be repeated at will. A short evaluation study was also performed. Two groups (nonmedical and plastic surgery residents) of six-people each performed the anatomical marking task of the simulator four times. Results showed that the plastic surgery residents scored consistently better than the people without medical background. Every person's score increased with practice, and the length of time needed to complete the eleven markings decreased. The data was compiled and showed which specific markers consistently took users the longest to identify as well as which locations were hardest to accurately mark. Our findings suggest that the simulator is a valuable training tool, giving residents a way to practice anatomical identification for cleft lip surgery without the risks associated with training on a live patient. Educators can also use the simulator to examine which markers are consistently problematic, and modify their training to address these needs.
Moody L. Baber C. Arvanitis TN. Objective surgical performance evaluation based on haptic feedback. Studies in Health Technology & Informatics 2002;85:304-10.
In order to develop effective virtual reality training systems for surgery there is a need to provide appropriate sensory and performance feedback to the user. This paper aims to demonstrate a method by which performance data can be collected. This is used to investigate the effect of haptic feedback on performance. A PHANTOM desktop device was used in conjunction with a suturing simulation A pair of needle-holders was instrumented with strain gauges and attached to the stylus of the PHANTOM allowing the measurement of force application and time. Suturing performance was evaluated in terms of stitch completion time, peak force application, and the length and straightness of the stitch. The effect of the level of force feedback provided by the simulation and performance over time was considered. The results indicate that the presence of force feedback affected task completion time, peak force application and the straightness of the stitch. Task completion time was shown to increase with the level of force feedback provided. Performance was seen to improve over time in terms of task completion time and the accuracy ofthe stitch. The work has examined how the presence and level of force feedback affects performance of a simple task. The accuracy of haptic feedback is important in the design of surgical simulation systems to ensure effective training transfer. A data collection method by which objective performance evaluation can be made is demonstrated. The method can be applied to training using bench models, simulations and potentially in the operating theatre.
Mori T, Asano K, Kadosawa T, Motizuki M, Nishimura R & Maruo K. Evaluation of a dog abdominal surrogate model for teaching basic surgical skills by veterinary students. [Japanese] Journal of the Japan Veterinary Medical Association 2006;59(2):122-5.
A dog abdominal surrogate model for instructional exercises was evaluated to determine acceptance, by cooperation of two hundred and fifty-one fourth-year veterinary students at four universities in Japan. After practicing a celiotomy and intestinal anastomosis using the model, students' responses to a questionnaire were analyzed. Most students thought that the model was effective for acquiring basic surgical skills (99.2%) and necessary prior to surgical practice using live animals (96.8%). The major advantages of practical training using the model were effectiveness for acquiring basic surgical skills (40.8%), easy understanding of the structure (38.4%), reducing the need for live animals (21.6%) and multiple usage (14.8%). Meanwhile, more than half students (57.6%) suggested potential improvements of the materials and design of the model. The surrogate model used in the present study was well received by the students. We suggest that the model would be an acceptable alternative to live animals for certain basic surgical procedures.
Nakao M, Komori M, Oyama H, Matsuda T,
Sakaguchi G, Komeda M, Takahashi T. Haptic reproduction and interactive
visualization of a beating heart based on cardiac morphology. Medinfo
2001;10(Pt 2):924-928. Graduate School of Informatics, Kyoto University, Kyoto,
Japan. meg@kuhp.kyoto-u.ac.jp.
Nakao M. Oyama H. Komori M. Matsuda T. Sakaguchi G. Komeda M. Takahashi T. Haptic reproduction and interactive visualization of a beating heart for cardiovascular surgery simulation. International Journal of Medical Informatics. 68(1-3):155-63, 2002 Dec 18.
This
paper aims to achieve haptic reproduction and real-time visualization of a
beating heart for cardiac surgery simulation. Unlike most forgoing
approaches, the authors focus on time series datasets and propose a new
framework for interactive simulation of active tissues. The framework
handles both detection and response of collisions between a manipulator and
a beating virtual heart. Physics-based force feedback of autonomous cardiac
motion is also produced based on a stress-pressure model, which is adapted
to elastic objects filled with fluid. Time series datasets of an adult man
were applied to an integrated simulation system with a force feedback
device. The system displays multi-dimensional representation of a beating
heart and provides a basic training environment for surgical palpation.
Finally, results of measurement and medical assessment confirm the achieved
quality and performance of the presented framework.
Niemeyer G. Kuchenbecker KJ. Bonneau R. Mitra P. Reid AM. Fiene J. Weldon G. THUMP: an immersive haptic console for surgical simulation and training. Studies in Health Technology & Informatics. 98:272-4, 2004.
Telerobotic systems are revolutionizing minimally invasive surgery (MIS), giving the surgeon complete control over precise dexterous movements of tiny robotic instruments. Such 'surgery-by-wire' approaches also create unique opportunities for simulation and training, as the surgeon operates at a computer-mediated haptic console. Possible extensions include offline training in simulated environments and advanced guidance and mentoring during actual operations. To explore these options and further improve telerobotic interfaces, we have constructed a two-handed, fully articulating haptic console that provides force and torque feedback as well as a stereoscopic display.
Oyama H. Wakao F. Sekiguchi R. Ohmatsu H. Virtual reality enhanced surgical conference system. [Journal Article] Studies in Health Technology & Informatics. 29:273-9, 1996.
We present our ongoing work on an enhanced surgical conference system with a technology of virtual reality (VR). We reported on a surgical simulation support system by using a technology of virtual reality last year. In the present time, while using our VR simulation system, we realized that many surgeons and nurses needed to see both a solid real image and a virtual image of the surgical operation at the same time. According to this reason we added a solid video system to our previous VR simulation system. The new system can display both real and virtual images on 100 inch wide screen and a console monitor of Onyx computer. The doctors can see both images with shutter glasses on the screen or console. We can now simulate various cancer surgery while watching the real solid surgical picture. We expect our enhanced surgical conference system to be beneficial for surgeons and nurses with limited experience to familiarize surgical procedures. The system could be also employed in planning a surgical procedure and educating medical staffs. Here we discuss about the aim of the system, current implementation, its limitations and its future directions.
Patel HI. Levin AV. Developing a model system for teaching goniotomy. Ophthalmology. 112(6):968-73, 2005 Jun.
PURPOSE: To design a model-system instruction course to prepare trainees for performing goniotomy on patients. DESIGN: Experimental study. PARTICIPANTS: Three pediatric ophthalmology fellows and 1 recent graduate of the fellowship program. METHODS: We piloted 3 model systems: human cadaver eyes with and without Marty the Surgical Simulator (Iatrotech Inc., Del Mar, CA, hereafter referred to as Marty Head) eye supporting system and artificial eyes in Marty Head. For improving intraocular view in cadaver eyes, we used epithelial scrapping, intracameral viscoelastic, and/or intracameral lubricating jelly. Each trainee underwent a training course, including background reading, didactic lecture, and video review followed by goniotomy on model systems with the operating microscope. MAIN OUTCOME MEASURES: Each trainee evaluated each step of the course using modified 5-point Likert scales. Reading material and videos were evaluated for usefulness, readability/quality, and new information obtained. Each model system was evaluated for visibility, ease of setup, surgical feel, and transferability to live surgery. In the end, each trainee was asked to assess the overall course for usefulness. RESULTS: Trainees rated the reading materials and video highly for their usefulness and quality, yet they believed they did not learn substantial amounts of new information. Visibility and ease of setup was best with artificial eyes in the Marty Head model. Human cadaver eyes in the Marty Head provided somewhat less visibility and ease of setup, but the perceived feel and transferability to live surgery was slightly better than with artificial eyes. Cadaver eyes without the Marty Head got the lowest rating in all categories. At the end of the course, all participants felt more confident and ready to perform goniotomy on patients. All recommended this course as part of pediatric ophthalmology fellowship training programs. CONCLUSIONS: This model system instruction course can assist trainees in learning to perform goniotomy while potentially lessening the risks to patients.
Patronek G. Tufts University School of Veterinary Medicine Client Donation Program. Alternatives in Veterinary Medical Education 1999;11:2-3.
Pavletic MM, Schwartz A, Berg J, Knapp D. An assessment of the outcome of the alternative medical and surgical laboratory program at Tufts University. Journal of the American Veterinary Medical Association 1994;205(1):97–100.
Abstract:
The school of Veterinary Medicine had made it the rule that all dogs undergoing
major surgical procedures in its small animal teaching laboratories should be
killed at the end of the procedure. However in 1988 12 students formally
submitted a proposal requesting formation of an alternative small animal medical
and surgical procedures course that would not include euthanasia of dogs, as
they felt that it was morally wrong. An alternative training programme was
developed to satisfy the moral concerns of the students, yet maintain the
quality of their education. Cadavers were used of terminally ill or dead pets
which were donated by the owners for the education of veterinary students, and
were frozen until required. These students also spent 4 supplemental weeks in
small animal surgery, 1 week in small animal medicine and 1 week in intensive
care. Using this alternative training it was found that the use of cadavers
during the 3rd year laboratory programme, when supplemented with additional
clinical training during the 4th year, can provide training comparable to that
provided in a conventional laboratory programme.
[Pavletic and others (1994) studied new graduates from the Tufts University veterinary class of 1990. The class included 12 students who had participated in an alternative small animal medical and surgical procedures course. These students and 36 of their conventionally-trained counterparts were assessed by questionnaires sent to their employers. Employers were asked to rate the competency of the new graduates at the time of hiring and 12 months later. It was found that there was no significant difference on either occasion in the abilities of the conventional and alternative graduates to perform common surgical, medical and diagnostic procedures; in their attitudes towards performing orthopaedic or soft tissue surgery; confidence in performing the listed procedures; or ability to perform those procedures without assistance.]
Phillips NI. John NW. Web-based surgical simulation for ventricular catheterization. Neurosurgery. 46(4):933-6; discussion 936-7, 2000 Apr.
We have used new developments in computer technology and the Internet to create a small program that simulates catheterization of the lateral ventricle. The program can run on most personal computers connected to the Internet. The program allows trainee surgeons to practice the technique with varying degrees of visual feedback--and no risk to the patient. It allows them to learn both the technique and the associated anatomy. The trainees can be assessed while performing the procedure. This is a small, early-stage application of virtual reality in surgical education. There is a demand for surgical training techniques that expose the patient to no risk; the use of computers is appropriate to meet this demand. The technique presented here requires further development; in particular, it needs a standardized assessment element that will allow it to be tested by established surgeons and trainees. The real test of a good training technique is how well it discriminates between trainee and trainer.
Richardson, E. F. Gregory, C. R. Pascoe, J. R. Brooks, D. Incorporating survival surgical procedures into veterinary surgical education. [Abstract only. Conference paper] Veterinary Surgery. 1994. 23: 5, 415.
Roberts KE. Bell RL. Duffy AJ. Evolution of surgical skills training. [Review] [52 refs] World Journal of Gastroenterology. 12(20):3219-24, 2006 May 28.
Surgical training is changing: one hundred years of tradition is being challenged by legal and ethical concerns for patient safety, work hours restrictions, the cost of operating room time, and complications. Surgical simulation and skills training offers an opportunity to teach and practice advanced skills outside of the operating room environment before attempting them on living patients. Simulation training can be as straight forward as using real instruments and video equipment to manipulate simulated "tissue" in a box trainer. More advanced, virtual reality simulators are now available and ready for widespread use. Early systems have demonstrated their effectiveness and discriminative ability. Newer systems enable the development of comprehensive curricula and full procedural simulations. The Accreditation Council of Graduate Medical Education's (ACGME) has mandated the development of novel methods of training and evaluation. Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and to credential surgeons as technically competent. Simulators in their current form have been demonstrated to improve the operating room performance of surgical residents. Development of standardized training curricula remains an urgent and important agenda, particularly for minimal invasive surgery. An innovative and progressive approach, borrowing experiences from the field of aviation, can provide the foundation for the next century of surgical training, ensuring the quality of the product. As the technology develops, the way we practice will continue to evolve, to the benefit of physicians and patients.
Rogers DA,
Regehr G, Yeh KA, Howdieshell TR. Computer-assisted learning versus a lecture
and feedback seminar for teaching a basic surgical technical skill.
American Journal of
Surgery
1998 Jun;175(6):508-510. Department of Surgery, Medical College of Georgia,
Augusta 30912-4070, USA.
BACKGROUND: Rapid improvements in computer technology allow us to consider the
use of computer-assisted learning (CAL) for teaching technical skills in
surgical training. The objective of this study was to compare in a prospective,
randomized fashion, CAL with a lecture and feedback seminar (LFS) for the
purpose of teaching a basic surgical skill. METHODS: Freshman medical students
were randomly assigned to spend 1 hour in either a CAL or LFS session. Both
sessions were designed to teach them to tie a two-handed square knot. Students
in both groups were given knot tying boards and those in the CAL group were
asked to interact with the CAL program. Students in the LFS group were given a
slide presentation and were given individualized feedback as they practiced this
skill. At the end of the session the students were videotaped tying two complete
knots. The tapes were independently analyzed, in a blinded fashion, by three
surgeons. The total time for the task was recorded, the knots were evaluated for
squareness, and each subject was scored for the quality of performance. RESULTS:
Data from 82 subjects were available for the final analysis. Comparison of the
two groups demonstrated no significant difference between the proportion of
subjects who were able to tie a square knot. There was no difference between the
average time required to perform the task. The CAL group had significantly lower
quality of performance (t = 5.37, P <0.0001). CONCLUSIONS: CAL and LFS were
equally effective in conveying the cognitive information associated with this
skill. However, the significantly lower performance score demonstrates that the
students in the CAL group did not attain a proficiency in this skill equal to
the students in the LFS group. Comments by the students suggest that the lack of
feedback in this model of CAL was the significant difference between these two
educational methods.
Rossi JV. Verma D. Fujii GY. Lakhanpal RR. Wu SL. Humayun MS. De Juan E Jr. Virtual vitreoretinal surgical simulator as a training tool. Retina. 24(2):231-6, 2004 Apr.
OBJECTIVE: To demonstrate the feasibility and potential applicability of a virtual reality simulator for vitreoretinal surgery as a training and/or assessment tool. METHODS: The subjects of this study included medical students, ophthalmologic residents, and trained vitreoretinal surgeons. There were three study groups. Group I comprised 22 subjects who performed a navigation task. The time to complete the task was recorded. The relationship between the completion time, experience, and stereopsis was evaluated. Group II included 6 subjects who consecutively performed the navigation task to evaluate their learning curve. Group III included 16 subjects who performed the membrane peeling task. The number of retinal contacts and the completion time were recorded. The relationship between experience and stereopsis with the number of contacts and the completion time were evaluated. RESULTS: The average completion time in Group I for students, residents, and trained surgeons was 121.6, 92.5, and 70.6 seconds. There was a significant difference between students and trained surgeons (P = 0.004). In Group II, there was a significant decrease in the completion time with training (P = 0.001). In Group III, the average completion time for students, residents, and trained surgeons was 197, 144, and 118.2 seconds; the respective number of retinal contacts was 14, 8, and 3. There was a significant difference between students and residents (P = 0.05) and between residents and trained surgeons (P = 0.003) for the average completion time in Group III. There was a significant difference between students and trained surgeons (P = 0.003) for the number of contacts per average time and between students and residents (P = 0.05). There was a significant inverse correlation between stereopsis vision score and completion time in Group I and number of contacts per average time (P = 0.0004 and P = 0.01, respectively). CONCLUSIONS: This study demonstrates potential applications of a vitreoretinal surgical simulator as a training and skills assessment tool for novice, inexperienced, and trained surgeons. A simulator can be used to teach specific techniques and train surgeons.
Silva RMG, da Matera JM & Ribeiro AACM. Evaluation of the surgical technique teaching method using chemically preserved cadavers. [Portuguese] Revista de Educacao Continuada do CRMV-SP 2003;6(1/3):95-102.
Objective: To assess surgical training using chemically-preserved cadavers in the Surgical Techniques and Orthopaedics classes of "Faculdade de Medicina Veterinaria e Zootecnia da Universidade de Sao Paulo" (College of Veterinary Medicine and Zootechnics of the University of Sao Paulo) - (FMVZ/USP), Sao Paulo, SP, Brazil, as an alternative method to use in the place of live animals in classrooms. Materials and Methods: A modified Larssen solution that preserves the characteristics of the animals' colour, the consistency and texture of tissues, and the flexibility of joints as similar as possible to those found in live animals was used. Cadavers with body weight between 1-25 kg, of different sexes and species, were cleaned and received a lavage of the vascular circuit with hot physiologic solution and a second lavage with modified Larssen solution at a volume corresponding to 5% of the cadaver body weight. At a second stage, fixing solution was injected into the cadaver, the volume of which corresponded to 10% of cadaver weight. After fixation, cardavers were cryopreserved in cold chambers with temperatures between -20 to -16 degrees C. Acceptance of the use of cadavers as a teaching method was assessed using a survey questionnaire distributed among students of the Surgical Techniques and Orthopaedics classes in 2001, 2003 and 2003. Results and Conclusions: Based on responses of students to the questionnaires it was possible to conclude that the described teaching methodology of using cadavers is well accepted. The use of modified Larssen solution to chemically preserve the cadavers allows for intense and adequate training of surgical techniques during the course. The said practice allows the repeated use of cadavers, decreasing the number of animals needed for classroom purposes.
Satava RM. Accomplishments and challenges of surgical simulation. Surgical Endoscopy. 15(3):232-41, 2001 Mar.
For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.
Satava RM. Surgical education and surgical simulation. [Review] [9 refs] World Journal of Surgery. 25(11):1484-9, 2001 Nov.
The science of virtual reality provides an entirely new opportunity in the area of simulation of surgical skills using computers for training, evaluation, and eventually certification. A taxonomy of the types of simulators is proposed based upon the level of complexity of the task which is being simulated. These tasks are precision placement, simple manipulation, complex manipulation, and integrated procedure. Representative simulators in each category are illustrated and discussed in the context of their contribution to the education and training of a surgeon. The importance of a curriculum is to give content to the role of simulators as another advanced tool for education. Simulators must be integrated into a comprehensive curriculum and not considered as a stand-alone system. The current accomplishments as well as challenges are discussed.
Schendel S.
Montgomery K. Sorokin A. Lionetti G. A surgical simulator for planning and
performing repair of cleft lips. Journal of Cranio-Maxillo-Facial Surgery.
33(4):223-8, 2005 Aug.
The objective of this project was to develop a computer-based surgical simulation system for planning and performing cleft lip repair. This system allows the user to interact with a virtual patient to perform the traditional steps of cleft-lip repair (rotation-advancement technique). MATERIALS AND METHODS: The system interfaces to force-feedback (haptic) devices to track the user's motion and provide feedback during the procedure, while performing real-time soft-tissue simulation. An 11-day-old unilateral cleft lip, alveolus and palate patient was previously CT scanned for ancillary diagnostic purposes using standard imaging protocols and 1mm slices. High-resolution 3D meshes were automatically generated from this data using the ROVE software developed in-house. The resulting 3D meshes of bone and soft tissue were instilled with physical properties of soft tissues for purposes of simulation. Once these preprocessing steps were completed, the patient's bone and soft tissue data are presented on the computer screen in stereo and the user can freely view, rotate, and otherwise interact with the patient's data in real time. The user is prompted to select anatomical landmarks on the patient's data for preoperative planning purposes, then their locations are compared against that of a 'gold standard' and a score, derived from their deviation from that standard and time required, is generated. The user can then move a haptic stylus and guide the motion of the virtual cutting tool. The soft tissues can thus be incised using this virtual cutting tool, moved using virtual forceps, and fused in order to perform any of the major procedures for cleft lip repair. Real-time soft tissue deformation of the mesh realistically simulates normal tissues and haptic-rate (>1 kHz) force-feedback is provided. The surgical result of the procedure can then be immediately visualized and the entire training process can be repeated at will. A short evaluation study was also performed. Two groups (non-medical and plastic surgery residents) of six persons each performed the anatomical marking task of the simulator four times. RESULTS: Results showed that the plastic surgery residents scored consistently better than the persons without medical background. Every person's score increased with practice, and the length of time needed to complete the 11 markings decreased. The data was compiled and showed which specific markers consistently took users the longest to identify as well as which locations were hardest to accurately mark. CONCLUSION: These findings suggest that the simulator is a valuable training tool, giving residents a way to practice anatomical identification for cleft lip surgery without the risks associated with training on a live patient. Educators can also use the simulator to examine which markers are consistently problematic, and modify their training to address these needs.
Seevinck J. Scerbo MW. Belfore LA 2nd. Weireter LJ Jr. Crouch JR. Shen Y. McKenzie FD. Garcia HM. Girtelschmid S. Baydogan E. Schmidt EA. A simulation-based training system for surgical wound debridement. Studies in Health Technology & Informatics. 119:491-6, 2006.
A simulation-based training system for surgical wound debridement was developed and comprises a multimedia introduction, a surgical simulator (tutorial component), and an assessment component. The simulator includes two PCs, a haptic device, and mirrored display. Debridement is performed on a virtual leg model with a shallow laceration wound superimposed. Trainees are instructed to remove debris with forceps, scrub with a brush, and rinse with saline solution to maintain sterility. Research and development issues currently under investigation include tissue deformation models using mass-spring system and finite element methods; tissue cutting using a high-resolution volumetric mesh and dynamic topology; and accurate collision detection, cutting, and soft-body haptic rendering for two devices within the same haptic space.
Closed-chest thoracostomy with tube drainage is recognized as a necessary skill for primary care physicians. The usual teaching methods used to train medical students and resident physicians involve either instruction on patients or the use of costly animal models. An inexpensive model using commonly available materials to teach this skill is described.
Shires P.K. One educator's perspective on the role of instructional technology in veterinary surgical education. Journal of Veterinary Medical Education 2003;30(4):338-43. Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, VA 24061, USA. shirespk@vt.edu
A brief overview of the history of instructional technology (IT) use in veterinary surgery education is followed by an assessment of the state of the art in this discipline in the United States. Comments on assessment of teaching tools and the need for a concerted effort at future assessments are made in light of published information regarding the success of alternative learning methods in education in other disciplines. A few final comments are shared about discipline specific technology demands in surgical education and the issue of copyrights versus sharing resources.
Smeak DD, Beck ML, Shaffer CA, Gregg CG.
Evaluation of video tape and a simulator for instruction of basic surgical
skills. Veterinary Surgery 1991 Jan-Feb;20(1):30-36. Department of
Veterinary Clinical Sciences, Ohio State University College of Veterinary
Medicine, Columbus.
Twenty first-year veterinary students with no prior participatory experience in
surgery were randomly paired and assigned into two study groups. Ten students
(group V) viewed a hemostatic technique video tape until they thought they could
competently perform and assist in performing a hand-tied ligature on a blood
vessel in a live animal. Ten students (group VS) were also given a simulator for
technique practice. Paired students were video recorded and blindly evaluated on
their ability to perform and assist proper ligation of a bleeding vessel.
Inexpensive hemostasis models were very helpful for teaching students essential
surgeon and assistant skills involved in hand-tied ligature placement. Students
who practiced with simulators performed significantly better as surgeon and
assistant, and in total psychomotor skill evaluation, then students watching the
video only. Students using simulators performed ligation with significantly more
accuracy and tended to be more expeditious at this task. Further training is
needed for students to acquire skills necessary for efficient bleeding vessel
exposure and isolation.
Smeak DD, Hill LN, Beck ML, Shaffer CA, Birchard SJ. Evaluation of an autotutorial-simulator program for instruction of hollow organ closure. Veterinary Surgery 1994 Nov-Dec;23(6):519-528. Department of Veterinary Clinical Sciences, Ohio State University College of Veterinary Medicine, Columbus.
Forty students were randomly assigned into two study groups (traditional, T; and
simulator, S) of 20 students each for a core operative practice laboratory.
Students were randomly paired and their group assignment and identity remained
anonymous to the evaluators throughout the study. Questionnaires were
distributed to students to evaluate prior surgical experience and obtain
learning resource use information. Before the evaluation sessions, both groups
were given identical learning resource opportunities except students in Group S
received hollow organ simulators and practice materials for gastrotomy closure.
All students were forewarned that surgical instruction would not be available
during the evaluation sessions. In the first live animal evaluation session, all
student pairs were videotaped after which stomachs were harvested for gross
evaluation of the surgical site. Group T performed an additional gastrotomy for
video and gross evaluation 2 weeks later. Questionnaire, and gross and video
evaluation results were compared statistically between groups and sessions. The
hollow organ model did not suitably simulate live stomach tissue; the material
was more fragile and stiff and suture cut-out was a problem even with
appropriate suture tension and technique. The model was effective for teaching
needle placement, instrument usage, creating proper tissue inversion, and
methods to minimize instrument handling of tissue during gastrotomy closure.
Prior practice with models did not boost student confidence during their live
gastrotomy session. The autotutorials (ATs) were well received by students but
did not sufficiently address how to manage mucosal eversion, suture tension, and
bleeding encountered during live gastrotomy. AT viewing time positively
correlated with mean total video score for Group T during both sessions. None of
the students had prior experience performing hollow organ closure and no
significant difference in experience level was evident between groups. Mean
closure time was not significantly different between groups for session one
(Group T, mean, 31.5 minutes, range, 18.4 to 53.4; Group S, mean, 28.2 minutes,
range, 16.8 to 36), but was significantly reduced for session two (Group T,
mean, 21.3 minutes, range, 13.9 to 31). This AT/simulator program does not
significantly influence students' overall gastrotomy closure technique; gross
and video evaluation scores were not significantly different between groups.
Without instructor supervision, an additional gastrotomy experience did not
improve surgical technique appreciably for Group T; however, these students
performed the second procedure with more confidence and speed.
Smith, R. E. Hagstad, H. V. How to write a simulation. [Journal article] Journal of Veterinary Medical Education. 1989. 16: 2, 53-54. 8 ref.
Spencer BS. Incorporating the sense of smell into haptic surgical simulators. Studies in Health Technology & Informatics. 114:54-62, 2005.
It is widely recognized that the sense of smell plays an important role in the field of medicine. The sense of smell not only assists the physician in the diagnosis of certain disorders, but it also plays a surgical role as well. Historically, learning this skill was contingent upon some level of clinical exposure to medically related odors. The advent of computerized scent production devices could change this. This article proposes a hypothetical surgical simulation model that incorporates olfactory technologies into existing, haptic, surgical simulators. If incorporated into virtual educational settings such as these, computerized scent production devices could be used not only as a novel way to enhance the virtual experience, but also as a way for medical students to begin to recognize the important role that the sense of smell can play during surgery.
Spicer MA. Apuzzo ML. Virtual reality surgery: neurosurgery and the contemporary landscape.[see comment]. [Review] [58 refs] Neurosurgery. 52(3):489-97; discussion 496-7, 2003 Mar.
OBJECTIVE: Virtual reality-simulated environments have been used for the training of personnel, most notably for military applications, for more than 35 years. The advantages conferred by being able to train novice personnel in a low- to no-risk simulated environment have long been appreciated by the medical community. The recent availability of affordable gigahertz-range microprocessors (once the exclusive domain of the Cray supercomputer) has made photorealistic graphical rendering and manipulation of virtual surgical substrates a reality. Concomitant advances in artificial intelligence systems and the portability of patient-specific magnetic resonance imaging, computed tomographic scanning, and angiographic image data presage the emergence of the surgical simulator as a modern surgical training adjunct. An overview of the status of surgical simulation with regard to its adaptability to current surgical training regimens is presented. METHODS: Extensive MEDLINE, Internet, and other database searches spanning the years 1960 to 2002 were conducted in an effort to delineate the status of simulated surgical environments. RESULTS: As would be expected, most articles addressing surgical simulation as their primary focus have been published in the past decade. A review of this literature demonstrates the broadest application in the field of endoscopic (and laparoscopic) procedures, most likely as a result of the reduced engineering burden with respect to incorporation of a haptic interface. CONCLUSION: The realization of ergonomically acceptable haptic interfaces remains elusive. Improvements in graphical rendering and the incorporation of artificial intelligence functions signal the certain emergence of surgical simulators as a viable supplement to the Halstedian method of surgical training.
Stefanich L, Cruz-Neira C. A virtual surgical simulator for the lower limbs. Biomedical Sciences Instrumentation 1999;35:141-145. Technology (ICEMT), Iowa State University, Ames, IA 50010, USA. stefanch@icemt.iastate.edu.
Steffens K, Koob E, Hong G. Training in basic microsurgical techniques without experiments involving animals. Archives of Orthopaedic and Trauma Surgery 1992;111(4):198-203.
Sutherland LM. Middleton PF. Anthony A. Hamdorf J. Cregan P. Scott D. Maddern GJ. Surgical simulation: a systematic review. Annals of Surgery 2006;243(3):291-300.
OBJECTIVE: To evaluate the effectiveness of surgical simulation compared with other methods of surgical training. SUMMARY BACKGROUND DATA: Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans. METHODS: Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance. RESULTS: Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training. CONCLUSIONS: While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.
Szinicz G, Beller S & Zerz A. [Role of the pulsatile organ perfusion surgical simulator in surgery education]. [German] Langenbecks Archiv fur Chirurgie - Supplement – Kongressband 1997;114:687-93.
The operation simulator with pulsatile organ perfusion ("POP trainer") simulates the blood supply of organs or organ complexes and was developed for the training in both minimally invasive and conventional surgery. With the redesigned new POP-trainer, even complex operations, such as colorectal and antireflux procedures can be practised. Due to perfect quality of simulation, simple handling and economic aspects, the POP trainer serves to intensify the training of surgeons, simultaneously decreasing the number of animal experiments.
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.
Thurfjell L. Lundin A. McLaughlin J. A medical platform for simulation of surgical procedures. Studies in Health Technology & Informatics. 81:509-14, 2001.
Surgery simulation is a promising technique for training of surgical procedures. The overall goal for any surgical simulator is to allow for efficient training of the skills required and to improve learning by giving the user proper feedback. This goal is easier achieved if the training is performed in a realistic environment. Therefore functionality such as soft tissue deformation, tearing and cutting, penetration of soft tissue etc. is necessary. Furthermore, a realistic simulator must provide haptic feedback so that all senses match, that is, there should be a correspondence between what you see and what you feel with your hands. In this paper we describe a medical platform that provides all this functionality. It is based on the Reachln Magma API, which has been extended for surgery simulation. We describe the development of the platform and illustrate the use of it for the development of two different types of surgical simulators, both of which represents work in progress.
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.
Tsai MD. Hsieh MS. Jou SB. Virtual reality orthopedic surgery simulator. Computers in Biology & Medicine 2001;31(5):333-51.
This paper describes a highly interactive virtual reality orthopedic surgery simulator. The simulator allows surgeons to use various surgical instruments to operate on virtual rigid anatomic structures, such bones, prostheses and bone grafts, to simulate every procedure on the rigid structures for complex orthopedic surgeries, including arthroplasty, corrective or open osteotomy, open reduction of fractures and amputation. A comparative study of the simulator with paper simulation was performed and showed that interns and residents found the simulator to be a useful learning tool, and that visiting doctors could use it effectively for planning verification and rehearsal of operations.
Weber D, Moser N, Rosslein R. A synthetic model for microsurgical training: a surgical contribution to reduce the number of animal experiments. European Journal of Pediatric Surgery 1997 Aug;7(4):204-206.
White KK, Wheaton LG, Greene SA. Curriculum change related to live animal use: a four-year surgical curriculum. Journal of Veterinary Medical Education 1992;19:6–10.
After hesitancy in their first live tissue surgery, veterinary students from an alternative surgical laboratory program performed on par with students with a standard laboratory experience.
Wiet GJ. Stredney D. Sessanna D. Bryan JA. Welling DB. Schmalbrock P. Virtual temporal bone dissection: an interactive surgical simulator. [Review] [10 refs] Otolaryngology - Head & Neck Surgery. 127(1):79-83, 2002 Jul.
OBJECTIVE: Our goal was to integrate current and emerging technology in virtual systems to provide a temporal bone dissection simulator that allows the user interactivity and realism similar to the cadaver laboratory. STUDY DESIGN: Iterative design and validation of a virtual environment for simulating temporal bone dissection. SETTING: University otolaryngology training program with interdisciplinary interaction in a high-performance computer facility. RESULTS: The system provides visual, force feedback (haptic), and aural interfaces. Unlike previous "fly through" virtual systems, this environment provides a richer emulation of surgical experience. CONCLUSION: The system provides a high level of functional utility and, through initial evaluations, demonstrates promise in adding to traditional training methods. SIGNIFICANCE: The system provides an environment to learn temporal bone surgery in a way similar to the experience with cadaver material where the subject is able to interact with the data without constraints (nondeterministic). Eventually, it may provide the "front end" to a large repository of various temporal bone pathologies that can be accessed through the Internet.
Wysocki WM. Moesta KT. Schlag PM. Surgery, surgical education and surgical diagnostic procedures in the digital era. [Review] [39 refs] Medical Science Monitor. 9(3):RA69-75, 2003 Mar.
Computers have quickly proven to be an essential part of routine, everyday clinical work. New disciplines are being developed: telesurgery (surgery at a distance), computer- and robotic-aided surgery, image-guided surgery, medical teleconsultations, postoperative telefollow-up, etc. What are the future directions of computer-aided medicine? The digital revolution in medicine, which we are currently witnessing, is leading towards the development of new surgical treatment modalities, toward surgical simulation and improved surgical teaching. The old surgical teaching rule, 'See one, do one, teach one' promulgated by Halsted is fading into history. There are new diagnostic tools expanding the available diagnostic modalities and turning their results into a more comprehensible form. Neural networks are being successfully introduced into differential diagnostics. The capacity of human hands is being increased by telemanipulation and movement downscaling. The cost of useful applications of computers is in many cases not as high as might be expected. Analogue telephone lines are often good enough for telemedical purposes, which is particularly important for developing countries. We review the current status of computer-aided surgery. It is presumed that surgery in the future will rely on computers to a much larger extent than today. All surgery will be to some extent computer-aided, or even completely robotic, but it can never be performed without human professional guidance, supervision and control.
