Elsevier

Journal of Surgical Education

Volume 64, Issue 6, November–December 2007, Pages 424-430
Journal of Surgical Education

Original report
Documenting a Learning Curve and Test-Retest Reliability of Two Tasks on a Virtual Reality Training Simulator in Laparoscopic Surgery

Presented at the 10th World Congress of Endoscopic Surgery, Berlin, Germany, September 2006.
https://doi.org/10.1016/j.jsurg.2007.08.007Get rights and content

Background

Virtual reality simulators are a component of the armamentarium for training surgical residents. No one knows exactly how to incorporate virtual reality simulators into a curriculum. The purpose of this study was to document and show the learning curve and test–retest reliability of 2 tasks on a virtual reality-training simulator (LapSim; Surgical Science, Göteborg, Sweden) in laparoscopic surgery.

Methods

Twenty-nine medical students participated in 8 iterations of 7 virtual reality tasks (“camera navigation” (CN), “instrument navigation,” “coordination,” “grasping,” “lifting and grasping” (LG), “cutting,” and “clip applying”) Learning curves for each outcome variable of the CN and LG tasks were generated. Using ANOVA, we evaluated the differences between each score from attempt number 7 to attempt number 8 to document test–retest reliability.

Results

A plateau in the learning curve occurred within 8 sessions for CN misses, CN tissue damage, CN maximum damage, and LG maximum damage. Over the course of 8 sessions, a plateau in the learning curve was nearly reached for CN time, CN drift, CN path, CN angular path, and LG left and right path. The following variables had a downward trend to the mean learning curve over 8 sessions, but they did not reach a plateau: LG time, LG left and right miss, LG left and right angular path, and LG tissue damage.

Conclusion

Using the LapSim virtual reality simulator, we documented a learning curve and test–retest reliability for each outcome variable for CN and LG for rank novices. The modeling of the general learning curve is useful in designing training program. These results may be important in developing standards for technical evaluation in a surgical training curriculum.

Introduction

The advent of innovative and technically demanding surgical procedures has affected surgery over the last 20 years. Yet, surgical training has changed very little since the days of William Halstead. Surgery training to this day has a strong emphasis on graded responsibility as expertise is acquired and a master-apprenticeship model of surgical training.1 Traditionally, Halstedian teaching methods have been used in open surgery and are the basis of most American surgery training programs.2 With the introduction of novel technologies in the surgical arena since the late 1980s, technical surgical training has become paramount. An important modern advance in surgical technology has been the introduction of minimal access techniques, including laparoscopic surgery. Laparoscopic surgery involves the acquisition of new skills, which are distinct from those used to perform open surgery.

Objective assessment of surgical skills assessment is a challenge. In current practice, assessment of surgical skills is often unstructured, subjective, and may even be biased. Descriptions of surgical competence use “vague” phraseology such as “too long, too short” or “too close, too far” or “good hands.” A generally accepted, standardized, objective, and valid method for quantitative measurement of laparoscopic operative skills does not exist.3 No gold standard is available for technical performance in the operating room. Several methods of providing an objective assessment of open and laparoscopic surgical performance are available.4, 5, 6, 7, 8, 9 Each of these methods requires additional personnel to collect the data. Virtual reality simulators have received investigation as a laparoscopic surgery training tool.10, 11, 12 Computers assess and simultaneously document whether trainees can perform the tasks, how efficiently they move, how long they take, and whether they make any serious errors. This independent documentation is the first step in potentially mandating training outside the operating room for surgical trainees. However, unless one quantifies the amount of time necessary to master skills required to perform surgery, simulators may not gain widespread acceptance as a training tool, especially in light of regulations limiting resident work hours.

This study addresses the void in the literature regarding learning curves for surgical skills. The purpose of this study is to document the amount of time required to demonstrate proficiency of 2 tasks on a virtual reality training simulator in laparoscopic surgery (LapSim; Surgical Science, Göteborg, Sweden). In this study, we sought to provide new and currently unavailable information about the length of time required to acquire specific laparoscopic skills (ie, the learning curve) in the LapSim surgical simulator. Our hypothesis is that a novice laparoscopist would achieve learning of a simple and a complex task within 8 attempts.

Section snippets

Methods

The Columbia University Medical Center Institutional Review Board reviewed and approved this study. Medical students in years 1 through 4 from Columbia University College of Physicians and Surgeons participated in this study. The Dean of the Medical Students at Columbia University College of Physicians and Surgeons assisted with distribution of a mass e-mail announcement to all medical students informing them of the study.

Medical students are a group that is most similar to interns in surgical

Procedure

After signing the informed consent document and completing the background questionnaire, all participants received an identical tutorial on the simulator to acquire the limited cognitive skills required to perform the tasks and to familiarize them with the equipment. The tutorial included a 20-minute initial familiarization demonstration of the laparoscopic simulator, the 7 skills on the simulator, and a review of the skill parameters and errors documented. All participants performed the same 7

Characteristics of Participants

Eighteen male and 11 female medical students at all levels of training and without prior clinical experience with laparoscopic surgery as the assistant surgeon or prior simulator training, mechanical, personal computer based, or otherwise, were enrolled voluntarily in the study. All participants gave written informed consent to participate. Twenty-six of the 29 participants enrolled completed the study. Table 1 provides descriptive statistics from the background questionnaire.

Learning Curve

TABLE 2, TABLE 3

Discussion

The goal of this study was to document the learning curve for 2 tasks in a virtual reality laparoscopic simulator, the LapSim surgical simulator. This goal is important because the benefit of simulator training seems to outweigh the risks and because currently no study documents a learning curve or test–retest reliability of the simulator. Training in laparoscopic surgery by developing basic skills in an environment outside the operating room, without time constraints, where trainees can

Conclusions

Using the LapSim virtual reality simulator, we documented a learning curve and test–retest reliability for each outcome variable for CN and LG for rank novices. For many CN variables, the learning curve reached a plateau in 8 hours or less, meaning 8 attempts is adequate for purposes of training. For most LG variables, the learning curve did not reach a plateau, indicating the task is more complex and training beyond 8 attempts is required.

References (18)

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