Does Warm-Up Training in a Virtual Reality Simulator Improve Surgical Performance? A Prospective Randomized Analysis

Aims Excellent surgical technical skills are of paramount importance to perform surgical procedures, safely and efficiently. Virtual reality surgical simulators can both simulate real operations while providing standardized, risk-free surgical hands-on experience. The integration of AI (artificial intelligence) and virtual reality simulators provides opportunities to carry out comprehensive continuous assessments of surgical performance. We developed and tested a deep learning algorithm which can continuously monitor and assess surgical bimanual performance on virtual reality surgical simulators. Methods Fifty participants from four expertise levels (14 experts/neurosurgeons, 14 senior residents, 10 junior residents, 12 medical students) performed a simulated subpial tumor resection 5 times and a complex simulated brain tumor operation once on the NeuroVR platform. Participants were asked to remove the tumors completely while minimizing bleeding and damage to surrounding tissues employing a simulated ultrasonic aspirator and bipolar forceps. A deep neural network continually tracked the surgical performance utilizing 16 performance metrics generated every 0.2-seconds. Results The deep neural network was successfully trained using neurosurgeons and medical students’ data, learning the composites of expertise comparing high and lower skill levels. The trained algorithm was able to score the technical skills of individuals continuously at 0.2-second intervals. Statistically significant differences in average scores were identified between the 4 groups. Conclusions AI-powered surgical simulators provide continuous assessment of bimanual technical skills during surgery which may further define the composites necessary to train surgical expertise. To our knowledge, this is the first attempt in surgery to continuously assess surgical technical skills using deep learning.

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Over the last few years, minimally invasive urological surgery has evolved towards less invasive, 'scarless' procedures. New surgical concepts, such as those of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been introduced. Mini-laparoscopy has been rediscovered in an attempt to reduce the invasiveness of standard laparoscopy. This study is the first to compare the perception of surgeons when first facing three different scarless options for performing a porcine nephrectomy and when dealing with the constraints of each technique. The study findings suggest that: (i) when first approaching these techniques, surgeons tend to perform equally well under expert guidance in the porcine model; (ii) mini-laparoscopy is perceived as less difficult to perform; (iii) for all the techniques, surgeon's impressions are in line with their expectations. • To evaluate the perception and performance of urological surgeons when first applying scarless surgical techniques. • The study was conducted during the 2(nd) Minimally Invasive Urological Surgical Week annual course in Braga, Portugal. • Fourteen attendees performed three porcine nephrectomies by using each of the following techniques: mini-laparoscopy, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopy. • Peri-operative data were recorded, and operating performance was scored by one experienced surgeon for each working station, using a global rating scale. • The surgeons' subjective perceptions of degree of difficulty were graded and their expectations before the procedures were recorded. • Forty-two porcine nephrectomies were performed. • There were no differences in overall operating time, or time to dissect and manage the renal vascular hilum, whereas time to gain access was faster for LESS than for mini-laparoscopy or NOTES-assisted laparoscopy (mean [sd] 8 [6] min vs 10.2 [5.3] min vs 9.9 [5.3] min, respectively; P = 0.59). • A better visualization of the surgical field was obtained with mini-laparoscopy and there was a higher degree of difficulty of bimanual dexterity for LESS, but no significant differences were found among the three techniques for any variable (operating field view: P = 0.52; bimanual dexterity: P = 0.49; efficiency: P = 0.77; tissue handling: P = 0.61; autonomy: P = 0.2). • Subjective perception of the degree of difficulty trended in favour of mini-laparoscopy (P= 0.17), but no significant difference was found in terms of surgeons' impression as compared with their expectations (P = 0.34). • When first approaching new scarless techniques, surgeons tend to perform equally well under expert guidance in the porcine model. • Mini-laparoscopy is perceived as less difficult to perform and, for all the techniques, surgeons' impressions are in line with their expectations.

Objective: The objective of this study is to compare the use of three-dimensional (3D) vision systems with traditional two-dimensional systems in laparoscopic urological surgery, analyzing the benefits, limitations, and impact of introducing this medical technology with regard to surgical performance and the surgeon's ergonomics. Methods: A systematic review with a structured bibliographic search was conducted in the electronic libraries (PubMed and EMBASE) until August 2019 and with no language restrictions. Studies on 3D visualization technology in laparoscopic urologic surgery, randomized controlled trials, and observational comparative studies were included. Relevant data were extracted and analyzed. Results: A total of 25 articles were obtained, of which 4 were clinical studies with patients, 2 studies were carried out in experimental animal models, and the remaining 19 were conducted in simulated environments. Regarding the European training program in basic laparoscopic urological skills, the results showed no significant differences in execution time using either imaging system. Three-dimensional vision led to a significant reduction in surgery time in pyeloplasty and radical nephrectomy. In addition, there was a reported decrease in blood loss in adrenalectomy, nephron-sparing nephrectomy, radical nephrectomy, simple nephrectomy, and pyeloplasty using 3D vision. Regarding ergonomics, the studies generally described no differences in side effects (headache, nausea, eye strain) when comparing the two types of visualization systems. Surgeons reported reduced workloads and stress with 3D vision than with traditional laparoscopy. Conclusions: Three-dimensional laparoscopic systems essentially advance surgical performance in less-experienced laparoscopic surgeons. Three-dimensional laparoscopy leads to improvements in surgery time, which is important for specific surgical procedures involving intracorporeal ligatures and sutures. The results achieved on the surgeons' ergonomics showed better depth perception and decreased stress and workloads during 3D vision with no differences in potential side effects.

Does Training Novices to Criteria and Does Rapid Acquisition of Skills on Laparoscopic Simulators Have Predictive Validity or Are We Just Playing Video Games?

Benchmarks for 3-D Systems (Simbionix) Bladder Flap Module for the Xi Robot: Differentiating Novice from Experienced and Expert Surgeons

To demonstrate the feasibility and potential of robotic single-site cholecystectomy, the study aimed to compare it with conventional laparoscopic cholecystectomy. In total, 791 consecutive patients underwent conventional laparoscopic cholecystectomy or robotic single-site cholecystectomy at our center between 2019 and 2022. After 1:1 propensity score matching, 117 patients for each group were selected. After propensity score matching, the only statistically significant difference between conventional laparoscopic cholecystectomy and robotic single-site cholecystectomy was operative time, which was 29.15 ±11.45 min in the conventional laparoscopic cholecystectomy group versus 38.57 ± 12.59 min in the robotic single-site cholecystectomy group (P < 0.001). Because the difference in surgical time between the two groups was minimal, it has little clinical relevance. Using cumulative sum analysis, the maturation phase of the total operation and docking times occurred after the 53rd case. To reduce bias, a comparison of results with conventional laparoscopic cholecystectomy and cases of robotic single-site cholecystectomy was performed in the maturation phase, which revealed only total operative time as statistically significant (P < 0.001). Robotic single-site cholecystectomy is a technically feasible and safe method for treating benign gallbladder diseases, with a relatively short learning curve and reasonable operative time.

Current Techniques of Teaching and Learning in Bariatric Surgical Procedures: A Systematic Review

Mindfulness meditation training has been shown to be feasible in surgical trainees, but affective, cognitive, and performance benefits seen in other high-stress populations have yet to be evaluated. To explore potential benefits to stress, cognition, and performance in postgraduate year 1 (PGY-1) surgery residents receiving modified mindfulness-based stress reduction (modMBSR). This follow-up study is an analysis of the Mindful Surgeon pilot randomized clinical trial of modMBSR (n = 12) vs an active control (n = 9), evaluated at baseline (T1), postintervention (T2), and 1 year (T3), took place at an academic medical center residency training program among PGY-1 surgery residents. Data were collected between June 2016 and June 2017 and analyzed from June 2017 to December 2017. Weekly 2-hour modMBSR classes and 20 minutes of daily home practice during an 8-week period vs an active control (different content, same structure). Preliminary evidence of efficacy was explored, primarily focusing on perceived stress and executive function and secondarily on burnout, depression, motor skill performance, and changes in blood oxygen level-dependent functional neuroimaging during an emotion regulation task. Group mean scores were calculated at T1, T2, and T3 and in linear mixed-effects multivariate analysis. Effect size for analysis of covariance is presented as partial η2 with the following cutoff points: small, less than 0.06; medium, 0.06 to 0.14; large, greater than 0.14. Postgraduate year 1 surgery residents (N = 21; 8 [38%] women) were randomized to a modMBSR arm (n = 12) or an active control arm (n = 9). Linear mixed-effects modeling revealed differences at T2 and T3 in perceived stress (mean [SD] difference at T2: modMBSR, 1.42 [5.74]; control, 3.44 [6.71]; η2 = 0.07; mean [SD] difference at T3: modMBSR, 1.00 [4.18]; control, 1.33 [4.69]; η2 = 0.09) and in mindfulness (mean [SD] difference at T2: modMBSR, 3.08 [3.63]; control, 1.56 [4.28]; η2 = 0.13; mean [SD] difference at T3: modMBSR, 2.17 [3.66]; control, -0.11 [6.19]; η2 = 0.15). Burnout at T2 (mean [SD] difference: modMBSR, 4.50 [9.08]; control, 3.44 [6.71]; η2 = 0.01) and T3 (mean [SD] difference: modMBSR, 5.50 [9.96]; control, 5.56 [9.69]; η2 = 0.01) showed similar increase in both groups. Working memory increased more at T2 in the modMBSR arm (mean [SD] difference, 0.35 [0.60]) than in the control arm (mean [SD] difference, 0.21 [0.74]; η2 = 0.02) and at T3 (modMBSR, 0.68 [0.69]; control, 0.26 [0.58]; η2 = 0.20). Cognitive control decreased more in the control arm at T2 (mean [SD] difference at T2: modMBSR, 0.15 [0.40]; control, -0.07 [0.32]; η2 = 0.13) and at T3 (mean [SD] difference: modMBSR, 0.07 [0.59]; control, -0.26 [0.53]; η2 = 0.16). Mean (SD) circle-cutting time improved more at T2 in the modMBSR arm (-24.08 [63.00] seconds) than in the control arm (-4.22 [112.94] seconds; η2 = 0.23) and at T3 in the modMBSR arm (-4.83 [77.94] seconds) than in the control arm (11.67 [145.17] seconds; η2 = 0.13). Blood oxygen level-dependent functional neuroimaging during an emotional regulation task showed unique postintervention activity in the modMBSR arm in areas associated with executive function control (dorsolateral prefrontal cortex) and self-awareness (precuneus). In this pilot randomized clinical trial, modMBSR in PGY-1 surgery residents showed potential benefits to well-being and executive function, suggesting a powerful role for mindfulness-based cognitive training to support resident well-being and performance, as mandated by the Accreditation Council for Graduate Medical Education. ClinicalTrials.gov identifier: NCT03141190.

Nephrostomy tract dilation is one of the important steps in percutaneous renal surgery. We present our experiences with using Amplatz and metal telescopic dilators (Alken) to create a percutaneous tract and compare the advantages and risk factors of both procedures. We retrospectively reviewed the medical records of 173 patients who had undergone 188 percutaneous nephrolithotomy procedures between April 2007 and December 2010. The nephrostomy tracts had been created by using Amplatz (67 cases) or Alken dilators (121 cases). Total operative time, scope time, tract formation time, decrease in hemoglobin concentrations, blood transfusion rates, tract dilation failures, and the cost of both systems were compared between the groups. There were no statistically significant differences in total operative time (103.3 ± 46.5 vs 99.1 ± 44.4 min, P=0.583), scope time (5.23 ± 3.06 vs 5.28 ± 2.52 min, P=0.732), decrease in hemoglobin concentration (-1.5 ± 1.2 vs-1.3 ± 1.1 mg/dL, P=0.230), blood transfusion rates (13.4% vs 11.6%, P=0.709), and tract dilation failure rates (6.0% vs 1.7%, P=0.107) for Amplatz and Alken dilation groups, respectively. A shorter tract formation time (6.56 ± 3.04 vs 5.42 ± 3.07 min, P<0.001) was observed in the Alken dilation group. The approximate costs per each case were $220 and $7.25 for Amplatz and Alken dilation groups, respectively. The Alken dilation technique produces similar results to the Amplatz dilators in terms of efficiency, safety, and total operative time. Notwithstanding, it is more cost-effective in comparison.

PurposeTo compare the effectiveness and safety of a 27-gauge (27G) beveled-tip microincision vitrectomy surgery (MIVS) with a 25-gauge (25G) flat-tip MIVS for the treatment of proliferative diabetic retinopathy (PDR).MethodsA prospective, single-masked, randomized, controlled clinical trial included 52 eyes (52 patients) with PDR requiring proliferative membrane removal. They were randomly assigned in a 1:1 ratio to undergo the 27G beveled-tip and or 25G flat-tip MIVS (the 27G group and the 25G group, respectively). During surgery, the productivity of cutting the membrane, the number of vitrectomy probe (VP) exchanges to microforceps, total operation time, vitrectomy time and intraoperative complications were measured. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) and postoperative complications were also assessed to month 6.ResultsForty-seven eyes (47 patients) completed the follow-up, including 25 in the 27G group and 22 in the 25G group. During surgery in the 27G group, cutting the membrane was more efficient (P = 0.001), and the number of VP exchanges to microforceps was lower (P = 0.026). The occurrences of intraoperative hemorrhages and electrocoagulation also decreased significantly (P = 0.004 and P = 0.022). There were no statistical differences in the total operation time or vitrectomy time between the two groups (P = 0.275 and P = 0.372), but the former was slightly lower in the 27G group. Additionally, the 27G group required fewer wound sutures (P = 0.044). All the follow-up results revealed no significant difference between the two groups.ConclusionsCompared with the 25G flat-tip MIVS, the 27G beveled-tip MIVS could be more efficient in removing the proliferative membrane while reducing the occurrence of intraoperative hemorrhages and electrocoagulation using appropriate surgical techniques and instrument parameters. Its vitreous removal performance was not inferior to that of the 25G MIVS and might offer potential advantages in total operation time. In terms of patient outcomes, advanced MIVS demonstrates equal effectiveness and safety to 25G flat-tip MIVS.Trial registrationThe clinical trial has been registered at Clinicaltrials.gov (NCT0544694) on 07/07/2022. And all patients in the article were enrolled after registration.

Objective:The aim of this study was to evaluate the effect of three training methodologies on the acquisition of psychomotor skills for laparoendoscopic single-site surgery (LESS), using straight and articulating instruments.Methods: A prospective study was conducted with subjects randomly divided into three groups, who performed a specific training for 12 days using three laparoscopic tasks in a laparoscopic simulator.Group-A trained in conventional laparoscopy setting using straight instruments and in LESS setting using both straight and articulating instruments.Group-B trained in LESS setting using straight and articulating instruments, whereas Group-C trained in LESS setting using articulating instruments.Participants' performance was recorded with a video-tracking system and evaluated with 12 motion analysis parameters (MAPs).Results: All groups obtained significant differences in their performance in most of the MAPs.Group-C showed an improvement in nine MAPs, with a high level of technical competence.Group-A presented a marked improvement in bimanual dexterity skills.Conclusions: Training in LESS surgery using articulating laparoscopic instruments improves the quality of skills and allows smoother learning curves.

To evaluate the efficacy and safety of submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) for upper gastroenterology submucosal tumors (SMT) originating from the muscularis propria (MP) layer. Clinicopathological and endoscopic data of 42 cases with upper gastroenterology tumors originating from the MP layer who were treated with STER (n=28) or ESE (n=14) between April 2013 and December 2016 in Peking University Third Hospital were retrospectively analyzed. The treatment and complications of the two groups were compared. In the study, 42 cases were all resected by therapeutic endoscopy successfully．There was no significant difference (STER vs. ESE) in gender, age, mean tumor size [1.5 (1.0-6.0) cm vs. 1.3 (0.5-2.0) cm, P=0.056]. STER was superior to ESE with reduced sutured time [3.5 (1.0-11.0) min vs. 8.0 (2.0-33.0) min, P=0.006], but more resection time [46.5 (11.0-163.0) min vs.19.5 (6.0-56.0) min, P=0.007]. There was statistical difference between the two groups in resection time or sutured time, but no significant difference (STER vs. ESE) in total operative time [52.0 (14.0-167.0) min vs. 31.5 (10.0-88.0) min, P=0.080]. En bloc resection rates (92.9% vs. 85.7%), hospital stay duration and complications (10.7 vs. 0.0) were similar in the STER and ESE groups. One case developed mediastinal emphysema and 2 pneumonia after operation in STER group, and all of them recovered uneventfully after conservative treatments; There were no complications in the ESE group. After operation, 28 cases of leiomyoma and 14 cases of stromal tumor were diagnosed by routine pathological and immunohistochemical staining. Among them, 6 cases of stromal tumors in group STER were all extremely low risk, 4 cases of stromal tumors in group ESE were extremely low risk, 4 cases of stromal tumors in group ESE were medium risk (the size of the lesion was about 1.0-2.0 cm, and mitotic figures counted (6-8)/50 high power field). The median follow-up time of all the patients was 46.5 (24-60) months, and the shortest follow-up time for medium risk stromal tumors was 32 months. No residual tumor, recurrence and implantation in the tunnel were observed. STER or ESE can be used as an effective and safe option for treatment of submucosal tumors originating from the muscularis propria of the upper digestive tract. Compared with STER, ESE had shorter resection time but longer wound closure time. There was no significant difference in total operation time.

Construction and Validation of a Low-Cost Laparoscopic Simulator for Surgical Education

Mixed reality technology can be applied to simulation training, improve surgical performance, enhance 3D game experience, and so on, attracting extensive attention of researchers. The perception of the user about head‐mounted display MR using HoloLens is critical, especially for precision applications such as virtual hoisting. Designing and adding appropriate depth cues in MR scenes is an effective way to improve users' depth perception. In this study, taking virtual hoisting training system as an example, the depth perception strategy of multi‐cue fusion is proposed to improve the perception effect. Based on the mechanism of human depth perception, five kinds of depth cues are designed. The depth perception effect of adding single cue is studied by perceptual matching experiment. Based on the principle of fuzzy clustering, a multiple‐cue comprehensive depth optimization strategy on viewing distance scale is proposed. Finally, the perceptual matching results demonstrate the effectiveness of the multi‐cue fusion strategy, and the average error is reduced by 20.68% compared with the single‐cue strategy, which can significantly improve the spatial depth perception. This research can provide a reference for improving users' depth perception in interactive MR simulation systems.

To determine the effect of warm-up on the performance of laparoscopic ovariectomy (LOVE) on a live dog by veterinary medical students. Randomized experimental, post-test only, control group design. A total of 15 fourth-year veterinary students with prior training in basic laparoscopy. Participants were randomly assigned to Group NW (n = 8), who did no warm-up, or Group W (n = 7), who engaged in a 30-min preoperative warm-up using a laparoscopic simulator and a laparoscopic video game (Underground). Laparoscopic surgical procedures were video-recorded and evaluated by a blinded board-certified surgeon (MF). The duration of surgery was recorded, and the student's performance was scored using a previously validated rubric. Outcomes were compared between groups with two-sample t-tests. The a priori significance was set to 0.05 (α = 0.05). The duration of surgery was 20 min less in Group W (M = 63; range: 58-86) compared to Group NW (M = 84; range: 58-86; ). Students in Group W achieved higher scores (M = 138.4; range: 122-152) than those in Group NW (M = 121.5; range: 106-130; ). Veterinary students who did warm-up on a laparoscopic simulator and laparoscopic video game just before LOVE effectively decreased surgical time and increased efficiency. This study is consistent with the findings in human medicine, supports the use of warm-up exercises in surgical trainee programs before performing laparoscopic surgeries on live animals.