Virtual Reality in Surgical Training current status and future prospects

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Virtual Reality in Surgical Training-current
status and future prospects-

• Sean Mackay, and Ara Darzi
• Imperial College School of Medicine
• St Marys Hospital campus

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Outline

• Surgical Competence
• Surgical Training
• Current assessment process
• New methods in assessment
• Virtual reality
• Future prospects

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Surgical Competence

• care of a surgical patient
• not all will require an operation
• have conditions that may require surgery
• many different surgical disciplines
• our unit is largely general surgery
• subspecialist colorectal interest

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Surgical Competence

• Diagnostic ability
• includes special tests, imaging etc
• Treatment plan
• a plan of management for this patient
• Technical ability
• in the operating room
• Post-operative care
• may be the key to the best results

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Technical ability

• Judgement
• deciding on the course of action, intra-op
• Knowledge
• knowing how to implement that plan
• Dexterity
• execution of the plan

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Example - technical ability

• Mesenteric ischaemia
• poor blood supply to the gut
• various causes
• Options
• do nothing
• resection /- anastomosis
• second look laparotomy

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Surgical training

• medical course is 5 or 6 years
• houseman year is pre-registration
• senior house officer for at least 2 years
• ATLS, BSSC, MRCS
• specialist registrar for 6 years
• four general, two subspecialist
• CCST exam in final year

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Recent changes

• formerly had senior registrars
• qualified FRCS at about SHO/SpR level
• no consultant post
• continued to work as registrars
• Calman report/ reforms
• lately the new deal for SHOs
• fewer hours worked

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Training

• Mentor style program
• change jobs each year
• several consultants on each unit
• Apprenticeship
• supervision
• guidance
• experience

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Training

• however, often the supervision and guidance were
  lacking
• concerns increased with Calman and new deal
• shorter training
• less intense

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Training

• response has been to make training more formal
• in training assessment
• skills courses, eg BSSC
• evaluation of training by trainees
• still hampered by the old perceptions
• RCS etc are pursuing better training

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Components of training
Practice Training Assessment
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Current assessment

• without feedback, there is no training
• current assessment
• in-training reports
• logbook
• examinations (not of technical skill)
• hence there is a large gap in training in
  technical skill
• mentor advice

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New assessment methods

• OSATS
• ICSAD
• Skills Course
• Virtual Reality
• Competence exams

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OSATS

• objective structured assessment of technical
  skill
• described by Martin, Reznick et al
• standardised task
• trained observer
• checklist of task components
• global assessment of performance

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OSATS

• revolutionary idea in this area
• validated as a technique on a task-by-task basis
• shortcomings
• better for simple tasks
• labour intensive
• next development will be in error detection

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Error detection

• looks at mistakes rather than building blocks
  of a given task
• allows insight into the subjects capacity for
  monitoring own performance
• has potential for use in more complex tasks than
  previous OSATS

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ICSAD

• Imperial College Surgical Assessment Device
• electromagnetic tracking of the hands
• software analysis of Cartesian coordinates
• data on movements, pathlength, and time
• developed and validated within our unit

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2/0 PG at depth movements
p lt 0.001
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2/0 PG at depth time
p 0.006
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Movement/Time
Rsq 0.88 (Senior), and 0.99
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Movement/Time

• Spearman correlation 0.93
• partial (group) 0.99
• relationship is not fixed (previous work)
• Regression analysis
• interaction seniority and time
• observed b/n groups p lt 0.001
• GLM - univariate

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Comparison of motion and video analysis for small
bowel anastomosis
Motion Analysis
Video Analysis Global Scoring
A SHO B SPR 1-2 C SPR 3-4 D SPR 5-6 E
CONSULTANT
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Skills Course

• concept is to assess during skills training
• subjects have different prior experience
• confusion between training and assessment
• slow down the course, so less could be taught
• current system is a simple satisfactory or not
  assessment

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Virtual Reality

• several potential advantages
• has a research role only at this point in time
• several systems seem to be close to real utility
  in training
• one problem current training is during service
  time

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VR Advantages

• no patient involved
• discomfort
• embarrassment at slow progress
• risk from less competent practitioner
• perception of being experimented upon
• slow the progress of the surgical caseload

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VR Advantages

• repeated trials are possible
• one component of a task, or the whole task
• specific feedback directed towards weaknesses
• same circumstances or slightly different
• allows replay of what was done for later
  discussion

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VR advantages

• sensitive data collection
• even more so than a video of a real task
• allows more precise assessment of performance
• allows more detailed feedback on the various
  parameters

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VR disadvantages

• not ready yet
• potentially expensive
• high-fidelity v low fidelity
• content based v task based
• this question is far from settled
• generalise from a low fidelity task, or have
  real practice on a high fidelity one

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Competence Day

• new concept
• much support from RCS
• OSCE in technical skills
• part of MRCS, ? CCST
• present for exam when ready
• several components
• VR a component of our SHO exam

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Six station OSCE
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Panel of tasks

• knowledge of instruments
• knot formation
• suturing skin wound
• excise sebaceous cyst
• closure of enterotomy
• MIST VR laparoscopy trainer

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Competence Day

• each task independently evaluated and validated
• examine the trainee against the performance of
  his/her peers, and that of senior colleagues

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MIST VR
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MIST VR
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MIST VR

• non-fidelity simulation
• validated
• performance is indicative of level of ability
• not yet as a training tool
• trials have been lacking
• some early work on TER to conventional closed box
  trainer

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Prosolvia Shoulder
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Prosolvia Shoulder
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Prosolvia Shoulder
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Prosolvia Shoulder

• initial validation failed
• seniors scored worse and worse
• Prosolvia Medical bought out by Mentice
• dual pentium PC
• improved software
• knee arthroscopy
• generic tasks under development

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HT Sigmoidoscope
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HT Sigmoidoscope
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HT sigmoidoscope

• endoscopic procedures well suited to VR
• minimal need for haptics
• conventionally viewed on a screen
• quite short procedures
• large need for training
• initial validation in our department

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HT bronchoscope
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HT pacemaker
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ReachIn
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Summary

• surgical training and assessment are closely
  linked
• new approaches are being developed, in response
  to recent pressures
• VR offers unique advantages, and several systems
  are close to being suitable for implementation as
  part of training

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Acknowledgements

• Virtual Presence www.vrweb.com
• HT Medical www.ht.com
• Mentice www.mentice.com
• ReachIn www.reachin.se
• RACS www.racs.edu.au