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Background: It is currently unclear what the added value is of 3D-laparoscopy during pancreatic and biliary surgery. 3D-laparoscopy could improve procedure time and/or surgical performance, for instance in demanding anastomoses such as pancreatico- and hepaticojejunostomy. The impact of 3D-laparoscopy could be negligible in more experienced surgeons., Methods: We conducted a randomized controlled cross-over trial including 20 expert laparoscopic surgeons and 20 surgical residents from 9 countries (Argentina, Estonia, Israel, Italy, the Netherlands, South Africa, Spain, UK, USA). All participants performed a pancreaticojejunostomy (PJ) and a hepaticojejunostomy (HJ) using 3D- and 2D-laparoscopy on biotissue organ models according to the Pittsburgh method. Primary endpoint was the time required to complete both anastomoses. Secondary endpoint was the objective structured assessment of technical skill (OSATS; range 12-60) rating. Observers were blinded for 3D/2D and expertise., Results: A total of 40 participants completed 144 PJs and HJs. 3D-laparoscopy reduced the operative time with 15.5 min (95%CI 10.2-24.5 min), from 81.0 to 64.4 min, p = 0.001. This reduction was observed for both experts and residents (13.0 vs 22.2 min, intergroup significance p = 0.354). The OSATS improved with 5.1 points, SD ± 6.3, with 3D-laparoscopy, p = 0.001. This improvement was observed for both experts and residents (4.6 vs 5.6 points, p = 0.519). Of all participants, 37/39 participants stated to prefer 3D laparoscopy whereas 14/39 reported side effects. Minor side effects were reported by 10/39 participants whereas 2/39 participants reported severe side effects (both severe eye strain)., Conclusion: 3D-laparoscopy, as compared to 2D-laparoscopy, reduced the operative time and improved surgical performance for PJ and HJ anastomoses in both experts and residents with mostly minor side effects., (Copyright © 2019 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Virtual reality (VR-)trainers are well integrated in laparoscopic surgical training. However, objective feedback is often provided in the form of single parameters, e.g., time or number of movements, making comparisons and evaluation of trainees' overall performance difficult. Therefore, a new standard for reporting outcome data is highly needed. The aim of this study was to create a weighted, expert-based composite score, to offer simple and direct evaluation of laparoscopic performance on common VR-trainers., Materials and Methods: An integrated analytic hierarchy process-Delphi survey was conducted with 14 international experts to achieve a consensus on the importance of different skill categories and parameters in evaluation of laparoscopic performance. A scoring algorithm was established to allow comparability between tasks and VR-trainers. A weighted composite score was calculated for basic skills tasks and peg transfer on the LapMentor™ II and III and validated for both VR-trainers., Results: Five major skill categories (time, efficiency, safety, dexterity, and outcome) were identified and weighted in two Delphi rounds. Safety, with a weight of 67%, was determined the most important category, followed by efficiency with 17%. The LapMentor™-specific score was validated using 15 (14) novices and 9 experts; the score was able to differentiate between both groups for basic skills tasks and peg transfer (LapMentor™ II: Exp: 86.5 ± 12.7, Nov. 52.8 ± 18.3; p < 0.001; LapMentor™ III: Exp: 80.8 ± 7.1, Nov: 50.6 ± 16.9; p < 0.001)., Conclusion: An effective and simple performance measurement was established to propose a new standard in analyzing and reporting VR outcome data-the Heidelberg virtual reality (VR) score. The scoring algorithm and the consensus results on the importance of different skill aspects in laparoscopic surgery are universally applicable and can be transferred to any simulator or task. By incorporating specific expert baseline data for the respective task, comparability between tasks, studies, and simulators can be achieved.

Background: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training., Methods: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations., Results: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students., Discussion: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities., Conclusion: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Background: Equipment-related malfunctions directly relate to one-fourth of the adverse events in the surgical theater. A serious game trains residents to recognize and respond to equipment problems in minimally invasive surgery (MIS). These include disturbed vision, gas transport, electrocautery, and pathophysiological disturbances. This randomized controlled trial explores whether game-based training improves surgical residents' response to equipment-related problems during surgery., Methods: Thirty-one surgical residents with no previous experience in MIS took part in a standardized basic laparoscopy training course. Fifteen residents were randomly assigned to the game-enhanced curriculum (intervention) and sixteen were assigned to the regular curriculum (control). Participants performed a MIS task in a live anesthetized pig model, during which three standardized equipment malfunction scenarios occurred. Observers recorded the problems recognized and solved, time, and participants' technical performance., Results: Twenty-four participants completed the post-test (n = 12 per group). The intervention group solved more problems than the control group (59 vs. 33%, p = 0.029). The intervention group also recognized a larger proportion of problems, although this parameter was non-significant (67 vs. 42%, p = 0.14). Random effects modeling showed a significant improved game performance per participant over time., Conclusions: Surgical residents, who play for only 1 h on a custom-made serious game, respond significantly better to equipment-related problems during surgery than residents trained by a standard training curriculum. These results imply that entertaining serious games can indeed be considered for use in official training for surgeons and other medical specialists.

Purpose: Arthroscopy has assumed an important place in wrist surgery. It requires specific operative skills that are now mainly acquired in the operating room. In other fields of endoscopic surgery, e-learning and virtual reality (VR) have introduced new perspectives in teaching skills. This leads to the following research question: Could the current way of teaching wrist arthroscopy skills be supported using new educational media, such as e-learning and simulator training?, Method: The literature was searched for available methods of teaching endoscopic skills. Articles were assessed on the evidence of validity. In addition, a survey was sent to all members of the European Wrist Arthroscopy Society (EWAS) to find out whether hand surgeons express a need to embrace modern educational tools such as e-learning or simulators for training of wrist arthroscopy skills., Results: This study shows that the current way of teaching wrist arthroscopy skills can be supported using new educational media, such as e-learning and simulator training. Literature indicates that e-learning can be a valuable tool for teaching basic knowledge of arthroscopy and supports the hypothesis that the use of virtual reality and simulators in training enhances operative skills in surgical trainees. This survey indicates that 55 out of 65 respondents feel that an e-learning program would be a valuable asset and 62 out of the 65 respondents are positive on the additional value of wrist arthroscopy simulator in training., Conclusion: Study results support the need and relevance to strengthen current training of wrist arthroscopy using e-learning and simulator training., Level of Evidence: V.

Background: Surgical errors result from faulty decision-making, misperceptions and the application of suboptimal problem-solving strategies, just as often as they result from technical failure. To date, surgical training curricula have focused mainly on the acquisition of technical skills. The aim of this review was to assess the validity of methods for improving situational awareness in the surgical theatre., Methods: A search was conducted in PubMed, Embase, the Cochrane Library and PsycINFO using predefined inclusion criteria, up to June 2014. All study types were considered eligible. The primary endpoint was validity for improving situational awareness in the surgical theatre at individual or team level., Results: Nine articles were considered eligible. These evaluated surgical team crisis training in simulated environments for minimally invasive surgery (4) and open surgery (3), and training courses focused at training non-technical skills (2). Two studies showed that simulation-based surgical team crisis training has construct validity for assessing situational awareness in surgical trainees in minimally invasive surgery. None of the studies showed effectiveness of surgical crisis training on situational awareness in open surgery, whereas one showed face validity of a 2-day non-technical skills training course., Conclusion: To improve safety in the operating theatre, more attention to situational awareness is needed in surgical training. Few structured curricula have been developed and validation research remains limited. Strategies to improve situational awareness can be adopted from other industries., (© 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.)

Background: Equipment-related malfunctions during minimally invasive surgery (MIS) are common and threaten patient safety. As they occur in the periphery of the surgeon's vision, the surgical team requires a high level of situational awareness in order to intercept these errors timely. A serious game has been developed to train surgical residents to deal with equipment-related errors. This study investigates to what extent surgical educators and trainees would accept a serious game as a training method., Materials and Methods: A cross-sectional survey was conducted among 45 surgeons, surgical residents, and medical students who played the serious game at a scientific convention. The questionnaire contained statements on perceived realism, usefulness, teaching capability, user experience and application toward surgical training. RESULTS were analyzed according to participants' MIS experience ("expert," "intermediate," and "novice")., Results: The majority found that important medical constructs are represented realistically (64.4%-88.9%) and indicated the game to be particularly useful for training operating room nurses and surgical residents (75%-86%). Both educators and trainees found the game to be useful for surgical training (53%). Serious gaming was viewed as positive (78%) and challenging (60%), and 66% would play the game in their leisure time. Licensed surgeons perceived the game more frequently as boring than the intermediate-level and trainee groups (23.5% versus 6.7% and 8.3%; P=.045)., Conclusions: This is the first study to show acceptance of a serious game as a training format in surgical training by educators and trainees. Future research should investigate whether the serious game indeed improves problem-solving and situational awareness in the operating room.

In dynamic, high-risk environments such as the modern operating theatre, healthcare providers are required to identify a multitude of signals correctly and in time. Errors resulting from failure to identify or interpret signals correctly lead to calamities. Medical training curricula focus largely on teaching technical skills and knowledge, not on the cognitive skills needed to interact appropriately with fast-changing, complex environments in practice. The term 'situational awareness' describes the dynamic process of receiving, interpreting and processing information in such dynamic environments. Improving situational awareness in high-risk environments should be part of medical curricula. In addition, the flood of information in high-risk environments should be presented more clearly and effectively. It is important that physicians become more involved in this regard.

Background: Equipment malfunction accounts for approximately one-fourth of surgical errors in the operating room. A serious game was developed to train surgeons in recognizing and responding to equipment failure in minimally invasive surgery (MIS) adequately. This study determined the baseline performance of surgeons, surgical residents, surgical novices, and MIS equipment technicians in solving MIS equipment failure., Methods: The serious game included 37 problem scenarios on the subjects lighting and imaging, insufflation and gas transport, electrosurgery, and pathophysiological disturbances. The scenarios were validated by laparoscopic surgeons and MIS equipment specialists. Forty-nine licensed surgeons, surgical residents, medical students, and MIS equipment specialists played four sessions on the serious game at a surgical convention. Scores on different outcome parameters were compared between groups of a different MIS experience., Results: Laparoscopic equipment specialists solved significantly more MIS equipment-related problems than surgical novices, intermediates, and experts (68.9 vs. 51.0 %, 51.4, and 45.0 %, respectively, p = 0.01). Laparoscopic equipment specialists required significantly fewer steps to solve a problem accurately (median of 1.0 vs. 2.0 for the other groups). Most notably, experienced surgeons were unable to outperform novice and intermediate groups. Experienced surgeons took less time to solve the problems, but made more mistakes in doing so., Conclusions: Experienced surgeons did not outperform inexperienced surgeons in dealing with laparoscopic equipment failure. These results are worrying and need to be addressed by the surgical community.

Objective: The LAP Mentor is a procedural simulator that provides a stepwise training for laparoscopic cholecystectomy. This study addresses its "construct" validity that is present when a simulator is able to discriminate between persons with known differences in performance level on the laparoscopic cholecystectomy in real life., Design: Three groups with different skill levels performed 2 trials of 4 distinct parts of the cholecystectomy procedure (cholecystectomy exercises) and 1 full procedure on the LAP Mentor. Assessment parameters concerning the quantity and the quality of performance were compared between groups using the Kruskal-Wallis and Mann-Whitney U tests., Setting: The entire research was performed in the Center for Surgical Technologies, Leuven, Belgium., Participants: For study purposes, 5 expert abdominal laparoscopists (>100 laparoscopic cholecystectomies performed), 11 surgical residents (10-30 cholecystectomies performed), and 10 novices (minimal laparoscopic experience) were recruited., Results: With regard to the quantity of performance (time needed and number of movements), the experts showed significantly better results compared with the novices in the cholecystectomy exercises. Only in the full procedure, the results of all the parameters (except speed) were significantly different between the 3 groups, with the best results observed for the experts and worst for the novices. With respect to quality of performance, only the parameter "accuracy rate of dissection" in exercise 3 showed significantly better performance by the experts., Conclusions: Only the full procedure of the LAP Mentor procedural simulator has enough discriminative power to claim construct validity. However, the lack of quality control, which is indispensible in the evaluation of procedural skills, makes it currently unsuited for the assessment of procedural laparoscopic skills. The role of the simulator in a training context remains to be elucidated., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The application of digital games for training medical professionals is on the rise. So-called 'serious' games form training tools that provide a challenging simulated environment, ideal for future surgical training. Ultimately, serious games are directed at reducing medical error and subsequent healthcare costs. The aim was to review current serious games for training medical professionals and to evaluate the validity testing of such games., Methods: PubMed, Embase, the Cochrane Database of Systematic Reviews, PsychInfo and CINAHL were searched using predefined inclusion criteria for available studies up to April 2012. The primary endpoint was validation according to current criteria., Results: A total of 25 articles were identified, describing a total of 30 serious games. The games were divided into two categories: those developed for specific educational purposes (17) and commercial games also useful for developing skills relevant to medical personnel (13). Pooling of data was not performed owing to the heterogeneity of study designs and serious games. Six serious games were identified that had a process of validation. Of these six, three games were developed for team training in critical care and triage, and three were commercially available games applied to train laparoscopic psychomotor skills. None of the serious games had completed a full validation process for the purpose of use., Conclusion: Blended and interactive learning by means of serious games may be applied to train both technical and non-technical skills relevant to the surgical field. Games developed or used for this purpose need validation before integration into surgical teaching curricula., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objective: To obtain face and construct validity for a new training course to be used in any type of box/video trainer and to give a comprehensive overview of validated exercises for box/video training., Design: Cross-sectional study., Setting: University Medical Centre., Population: Students, residents and consultants., Methods: Participants (n = 42) were divided into three groups according to their laparoscopic experience: 'Novices' (n = 18), 'Intermediates' (n = 14) and 'Experts' (n = 10). A laparoscopic training course consisting of six exercises was constructed. To emphasise precision, a penalty score was added. Every participant performed two repetitions of the exercises; total score per exercise was calculated. To determine face validity, participants filled in a questionnaire after completion of the exercises. An evidence-based literature search for validated box/video trainer exercises was performed., Main Outcome Measures: Face and construct validity., Results: The mean score of the 'experts' was set as the training target. Total scores appeared to be positively correlated with individual's laparoscopic experience. The overall score and the score for each exercise were significantly higher in the intermediate and expert groups when compared with the novice group (P ≤ 0.001). All participants completed the questionnaire. The overall assessment of the exercises was considered to be good. The course was found to be most appropriate for training residents year 1-3., Conclusion: Face and construct validity for an inexpensive course for box/video training was established. A comprehensive and practical overview of all validated and published exercises for box/video trainers is provided to facilitate an inexpensive, but optimal and tailored selection for training purposes., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)

Background: A frequently heard comment is that the current "Playstation generation" will have superior baseline psychomotor skills. However, research has provided inconsistent results on this matter. The purpose of this study was to investigate whether the "Playstation generation" shows superior baseline psychomotor skills for endoscopic surgery on a virtual reality simulator., Methods: The 46 study participants were interns (mean age 24 years) of the department of surgery and schoolchildren (mean age 12.5 years) of the first year of a secondary school. Participants were divided into four groups: 10 interns with videogame experience and 10 without, 13 schoolchildren with videogame experience and 13 without. They performed four tasks twice on a virtual reality simulator for basic endoscopic skills. The one-way analysis of variance (ANOVA) with post hoc test Tukey-Bonferroni and the independent Student's t test were used to determine differences in mean scores., Results: Interns with videogame experience scored significantly higher on total score (93 vs. 74.5; p=0.014) compared with interns without this experience. There was a nonsignificant difference in mean total scores between the group of schoolchildren with and those without videogame experience (61.69 vs. 55.46; p=0.411). The same accounts for interns with regard to mean scores on efficiency (50.7 vs. 38.9; p=0.011) and speed (18.8 vs. 14.3; p=0.023). In the group of schoolchildren, there was no statistical difference for efficiency (32.69 vs. 27.31; p=0.218) or speed (13.92 vs. 13.15; p=0.54). The scores concerning precision parameters did not differ for interns (23.5 vs. 21.3; p=0.79) or for schoolchildren (mean 15.08 vs. 15; p=0.979)., Conclusions: Our study results did not predict an advantage of videogame experience in children with regard to superior psychomotor skills for endoscopic surgery. However, at adult age, a difference in favor of gaming is present. The next generation of surgeons might benefit from videogame experience during their childhood.

Background: Virtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program., Methods: A consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the t test for equality of means., Results: Consensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference., Conclusions: A European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.

Background: A demand for safe, efficient laparoscopic training tools has prompted the introduction of virtual reality (VR) laparoscopic simulators, which might be used for performance assessment. The purpose of this review is to determine the value of VR metrics in laparoscopic skills assessment., Data Sources: An exhaustive search of the MEDLINE and EMBASE databases was performed to identify publications concerning construct, concurrent and predictive validation of VR simulators. Of 643 publications found, 42 were included in this review. Studies into all 3 types of validation showed a large heterogeneity in study design. Although concurrence of VR metrics with box trainer metrics, mental aptitude tests, and in vivo surgical performance was generally weak, several metrics demonstrated construct validity in selected simulators., Conclusions: Using the right simulator, tasks, and metrics, trainees' and experts' laparoscopic skills can reliably be compared. However, VR simulators cannot yet predict levels of real life surgical skills., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Although the objective in European Union and North American surgical residency programmes is similar-to train competent surgeons-residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula., Methods: At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used., Results: No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P < 0.001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0.001) and OSATS global rating scale (P < 0.001) scores., Conclusion: Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly., ((c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

Background: Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation., Methods: A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education., Results: The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence., Conclusions: In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.

This study assesses the issue of voluntary training of a standardized online competition (serious gaming) between surgical residents. Surgical residents were invited to join a competition on a virtual reality (VR) simulator for laparoscopic motor skills. A final score was calculated based on the task performance of three exercises and was presented to all the participants through an online database on the Internet. The resident with the best score would win a lap-top computer. During three months, 31 individuals from seven hospitals participated (22 surgical residents, 3 surgeons and six interns). A total of 777 scores were logged in the database. In order to out-perform others some participants scheduled themselves voluntarily for additional training. More attempts correlated with higher scores. The serious gaming concept may enhance voluntary skills training. Online data capturing could facilitate monitoring of skills progression in surgical trainees and enhance (VR) simulator validation.

Introduction: Virtual reality (VR) simulators have been developed to train basic endoscopic surgical skills outside of the operating room. An important issue is how to create optimal conditions for integration of these types of simulators into the surgical training curriculum. The willingness of surgical residents to train these skills on a voluntary basis was surveyed., Methods: Twenty-one surgical residents were given unrestricted access to a VR simulator for a period of four months. After this period, a competitive element was introduced to enhance individual training time spent on the simulator. The overall end-scores for individual residents were announced periodically to the full surgical department, and the winner was awarded a prize., Results: In the first four months of study, only two of the 21 residents (10%) trained on the simulator, for a total time span of 163 minutes. After introducing the competitive element the number of trainees increased to seven residents (33%). The amount of training time spent on the simulator increased to 738 minutes., Conclusions: Free unlimited access to a VR simulator for training basic endoscopic skills, without any form of obligation or assessment, did not motivate surgical residents to use the simulator. Introducing a competitive element for enhancing training time had only a marginal effect. The acquisition of expensive devices to train basic psychomotor skills for endoscopic surgery is probably only effective when it is an integrated and mandatory part of the surgical curriculum.

Background: The SIMENDO is an affordable virtual reality simulator designed to train basic psychomotor skills for endoscopic surgery. This study aimed first to establish construct validity by determining which parameters can discriminate groups with different experience levels, and second to establish the extent to which training is useful by determining when inexperienced groups reach expert level., Methods: The study participants were divided into four groups according to their experience with endoscopic procedures: experienced group (group A, >50 procedures performed, n = 15), intermediate group (group B, 1-50 procedures performed, n = 18), endoscope navigation group (group C, endoscope navigation experience, n = 14), and novice group (group D, no endoscopic experience, n = 14). Each participant performed three repetitions of six consecutive exercises. The parameters studied were task time, path length of the instruments, and number of errors (collisions). Some participants continued training up to 10 repetitions to get insight in the learning curve., Results: Group A (expert) outperformed all the other groups (B, C, and D) in terms of total median task time (p < 0.05), groups C and D in terms of path length, and group D in terms of collision frequency in the first two repetitions. Group B (intermediate) outperformed group D (novice) in total time and endoscope path length for all repetitions, and group C (camera navigation) outperformed group D (novice) in the first repetition. Less experienced groups D and C did not reach expert level for the task time within 10 repetitions, and group B reached it after the eighth repetition (p < 0.05)., Conclusion: The study was able to establish construct validity for the training program with the simulator under study. The learning curve showed that training with this simulator is useful for subjects with or without limited endoscopic experience. Furthermore, previous endoscopic camera navigation already improves motor skills to more than the basic level.

Background: Virtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden)., Methods: Forty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer., Results: The higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters., Conclusions: Our results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

Background: This study was undertaken to investigate operating room performance of surgical residents, after participating in the Eindhoven virtual reality laparoscopic cholecystectomy training course. This course is the first formal surgical resident trainings course, using a variety of complementary virtual reality (VR) skills training simulation in order to prepare surgical residents for their first laparoscopic cholecystectomy. The course was granted EAES certification., Methods: The four-day course is based on multimedia and multimodality approach. A variety of increasingly difficult simulation training sessions, next to intimate focus-group "knowledge sessions" are included. Both basic and procedural VR simulation is featured, using MIST-VR and the Xitacts' LapChol simulation software. The operating room performance of twelve surgical residents who participated in the course and twelve case-control counterparts were compared. The case-control group was matched for clinical number laparoscopic cholecystectomy performance (maximum of 4 procedures). Two observers analyzed a randomly mixed videotape, featuring the part of the "clip-and-cut" procedure of the laparoscopic cholecystectomy, and were blinded for participants' group status. Structured questionnaires including multiple observation scales were used to assess performance., Results: Residents of both the experimental and control group did not differ in demographic parameters, except for number of laparoscopic cholecystectomies in favor of the control group (p-value 0.008). Both observers judge the experimental group to perform significantly better (p-value 0.004 and 0.013). Experimental group residents valued their course highly in terms of their laparoscopic surgical skills improvement and the use of VR simulators in the surgical curriculum., Conclusions: The Eindhoven Virtual Reality laparoscopic cholecystectomy training course improves surgical skill in the operating room above the level of residents trained by a variety of other training methods.

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

Background: This study was undertaken to establish the value of the Advanced Dundee Psychomotor Tester (ADEPT) as an objective real-time scoring system, correcting for subjective assessor opinion on endoscopic task performance. The main research questions were as follows: Are surgeons good estimators of their own performance on ADEPT? Do surgeons perceive ADEPT to be a valid instrument for measuring laparoscopic skills? Does performance on ADEPT reflect innate psychomotor ability?, Methods: Each of 45 surgeons completed two runs on ADEPT. The runs comprised five standardized tasks. A posttest visual analog scaled (VAS) questionnaire measuring attitude toward skills testing in general, validation, and performance on ADEPT was used. Subjective responses were compared with objective scores generated through performance on ADEPT., Results: Surgeons emphasize the importance of using a variety of training methods for surgical residents during their residency, including laparoscopic virtual reality simulators. Monitoring of residents' endoscopic progress seemed to be a key issue. Surgeons themselves underestimate their individual performance on ADEPT (mean subjective score of 6.1 vs mean objective score of 6.6). Self-reported performance on ADEPT is unreliable because confidence intervals between the VAS score and the ADEPT score overlap. Surgeons disagree on the validity of ADEPT. The mean score for validity was 5.8, ranging from 0 to 10 with almost equal distribution over the scale. Innate ability is established as surgeons' scores express high concordance between test run and true run, with 72.7% of the participants' true run score within one distance from the test run., Conclusions: Surgeons cannot correctly predict their standardized individual test result on ADEPT. Performance on ADEPT reflects innate psychomotor ability along with improvement over runs. Surgeons are ambivalent in assessing the validity of ADEPT, irrespective of personal performance.