Background Distractions during surgical procedures have been linked to medical error and team inefficiency. This systematic review identifies the most common and most significant forms of distraction in order to devise guidelines for mitigating the effects of distractions in the OR. Methods In January 2015, a PubMed and Google Scholar search yielded 963 articles, of which 17 (2%) either directly observed the occurrence of distractions in operating rooms or conducted a laboratory experiment to determine the effect of distraction on surgical performance. Results Observational studies indicated that movement and case-irrelevant conversation were the most frequently occurring distractions, but equipment and procedural distractions were the most severe. Laboratory studies indicated that (1) auditory and mental distractions can significantly impact surgical performance, but visual distractions do not incur the same level of effects; (2) task difficulty has an interaction effect with distractions; and (3) inexperienced subjects reduce their speed when faced with distractions while experienced subjects did not. Conclusion This systematic review suggests that operating room protocols should ensure that distractions from intermittent auditory and mental distractions are significantly reduced. In addition, surgical residents would benefit from training for intermittent auditory and mental distractions in order to develop automaticity and high skills performance during distractions, particularly during more difficult surgical tasks. It is unclear as to whether training should be done in the presence of distractions or distractions should only be used for post-training testing of levels of automaticity.

Background The Fundamentals of Laparascopic Surgery (FLS) trainer box is now established as a standard for evaluating minimally invasive surgical skills. A particularly simple task in this trainer box is the peg transfer task which is aimed at testing the surgeon’s bimanual dexterity, hand-eye coordination, speed and precision. The Virtual Basic Laparoscopic Skill Trainer (VBLaST©) is a virtual version of the FLS tasks which allows automatic scoring and real time, subjective quantification of performance without the need of a human proctor. In this paper we report validation studies of the VBLaST© peg transfer (VBLaST-PT©) simulator. Methods Thirty-five subjects with medical background were divided into two groups: experts (PGY 4-5, fellows and practicing surgeons) and novices (PGY 1-3). The subjects were asked to perform the peg transfer task on both the FLS trainer box and the VBLaST-PT© simulator and their performance was evaluated based on established metrics of error and time. A new length of trajectory (LOT) metric has also been introduced for offline analysis. A questionnaire was used to rate the realism of the virtual system on a 5-point Likert scale. Results Preliminary face validation of the VBLaST-PT© with 34 subjects rated on a 5-point Likert scale questionnaire revealed high scores for all aspects of simulation, with 3.53 being the lowest mean score across all questions. A two-tailed Mann-Whitney performed on the total scores showed significant (p=0.001) difference between the groups. A similar test performed on the task time (p=0.002) and the length of trajectory (p=0.004) separately showed statistically significant differences between the experts and novice groups (p<0.05). The experts appear to be traversing shorter overall trajectories in less time than the novices. Conclusion VBLaST-PT© showed both face and construct validity and has promise as a substitute for the FLS to training peg transfer skills.

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.

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Background Studies on a virtual reality simulator have demonstrated that sleep-deprived residents make more errors. Work-hour restrictions were implemented, among other reasons, to ensure enough sleep time for residents. The objective of this study was to assess the effects of sleep time, perceived fatigue, and experience on surgical performance. We hypothesized that performance would decrease with less sleep and fatigue, and that experienced surgeons would perform better than less experienced surgeons despite sleep deprivation and fatigue. Methods Twenty-two surgical residents and attendings performed a peg transfer task on two simulators: the Fundamentals of Laparoscopic Skills (FLS) trainer and the Virtual Basic Laparoscopic Surgical Trainer (VBLaST©), a virtual version of the FLS. Participants also completed questionnaires to assess their fatigue level and recent sleep hours. Each subject performed 10 trials on each simulator in a counterbalanced order. Performance was measured using the FLS normalized scores, and analyzed using a multiple regression model. Results The multiple regression analysis showed that sleep hours and perceived fatigue were not covariates. No correlation was found between experience level and sleep hours or fatigue. Sleep hours and fatigue did not appear to affect performance. Expertise level was the only significant determinant of performance in both FLS and VBLaST©. Conclusions Restricting resident work-hours was expected to result in less fatigue and better clinical performance. In our study, peg transfer task performance was not affected by sleep hours. Experience level was a significant indicator of performance. Further examination of the complex relationship between sleep hour, fatigue, and clinical performance is needed to support the practice of work-hour restriction for surgical residents.

In interventional radiology, physicians require high haptic sensitivity and fine motor skills development because of the limited real-time visual feedback of the surgical site. The transfer of this type of surgical skill to novices is a challenging issue. This paper presents a study on the design of a biopsy procedure learning system. Our methodology, based on a task-centered design approach, aims to bring out new design rules for virtual learning environments. A new collaborative haptic training paradigm is introduced to support human-haptic interaction in a virtual environment. The interaction paradigm supports haptic communication between two distant users to teach a surgical skill. In order to evaluate this paradigm, a user experiment was conducted. Sixty volunteer medical students participated in the study to assess the influence of the teaching method on their performance in a biopsy procedure task. The results show that to transfer the skills, the combination of haptic communication with verbal and visual communications improves the novices’ performance compared to conventional teaching methods. Furthermore, the results show that, depending on the teaching method, participants developed different needle insertion profiles. We conclude that our interaction paradigm facilitates expert-novice haptic communication and improves skills transfer; and new skills acquisition depends on the availability of different communication channels between experts and novices. Our findings indicate that the traditional fellowship methods in surgery should evolve to an off-patient collaborative environment that will continue to support visual and verbal communication, but also haptic communication, in order to achieve a better and more complete skills training.

a b s t r a c tWith the advent of new haptic feedback devices, researchers are giving serious consideration to the incorporation of haptic communication in collaborative virtual environments. For instance, haptic interactions based tools can be used for medical and related education whereby students can train in minimal invasive surgery using virtual reality before approaching human subjects. To design virtual environments that support haptic communication, a deeper understanding of humans 0 haptic interactions is required. In this paper, human 0 s haptic collaboration is investigated. A collaborative virtual environment was designed to support performing a shared manual task. To evaluate this system, 60 medical students participated to an experimental study. Participants were asked to perform in dyads a needle insertion task after a training period. Results show that compared to conventional training methods, a visual-haptic training improves user 0 s collaborative performance. In addition, we found that haptic interaction influences the partners 0 verbal communication when sharing haptic information. This indicates that the haptic communication training changes the nature of the users 0 mental representations. Finally, we found that haptic interactions increased the sense of copresence in the virtual environment: haptic communication facilitates users 0 collaboration in a shared manual task within a shared virtual environment. Design implications for including haptic communication in virtual environments are outlined.

Introduction The Fundamentals of Laparoscopic Surgery (FLS) trainer is currently the standard for training and evaluating basic laparoscopic skills. However, its manual scoring system is time-consuming and subjective. The Virtual Basic Laparoscopic Skill Trainer (VBLaST©) is the virtual version of the FLS trainer which allows automatic and real time assessment of skill performance, as well as force feedback. In this study, the VBLaST© pattern cutting (VBLaST-PC©) and ligating loop (VBLaST-LL©) tasks were evaluated as part of a validation study. We hypothesized that performance would be similar on the FLS and VBLaST© trainers, and that subjects with more experience would perform better than those with less experience on both trainers. Methods Fifty-five subjects with varying surgical experience were recruited at the Learning Center during the 2013 SAGES annual meeting and were divided into two groups: experts (PGY 5, surgical fellows and surgical attendings) and novices (PGY 1–4). They were asked to perform the pattern cutting or the ligating loop task on the FLS and the VBLaST© trainers. Their performance scores for each trainer were calculated and compared. Results There were no significant differences between the FLS and VBLaST© scores for either the pattern cutting or the ligating loop task. Experts’ scores were significantly higher than the scores for novices on both trainers. Conclusion This study showed that the subjects’ performance on the VBLaST© trainer was similar to the FLS performance for both tasks. Both the VBLaST-PC© and the VBLaST-LL© tasks permitted discrimination between the novice and expert groups. Though concurrent and discriminant validity has been established, further studies to establish convergent and predictive validity are needed. Once validated as a training system for laparoscopic skills, the system is expected to overcome the current limitations of the FLS trainer.