Background The increasingly pervasive presence of technology in the operating room raises the need to study the interaction between the surgeon and computer system. A new generation of tools known as commercial off-the-shelf (COTS) devices enabling touchless gesture–based human-computer interaction is currently being explored as a solution in surgical environments. Objective The aim of this systematic literature review was to provide an account of the state of the art of COTS devices in the detection of manual gestures in surgery and to identify their use as a simulation tool for motor skills teaching in minimally invasive surgery (MIS). Methods For this systematic literature review, a search was conducted in PubMed, Excerpta Medica dataBASE, ScienceDirect, Espacenet, OpenGrey, and the Institute of Electrical and Electronics Engineers databases. Articles published between January 2000 and December 2017 on the use of COTS devices for gesture detection in surgical environments and in simulation for surgical skills learning in MIS were evaluated and selected. Results A total of 3180 studies were identified, 86 of which met the search selection criteria. Microsoft Kinect (Microsoft Corp) and the Leap Motion Controller (Leap Motion Inc) were the most widely used COTS devices. The most common intervention was image manipulation in surgical and interventional radiology environments, followed by interaction with virtual reality environments for educational or interventional purposes. The possibility of using this technology to develop portable low-cost simulators for skills learning in MIS was also examined. As most of the articles identified in this systematic review were proof-of-concept or prototype user testing and feasibility testing studies, we concluded that the field was still in the exploratory phase in areas requiring touchless manipulation within environments and settings that must adhere to asepsis and antisepsis protocols, such as angiography suites and operating rooms. Conclusions COTS devices applied to hand and instrument gesture–based interfaces in the field of simulation for skills learning and training in MIS could open up a promising field to achieve ubiquitous training and presurgical warm up.

Background Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access. Objective This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence. Methods For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed. Results A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67). Conclusions The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained.

Background The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery. Objective The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality). Methods In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability. Results Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures. Conclusions The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery.

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