A synthetic model simulator for intracranial aneurysm clipping: validation of the UpSurgeOn AneurysmBox

Abstract

Background and objectivesIn recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn).MethodsExpert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove.ResultsTen experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p < 0.01) and STS score (18 vs. 9; p < 0.01); the STS score was strongly correlated with the previously validated mOSATS score (p < 0.01). Overall, there was a trend towards experts exerting a lower median force than novices, however, these differences were not statistically significant (3.8 N vs. 4.0 N; p = 0.77). Suggested improvements for the model included reduced stiffness and the addition of cerebrospinal fluid (CSF) and arachnoid mater.ConclusionAt present, the AneurysmBox has equivocal face and content validity, and future versions may benefit from materials that allow for improved haptic feedback. Nonetheless, it has good construct validity, suggesting it is a promising adjunct to training.

An evaluation of physical and augmented patient-specific intracranial aneurysm simulators on microsurgical clipping performance and skills: a randomized controlled study

“…Such solutions included physical and digital simulators with various degrees of patient specificity, haptic feedback, anatomical deformation, and rupture functionalities. [10][11][12][13][14] Because of long manufacturing times, high acquisition costs, or a lack of patient specificity and objective performance metric assessment, these previous simulators have not been widely established.…”

“…31 Recently published trials of sophisticated 3D-printed clipping simulators have focused on the assessment of the phantoms' realism by conducting Likert-based questionnaires. 13,14,35 In contrast to these previous studies, we evaluated the training effect of our physical aneurysm simulator in a randomized controlled study and introduced three different levels of training. 13,14 All study participants performed physical clipping simulations distributed over two sessions on day 1 and two sessions on day 14 in a realistic, microsurgical scenario.…”

“…13,14,35 In contrast to these previous studies, we evaluated the training effect of our physical aneurysm simulator in a randomized controlled study and introduced three different levels of training. 13,14 All study participants performed physical clipping simulations distributed over two sessions on day 1 and two sessions on day 14 in a realistic, microsurgical scenario. In between the simulated clipping sessions, we subjected the residents to no additional interim training, a video review session alone, or a combination of video review session and AR training.…”

“…So far, data regarding the use of modern aneurysm simulators in combination with objective performance metrics are scarce. 13,14,29,38 In the field of 3D-printed aneurysm simulation, our study's combination of objective assessment parameters, radiological aneurysm occlusion rates, clipping attempts, implant choices, surgical tool movement metrics, and active simulation times is unprecedented.…”

“…39 Ahmed et al presented a questionnaire-based study intended to validate a synthetic simulator. 14 Novice and expert study participants were required to wear force-sensitive gloves, allowing the evaluation of force applied by the dominant thumb to the applicator between both groups. 14,39 We introduced surgical tool movement metrics to better visualize the impact of repetitive physical simulation training and additional interim training on the residents' performance.…”