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The use of haptics in medical applications

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Abstract

Explains the need for haptics (feeling of touch) in medical simulation systems. Describes a variety of laparoscopic training systems and other surgical simulators. Highlights the Reachin Technologies AB Application Programming Interface (API) which is a software tool that significantly speeds up the development of surgical simulators.

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... Skilled actions, such as using tools, holding objects, or even plain walking, may become almost impossible upon losing the sense of touch [1]. Touch is the earliest sense developed in human embryology and is believed to be essential for good clinical practice [2,3]. Therefore, the potential of haptic technology may not be underestimated for clinical specialities that rely on sensory input, such as minimally invasive surgery (MIS). ...
... For CES the surgeon operates directly on the patient by using an endoscopic interface, whereas for RAS a computer-instrumented interface (surgical robot) is positioned between the surgeon and patient. Deprived haptic feedback, as experienced while performing CES, or a total lack of it, as experienced while performing RAS, may be a missing feature for the endoscopic surgeon [2,[9][10][11]. ...
... Virtual reality offers the possibility to train psychomotor skills using software, varying from simulating basic laparoscopic exercises to simple surgical tasks toward full operative procedures. By using repetitive VR training, a substantial part of the individual learning curve can be overcome before practicing on real patients [2,14,16]. One of the newest developments in VR training is VR training for RAS [11,28,29]. ...
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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. 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. The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. 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.
... The most widely used computer simulation technique is virtual reality [6]. Compared to other types as, the physical models simulation described above, offers several advantages [6][7][8]. The most important ones are: ...
... Being able to see, hear, touch and modify a virtual environment, allows the application of VR to many real life problems. With respect to surgery, a VR simulator can be used to improve the learning curve of some surgical procedures and also to train psychomotor skills [8]. ...
Conference Paper
The application of the Information and Communication Technologies to different disciplines such as surgical education opens new possible ways to carry out teaching and learning processes. While surgery used to be linked to the use of physical models, techniques such as Virtual Reality make possible new and more economic ways to learn. Virtual reality allows students to practice with virtual objects, with a very low cost. This may help those students to develop different skills. Some of them can be related with touch sense, which involves the addition of haptic interfaces to virtual reality simulators. The present work does not aim to do a specific haptic simulator to learn a surgical technique; the idea is to present a framework to build haptic surgical simulators to be used with educational proposes. In order to increase users motivation in the simulations are represented as serious games. The information of the simulations is sent to the LMS in a transparent way for the user, and once there students and teachers can evaluate it. In this way the framework enables the definition of serious games based in haptic simulations.
... Using active stereo, the virtual workbench creates the illusion of 3D objects lying below the horizontal projection plane. The computer image is normally projected onto a semitransparent screen that allows the user to see both their real hands below the mirror and projected virtual objects in collocation [47] if accurate eye tracking methods are employed. Commercial semi-transparent displays are marketed by Reachin (Stockholm, Sweden), SenseGraphics (Kista, Sweeden), and Immersive ...
... 15 A breast palpation simulation using passive haptics and a HMD visualization[83].47 ...
Article
It is widely accepted that a reform in medical teaching must be made to meet today's high volume training requirements. Receiving pre-training in a core set of surgical skills and procedures before novice practitioners are exposed to the traditional apprenticeship training model where an experienced practitioner must always be present, can reduce both skill acquisition time and the risks patients are exposed to due to surgeon inexperience. Virtual simulation offers a potential method of providing this training and a subset of current medical training simulations integrate haptics and visual feedback to enhance procedural learning. The role of virtual medical training applications, in particular where haptics (force and tactile feedback) can be used to assist a trainee to learn and practice a task, is investigated in this thesis. A review of the current state-of-the-art summarises considerations that must be made during the deployment of haptics and visual technologies in medical training, including an assessment of the available force/torque, tactile and visual hardware solutions in addition to the haptics related software. An in-depth analysis of medical training simulations that include haptic feedback is then provided after which the future directions and current technological limitations in the field are discussed.
... Research in the area is concerned with the development, testing, and refinement of the tactile and force feedback devices, and supporting software that permits users to sense and manipulate three-dimensional virtual objects. In addition to basic psychophysical research on human haptics, and issues in machine haptics such as collision detection, force feedback, and haptic data compression, work is being done in application areas such as surgical simulation, medical training, scientific visualization, and assistive technology for the blind and visually impaired (Fager et al., 2004;Seth et al., 2006). This paper is outlined as follows; section 1 provides a brief introduction of the research area. ...
... The field is intrinsically multidisciplinary and borrows from areas like computer science, psychology, control systems, robotics, biology and others. Haptic technologies have been studied and has applications in many fields such as engineering (design, manufacture, and training) and medicine (surgical planning and training) (Fager et al., 2004;Seth et al., 2006;Badillo et al., 2013). ...
Conference Paper
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Assembly is one of the most vital processes in manufacturing, and it has been extensively studied. Virtual reality systems are becoming eminent to simulate, analyze, and optimize the assembly process. During the design phase of product development cycle, even before any physical prototype is created, haptic technologies empower the user to feel the force feedback from the digital world, resulting into a more intuitive way to simulate the assembly process. This research explains the development of a haptic virtual reality platform to plan, perform, and assess virtual assemblies. The system permits real-time handling and interaction of virtual components. The practicability of using a desktop haptic virtual environment as a design tool for assessing assembly operations is investigated. The system combines various software packages including OpenHaptics, PhysX, and OpenGL/GLUT libraries to explore the advantages and limitations of combining haptics with physically based modelling. Single-handed force feedback is obtained through Phantom Desktop haptic device. A case study of blower house assembly is performed to assess the ability of system to handle complex part interactions.
... A step-change in VR simulation has come from the integration of haptic technology into simulators, as these systems have the potential to provide several advantages over conventional approaches. Advantages include the ability to interact with virtual objects through realistic feel and touch (1,4,5). Haptic technology also provides students with the ability to feel the various tooth surfaces through force feedback mechanisms and distinguish between soft and hard tissues-potentially useful pedagogical information (2,3,6). ...
Article
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Virtual reality simulators are becoming increasingly popular in dental schools across the world. But to what extent do these systems reflect actual dental ability? Addressing this question of construct validity is a fundamental step that is necessary before these systems can be fully integrated into a dental school’s curriculum. In this study, we examined the sensitivity of the Simodont (a haptic virtual reality dental simulator) to differences in dental training experience. Two hundred and eighty-nine participants, with 1 (n = 92), 3 (n = 79), 4 (n = 57) and 5 (n = 61) years of dental training, performed a series of tasks upon their first exposure to the simulator. We found statistically significant differences between novice (Year 1) and experienced dental trainees (operationalised as 3 or more years of training), but no differences between performance of experienced trainees with varying levels of experience. This work represents a crucial first-step in understanding the value of haptic virtual reality simulators in dental education.
... Source: Medical Robotics, Book edited by Vanja Bozovic, ISBN 978-3-902613-18-9, pp.526, I-Tech Education and Publishing, Vienna, Austria This telemanipulated technology is available for a minimal part of heart surgical patients only since the technical inconvenience of the system and the clumsy system is considerably limited in valve surgery, congenital heart surgery and a bigger part of bypass surgery. The necessity of haptic feedback is discussed controversially by robotically working surgeons and haptic engineers (Bethea et al., 2004;Fager, 2004;Hu et al., 2004). The postulate, that the integration of a supplementary haptic channel in addition to the visual channel improves the quality of surgical work and enhances the immersion for the surgeon in a remote system, is not yet demonstrated and evidenced. ...
Chapter
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Robots have a number of advantages over humans in performing routine manipulation tasks. Their accuracy and repeatability allow robots to succeed in the medical and surgical market. Some of the weaknesses in current robotic devices, such as substantial lack of haptic feedback and adaptability are to be highlighted. Currently it is not possible to “program” a robot to perform steps of a surgical operation autonomously. Nevertheless, some of these limitations do not prevent robots from being useful in the operating room; rather considerable human, technical and surgical input, guidance and advancement are needed. Surgical robots can be viewed as “extending and enhancing human capabilities” rather than replacing surgeons, in contrast to the example of industrial replacement of humans by robots. Intuitive Surgical® intended to create with the Da Vinci® Surgical System a conception of a surgeon-robot interface so transparent to the surgeon that his set of skills can be used in a natural and instinctive manner. Its accurate visualisation is critical since visual cues are used to compensate for the loss of haptic feedback. The haptic feedback is currently limited to interact with rigid structures, such as tool-on-tool collisions, not soft tissues. This requires the surgeon to rely on visual feedback in tasks such as suturing. Especially for fine suture material approaches began in research groups to analyse haptic feedback (Okamura, 2004; Kitagawa et al., 2005), but the way of the evaluating setup is not fulfilling the special medical interest for heart surgeons. The basic consideration in our work is to offer the heart surgeon an accessory sensory channel in addition to the visual channel not only to avoid breakage of surgical suture material and tissue, but also to decrease visual fatigue.
... The mechanical properties of the organs and tissues of humans can be displayed by virtual reality techniques [21,22]. In particular, stiffness and force interactions are demonstrated by using a haptic device, which gives the operator force feedback directly232425. Ladjal et al. used a haptic device to display the cell indentation process and simulate AFM experiments [26,27]. They developed a computer-based training system to simulate real-time ES cell indentation procedures in virtual environments through the combination of a haptic device and finite element simulations [27] . ...
Article
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The mechanical properties of cells are unique indicators of their states and functions. Though, it is difficult to recognize the degrees of mechanical properties, due to small size of the cell and broad distribution of the mechanical properties. Here, we developed a simple virtual reality system for presenting the mechanical properties of cells and their dispersion using a haptic device and a PC. This system simulates atomic force microscopy (AFM) nanoindentation experiments for floating cells in virtual environments. An operator can virtually position the AFM spherical probe over a round cell with the haptic handle on the PC monitor and feel the force interaction. The Young's modulus of mesenchymal stem cells and HEK293 cells in the floating state was measured by AFM. The distribution of the Young's modulus of these cells was broad, and the distribution complied with a log-normal pattern. To represent the mechanical properties together with the cell variance, we used log-normal distribution-dependent random number determined by the mode and variance values of the Young's modulus of these cells. The represented Young's modulus was determined for each touching event of the probe surface and the cell object, and the haptic device-generating force was calculated using a Hertz model corresponding to the indentation depth and the fixed Young's modulus value. Using this system, we can feel the mechanical properties and their dispersion in each cell type in real time. This system will help us not only recognize the degrees of mechanical properties of diverse cells but also share them with others.
... 49 This allows for a substantial part of the learning curve to be overcome during simulation, increasing safety for real patients and developing more confident surgeons with greater situational awareness. [50][51][52] Simulation-not just for trainees Simulation is not just for trainees, but also for experts learning new techniques. Cadaveric simulations were especially useful in the recent face transplantations. ...
Article
In the last three decades, simulation has become a key tool in the training of doctors and the maintenance of patient safety. Simulation offers an immersive, realistic way of learning technical skills. Recent changes to the training schemes in many surgical specialities mean that the hours spent working between senior house officer and consultant have been reduced. This, combined with other pressures (such as reduced operating hours), means that surgery has moved away from its traditional apprenticeship model and toward a competency-based one. Simulation can be a standardized and safe method for training and assessing surgeons. Use of simulation for training has become significant alongside the development of laparoscopic techniques, and evidence suggests that skills obtained in simulation are applicable in real clinical scenarios. Simulation allows trainees to make mistakes, to ask the "what if?" questions, and to learn and reflect on such situations without risking patient safety. Virtual reality simulators have been used to allow experts to plan complicated operations and assess perioperative risks. Most recently, fully immersive simulations, such as those with whole theater teams involved, and patient-centered simulations allow development of other key skills aside from purely technical ones. Use of simulation in isolation from traditional teaching methods will furnish the surgeon in training with skills, but the best time and place to use such skills comes only with experience. In this article we examine the role of simulation in surgical training and its impact in the context of reduced training time.
... 14 The perception of touch is regarded as one of the primitive grown sensation in the human body and considered as most important for clinical practice. 74 The application of virtual tools by using haptic technology enhanced the capability to explore and perceive virtual anatomy. 75 They used a learning resource named anatomy workbench, which presented a 3 D dynamic model of finger anatomy, a visuo-haptic environment for interactive segmentation of visible human data and 3 D surface model of hand anatomy that can be palpated by pencil like device. ...
Article
Full-text available
Teaching and learning of anatomy have greatly transformed in last two decades. Innovations in medical education, like integrated curricula and inclusion of PBL were considered to be responsible for the decline in anatomy learning. Allocated time for anatomy teaching has reduced in medical schools in last two decades across the world. Living and surface anatomy facilitates students in developing skills for future clinicians. Some educationist considered it to be main teaching tool for learning anatomy as a replacement of dissection based cadaveric anatomy. Innovations in medical technology and reduced allocated time paved the way for implementing teaching methodologies e.g., body painting, peer physical examination, medical imaging and virtual anatomy softwares in teaching and learning of living and surface anatomy. This article focuses on reviewing the historical background and current trends in teaching and learning of living and surface anatomy with special emphasis upon its pedagogical aspects also some views of medical educationists. It also compares pros and cons of various teaching methodologies used in learning of living and surface anatomy, emphasizing on challenges faced in its pedagogy. Finally, it concludes that living and surface anatomy should be considered as an integral part of the curriculum. Inclusion and implementation of teaching and learning strategies, such as body painting, peer physical examination, medical imaging and virtual anatomy softwares will enhance learning of living and surface anatomy in an integrated and relevant framework.
... Being able to see, hear, touch and modify a virtual environment, allows the application of VR to many real life problems. For instance, a VR simulator can be used to improve the learning curve of some surgical procedures and also to train psychomotor skills [22]. The inclusion of haptic interfaces improves the usefulness of any surgical procedure [23][24] because touch is more important than sight in this area. ...
Article
Full-text available
Virtual reality simulators represent an affordable alternative for teaching and learning specific skills in environments not available in reality for educational purposes. Their goal is to provide a simulated environment where students can practice real tasks in a safer way and with no real consequences in fields as engineering or surgery. For a simulator to become a more complete teaching and learning tool, it should also include the expert knowledge required to provide instant feedback to the user. SHULE is a framework for building haptic simulators to be used with educational purposes that includes expert knowledge. In order to increase users motivation, we have also considered game features in the framework design, development and integration with other tools. This process includes the elements needed to provide a challenging goal for the simulator with the correct amount of uncertainty that would increase user's curiosity enough to keep on using it until certain skill is achieved. Simulators produced with SHULE can be integrated with a Learning Management System (LMS) such as Moodle by means of web services. Their functionality offers the teacher the possibility to create new ativities to be performed at the simulator, and also offers the students the possibility to see the results of their simulator sessions in the LMS.
... We can also use video on demand and high resolution video so that monitoring will usually be not delayed. [9][10] We can also utilize the screen to display some texts in order to ensure that advice from telemedical group is recorded even in noisy conditions. ...
Preprint
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Medical expertise or doctors cannot be present everywhere in each and every country. So in order to overcome their physical limitation, we can use a concept of medical expertise pooling by telesensing and manipulation techniques. With the use of this proposed system we can provide medical facilities throughout the world in order to provide support in the critical situations of a patient.The proposed system can provide visual,body sound and tactile feedback of the patient which can increase its survival rates. In this paper we are going to explain haptic rendering methods in complex medical scenes.With the development of virtual surgery methods, haptic interaction of virtual scene become a very important requirement.The improved haptic camera view by culling with spatial portioning is proposed to keep down the size of haptic rendering.The dynamic proxy algorithm is introduced to calculate the force between haptic devices and virtual objects. An alternative traditional method of surgical learning is the use of virtual reality simulators.In order to guarantee the proper learning of virtual reality simulators,we have designed a framework which delves into implementation details gathered through SCRUM agile methodology. In this paper report we will also study in detail how to model the information obtained through simulators.
... This is due to the fact that those systems allow practicing in a secure and controlled environment, without having any kind of risk for both the patient and the medical trainee, the same way virtual words are being used for other types of training processes in health [11]. Working with haptic interfaces in a virtual environment allows having almost infinite practical cases [12]: from simply measuring the pulse of a patient or the hardness of a tissue to learning how to perform a special cut during a complex surgical procedure. This context presents the issue of the lack of a standard framework [13] that enables to develop virtual reality simulators to be used as tools for teaching surgery. ...
Article
Full-text available
Software engineering courses usually face a situation where a reasonable size application has to be developed within a semester period. But, on the one hand, if students begin from scratch and start with the knowledge acquisition and requirements phases, they usually do not get to the deployment one. And, on the other hand, developing quality software should go on being the main focus of a software engineering course. Our proposal is the development of a haptic simulator as a teaching/learning tool for this purpose using the SHULE framework and following a Scrum development methodology. The core of this framework includes a combination of design patterns that also guide the development of the whole simulator. This approach has been used in the development of a cataract surgery simulator as a teaching/learning tool, and the experience is shown as an example of the general Scrum development that is presented.
... Haptic feedback has been mentioned frequently in VR training, especially in the medical field. The sense of touch is the earliest developed in human embryology and is believed to be essential for practice [5,4]. Robot-assisted minimally invasive surgery (RMIS) holds great promise for improving the accuracy and dexterity of a surgeon [14]. ...
Article
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We propose a new approach for interaction in Virtual Reality (VR) using mobile robots as proxies for haptic feedback. This approach allows VR users to have the experience of sharing and manipulating tangible physical objects with remote collaborators. Because participants do not directly observe the robotic proxies, the mapping between them and the virtual objects is not required to be direct. In this paper, we describe our implementation, various scenarios for interaction, and a preliminary user study.
... Many medical procedures often involve the use of the force feedback to manipulate organs or tissues by using special tools [26]. Some of the medical procedures such as palpation, surgical interventions, phlebotomy and other interventional procedures are examples where the force feedback is of great importance [27]. In minimally invasive procedures, the force feedback has reduced compared to open surgery where the clinicians rely more on the feeling of net forces resulting from tool-tissue interactions, and thereby, there is a high requirement for training to have a successful surgery. ...
Article
Needle insertion being the most basic skill in medical care, training has to be imparted not only for physicians but also for nurses and paramedics. In most needle insertion procedures haptic feedback from the needle is the main stimulus that novices are to be trained in. For better patient safety, the classical methods of training the haptic skills have to be replaced with simulators based on new robotic and graphics technologies. This paper reviews the current advances in needle insertion modeling. It is classified into three sections: needle insertion models, tissue deformation models, and needle-tissue interaction models. Although understated in the literature, the classical and dynamic friction models which are critical for needle insertion modeling are also discussed. The experimental set-up or the needle simulators which have been developed to validate the models are described. The need of psychophysics for needle simulators and psychophysical parameter analysis of human perception in needle insertion are discussed, which are completely ignored in the literature.
... Many medical procedures often involve the use of the force feedback to manipulate organs or tissues by using special tools [26]. Some of the medical procedures such as palpation, surgical interventions, phlebotomy and other interventional procedures are examples where the force feedback is of great importance [27]. In minimally invasive procedures, the force feedback has reduced compared to open surgery where the clinicians rely more on the feeling of net forces resulting from tool-tissue interactions and thereby there is a high requirement for training to have a successful surgery. ...
Article
Full-text available
Needle insertion being the most basic skill in medical care, training has to be imparted not only for physicians but also for nurses and paramedics. In most needle insertion procedures haptic feedback from the needle is the main stimulus that novices are to be trained in. For better patient safety, the classical methods of training the haptic skills have to be replaced with simulators based on new robotic and graphics technologies. This paper reviews the current advances in needle insertion modeling. It is classified into three sections: needle insertion models, tissue deformation models, and needle-tissue interaction models. Although understated in the literature, the classical and dynamic friction models which are critical for needle insertion modeling are also discussed. The experimental setup or the needle simulators which have been developed to validate the models are described. The need of psychophysics for needle simulators and psychophysical parameter analysis of human perception in needle insertion are discussed, which are completely ignored in the literature.
... Many medical procedures often involve the use of the force feedback to manipulate organs or tissues by using special tools [26]. Some of the medical procedures such as palpation, surgical interventions, phlebotomy and other interventional procedures are examples where the force feedback is of great importance [27]. In minimally invasive procedures, the force feedback has reduced compared to open surgery where the clinicians rely more on the feeling of net forces resulting from tool-tissue interactions, and thereby, there is a high requirement for training to have a successful surgery. ...
... Esen et al. reported that audio-haptic augmented interactions increased performance of trainees and accelerated the skill training process in bone drilling [84]. Thus, the inclusion of haptic interactions improves the usefulness of simulated surgical procedures [85,86]. For gestures associated with sports, the entity of interest may be the correctness of the gesture [87]. ...
Article
Full-text available
Integration of haptics in Serious Games (SGs) remains limited compared to vision and audio. Many works seem to limit haptic interactions to the mimicking of real life feelings. Here, we address this by investigating the use of haptics to promote learning outcomes in serious games. By analyzing how we learn, we proposed a model that identifies three learning outcomes: (1) engage the user with the content of the game, (2) develop technical skills, and (3) develop cognitive skills. For each learning skill, we show how haptic interactions may be exploited. We also show that the proposed model may be used to describe and to evaluate existing methods. It may also help in the designing of new methods that take advantage of haptics to promote learning outcomes.
... The litterature in other fields (e.g. surgery field) shows that using repetitive VR training can improve the learning curve before practicing on real situations [10,14,31]. In our future works, it would so be interesting to let each group iterate on the same support (software or VR prototype), then analyse the total errors made, time spent and iterations needed to assess if it implies training time gains and effectiveness. ...
Conference Paper
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The infantrymen of the French army are equipped today with a combat system called FELIN, which includes an infrared sighting device: the IR sight. One of the first manipulations learnt by the soldier is the IR sight calibration. Currently, calibration training is a two-step procedure. The first step consists in practicing on a 2D WIMP software, and virtually practicing until making no mistakes. Then, if the soldier succeeds without mistakes, he can apply his knowledge in real situation on the shooting range. In this paper, we present a learning method that includes a prototype in Virtual Reality for training on the FELIN IR sight calibration procedure. We experimented it on real infantrymen learners in an infantry school. Results showed interesting added value of Virtual Reality in this specific use case. It improved the learners' motivation, learning efficiency and helped to identify specific mistake types not detected by the traditional learning software.
... The literature shows that using repetitive VR training can improve the learning curve before practicing on real situations [10,20,44]. In our future works, we plan to let each group iterate on the same medium (software or VR prototype), then analyze the total errors made, time spent and iterations needed to assess if it implies training time gains and effectiveness. ...
Conference Paper
Full-text available
French Army infantrymen's are equipped today with a combat system called FELIN, which includes an infrared sighting device: the IR sight. One of the first manipulations learned by the soldier is the IR sight calibration. Currently, calibration training is a two-step process. The first step consists of practicing on a 2D WIMP software until making no mistakes. Then, the soldiers can apply his knowledge in the real situation on the shooting range. In this paper, we present an ad-hoc study of a learning method including a prototype in Virtual Reality for training on the FELIN IR sight calibration procedure. It has been experimented on real infantrymen learners in an infantry school. Results showed an attractive added value of Virtual Reality in this specific use case. It improved the learners' intrinsic motivation to repeat the training task as well as the learning efficiency. It also helped the training team to identify specific mistake types not detected by the traditional learning software.
... The literature shows that using repetitive VR training can improve the learning curve before practicing on real situations [10,20,44]. In our future works, we plan to let each group iterate on the same medium (software or VR prototype), then analyze the total errors made, time spent and iterations needed to assess if it implies training time gains and effectiveness. ...
... [10,13] The perception of touch involved in this method is regarded as one of the most important methods for clinical practice. [16] MMT is the most commonly used method for documenting the muscle strength. The reliability and validity of different methods to do MMT has been studied by many researchers. ...
... [10,13] The perception of touch involved in this method is regarded as one of the most important methods for clinical practice. [16] MMT is the most commonly used method for documenting the muscle strength. The reliability and validity of different methods to do MMT has been studied by many researchers. ...
Article
Background: It is often presumed that physiotherapists need to be thorough in their knowledge in gross anatomy prior to learning new skills or therapeutic techniques. We implemented a Living (Surface) Anatomy module for physiotherapists, prior to the teaching of therapeutic techniques, in one of the continuous professional development (CPD) programs as a supportive venture for their clinical practice. The present study intended to evaluate the impact of a CPD program on reinforcing practicing physiotherapists’ knowledge, skills, and attitude for their clinical practice. Methods: A 1-day workshop was conducted on living (surface) anatomy for practicing physiotherapists (n = 27) through a CPD program. This training included manual muscle testing and body painting of selected muscles of trunk and limbs. Pre- and post-tests were conducted to analyze the impact of the module on improvement in participants’ knowledge and skills. In addition, participants were requested to respond to a questionnaire (15 items) on a 5-point Likert scale. Results:Analysis of the pre‑ and post‑testscoresrevealed a significant increase (34.6%) in surface anatomy knowledge. Majority of the participants opined that the workshop was organized effectively (100%) and the modules helped them to become aware of the lacunae in their knowledge (100%). They also echoed that they realized the need for continuous self-directed learning (100%) and responded that they would attempt to apply whatever they learned through the workshop in their clinical practice (96%). The overall satisfaction score reported by the participants was 9, on a rating scale ranging from 1 to 10 (1 = very poor; 10 = excellent). Conclusion: The CPD was well received by the participants, as evident from their feedback. The present study results demonstrated that the CPD had a positive impact on the participants’ knowledge, skills, and attitude.
... 11 In medicine, restoring sensory feedback to patients with skin damage, amputations, or peripheral neuropathy could significantly improve their overall quality of life. 12−14 Smart sensing interfaces are yet to be used for training in minimally invasive procedures, such as laparoscopy, 4,7,8 telepresence surgery, 15 and robotic-assisted interventional radiology. 15,16 Whether it is for robotics, prosthetics, or robotic-assisted surgery, the requirements for tactile sensing are similar. ...
Article
The distributed sense of touch forms an essential component that defines real-time perception and situational awareness in humans. Electronic skins are an emerging technology in conferring artificial sense of touch for smart human-machine interfaces. However, assigning conformably distributed sense of touch over a large area has been challenging to replicate in modern medical, social and industrial robots. Herein, we present a new class of soft tactile sensors that exploit the mechanisms of triplet-triplet annihilation, exciton harvesting and small Stokes shift in conjugated organic semiconductors such as rubrene. By multiplexing the electroluminescence and photosensing modes, we show that a compact optoelectronic array of multifunctional rubrene/fullerene diodes can accurately measure pressure, position and surface deformation applied to an elastomeric layer. The dynamic sensing range is defined by mechanical properties of the elastomer. This paves the way for soft, conformal and large-area compatible electronic skins for medicine and robotics.
... They did not include force measurement. However, the necessity of haptic feedback in robotic surgery has been discussed controversially by surgeons and haptic engineers (Bethea et al., 2004;Fager, 2004;Hu, Tholey, Desai, & Castellanos, 2002;MacFarlane, Rosen, Hannaford, Pellegrini, & Sinanan, 1999). At the Rensselaer Polytechnic Institute, a robotic system capable of knottying was developed (Kang & Wen, 2001), but they mainly focused on force control and have used dedicated instruments for knot-tying. ...
Article
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The implementation of telemanipulator systems for cardiac surgery enabled heart surgeons to perform delicate minimally invasive procedures with high precision un- der stereoscopic view. At present, commercially available systems do not provide force-feedback or Cartesian control for the operating surgeon. The lack of haptic feedback may cause damage to tissue and can cause breaks of suture material. In addition, minimally invasive procedures are very tiring for the surgeon due to the need for visual compensation for the missing force feedback. While a lack of Carte- sian control of the end effectors is acceptable for surgeons (because every move- ment is visually supervised), it prevents research on partial automation. In order to improve this situation, we have built an experimental telemanipulator for endo- scopic surgery that provides both force-feedback (in order to improve the feeling of immersion) and Cartesian control as a prerequisite for automation. In this article, we focus on the inclusion of force feedback and its evaluation. We completed our first bimanual system in early 2003 (EndoPAR Endoscopic Partial Autonomous Ro- bot). Each robot arm consists of a standard robot and a surgical instrument, hence providing eight DOF that enable free manipulation via trocar kinematics. Based on the experience with this system, we introduced an improved version in early 2005. The new ARAMIS system (Autonomous Robot Assisted Minimally Invasive Surgery) has four multi-purpose robotic arms mounted on a gantry above the working space. Again, the arms are controlled by two force-feedback devices, and D vision is provided. In addition, all surgical instruments have been equipped with strain gauge force sensors that can measure forces along all translational directions of the instrument's shaft. Force-feedback of this system was evaluated in a scenario of ro- botic heart surgery, which offers an impression very similar to the standard, open procedures with high immersion. It enables the surgeon to palpate arteriosclerosis, to tie surgical knots with real suture material, and to feel the rupture of suture ma- terial. Therefore, the hypothesis that haptic feedback in the form of sensory substi- tution facilitates performance of surgical tasks was evaluated on the experimental platform described in the article (on the EndoPAR version). In addition, a further hypothesis was explored: The high fatigue of surgeons during and after robotic op- erations may be caused by visual compensation due to the lack of force-feedback (Thompson, J., Ottensmeier, M., & Sheridan, T. 1999. Human Factors in Telesurgery, Telmed Journal, 5 (2) 129 -137.).
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A realistic human anatomy simulation model developed for training to perform laparoscopic Nissen fundoplication (antireflux surgery) could reduce the need and use of animal tissue models. This article elaborates the designing process of this model and the development process used to create the abdominal organs with realistic haptic feedback. Before developing the artificial organs, first the mechanical characteristics of human tissue were examined. Next, separate animal organs that resembled these characteristics the closest was used to create the model. The haptic feedback of the intra-abdominal organs variables studied included tissue, geometry, and context. The stress-strain curves of the different tissues were calculated and compared with the properties of industrial materials to find the best material for the production of the organs. The aspects that influenced haptic feedback as determined above and used to select the most promising material groups were: E-modulus, density, coefficient of friction, sensitivity to tearing, wall thickness, and shelf life. Based on these criteria, silicone and latex materials mimiked human tissue best. Changeable velvet rope was used for connections of the organs to the surface and other simulated tissue. A reusable modular model of the upper abdomen anatomy with haptic properties was created for training of upper gastrointestinal surgery laparoscopic procedures, such as the Nissen fundoplication.
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To prevent unnecessary mistakes and avoidable complications in laparoscopic surgery, there has to be proper training. A safe way to train surgeons for laparoscopy is simulation. This study addresses the face validity of ProMIS, an Augmented Reality laparoscopic simulator, as a tool for training suturing skills in laparoscopic surgery. A two-paged, 12-item structured questionnaire, using a five-point-Likert scale, was presented to 50 surgeons/surgical interns. The participants were allotted to two groups: an "expert" (>50 procedures; N=23) and a referent group (<50 procedures; N=27). Non-parametric statistics were used to determine statistical differences. General consensus existed in both expert and referent groups, delineating ProMIS as a useful tool in teaching suturing skills surgeons/surgical interns (mean + or - st dev, resp, score 4.91 + or - 0.42 and 4.93 + or - 0.38) with regard to realism, tactile feedback, and suturing techniques. Significant differences in opinion regarding the ergonomics and design of ProMIS between the expert and referent groups existed. The ProMIS Augmented Reality laparoscopic simulator is regarded as a useful tool in laparoscopic training in both expert and referent groups. Although significant differences in opinion existed with regards to ergonomics and design of ProMIS, they were present between experts and novices.
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The aim of the study was to determine if the concept of face and construct validity may apply to the SurgicalSim Educational Platform (SEP) "robot" simulator. The SEP robot simulator is a virtual reality (VR) simulator aiming to train users on the Da Vinci Surgical System. To determine the SEP's face validity, two questionnaires were constructed. First, a questionnaire was sent to users of the Da Vinci system (reference group) to determine a focused user-group opinion and their recommendations concerning VR-based training applications for robotic surgery. Next, clinical specialists were requested to complete a pre-tested face validity questionnaire after performing a suturing task on the SEP robot simulator. To determine the SEP's construct validity, outcome parameters of the suturing task were compared, for example, relative to participants' endoscopic experience. Correlations between endoscopic experience and outcome parameters of the performed suturing task were tested for significance. On an ordinal five-point, scale the average score for the quality of the simulator software was 3.4; for its hardware, 3.0. Over 80% agreed that it is important to train surgeons and surgical trainees to use the Da Vinci. There was a significant but marginal difference in tool tip trajectory (p = 0.050) and a nonsignificant difference in total procedure time (p = 0.138) in favor of the experienced group. In conclusion, the results of this study reflect a uniform positive opinion using VR training in robotic surgery. Concepts of face and construct validity of the SEP robotic simulator are present; however, these are not strong and need to be improved before implementation of the SEP robotic simulator in its present state for a validated training curriculum to be successful .
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Haptic information can be used to create our perception of the stiffness of objects and to regulate grip force. Introducing noise into sensory inputs can create uncertainty, yet a method of creating haptic uncertainty without distorting the haptic information has yet to be discovered. Toward this end, we investigated the effect of varying haptic information between consecutive interactions with an elastic force field on stiffness perception and grip force control. In a stiffness discrimination task, participants interacted with force fields multiple times. Low, medium, and high variability levels were created by drawing the stiffness levels applied in each consecutive interaction within a trial from normal distributions. Perceptual haptic uncertainty was created only by the medium variability level. Moreover, all the variability levels affected the grip force control: the modulation of the grip force with the load force decreased with repeated interactions with the force field, whereas no change in the baseline grip force was observed. Additionally, we ascertained that participants formed their perceived stiffness by calculating a weighted average of the different stiffness levels applied by a given force field. We conclude that the medium variability level can be effective in inducing uncertainty in both perception and action.
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This project aims to create a three-dimensional digital model of the human hand and wrist which can be virtually 'dissected' through a haptic interface. Tissue properties will be added to the various anatomical structures to replicate a realistic look and feel. The project will explore the role of the medical artist, and investigate cross-discipline collaborations in the field of virtual anatomy. The software will be used to train anatomy students in dissection skills, before experience on a real cadaver. The effectiveness of the software will be evaluated and assessed both quantitatively as well as qualitatively.
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Comprehensively covers the key technologies for the development of tactile perception in minimally invasive surgery. Covering the timely topic of tactile sensing and display in minimally invasive and robotic surgery, this book comprehensively explores new techniques which could dramatically reduce the need for invasive procedures. The tools currently used in minimally invasive surgery (MIS) lack any sort of tactile sensing, significantly reducing the performance of these types of procedures. This book systematically explains the various technologies which the most prominent researchers have proposed to overcome the problem. Furthermore, the authors put forward their own findings, which have been published in recent patents and patent applications. These solutions offer original and creative means of surmounting the current drawbacks of MIS and robotic surgery. Key features:- • Comprehensively covers topics of this ground-breaking technology including tactile sensing, force sensing, tactile display, PVDF fundamentals • Describes the mechanisms, methods and sensors that measure and display kinaesthetic and tactile data between a surgical tool and tissue • Written by authors at the cutting-edge of research into the area of tactile perception in minimally invasive surgery • Provides key topic for academic researchers, graduate students as well as professionals working in the area.
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Background Conventional and Modern Surgical Techniques Motivation Tactile Sensing Force Sensing Force Position Softness Sensing Lump Detection Tactile Sensing in Humans Haptic Sense Tactile Display Requirements Minimally Invasive Surgery (MIS) Robotics Applications References
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Robotic System for Endoscopic Heart Surgery da Vinci™ and Amadeus Composer™ Robot Surgical System Advantages and Disadvantages of Robotic Surgery Applications The Future of Robotic Surgery References
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A large proportion of allergic skin reactions are considered to be the result of skin exposure to small organic chemicals that possess the intrinsic ability to covalently modify skin proteins, either directly or following activation. In the absence of information about specific skin protein targets, studies of chemical modifications are limited to the use of model proteins. We have previously demonstrated that selected well known skin sensitizers (2,4-dinitro-1-chlorobenzene and phenyl salicylate) have the ability to covalently modify residues selectively on the model protein, human serum albumin. In the present work, we focus on the differences in covalent binding observed for two additional model proteins, human cytokeratin 14 and human cofilin, both constituent proteins of skin. Using matrix assisted laser desorption/ionization mass spectrometry (MALDI-MS) and nano LC-MS and -MS/MS strategies, the amino acid residues targeted by 2,4-dinitro-1-chlorobenzene on the two model proteins have been identified. In contrast, a structurally related non-sensitiser (2,4-dichloro-1-nitrobenzene) and a non-sensitising irritant (benzalkonium chloride) did not covalently modify the model proteins. Detailed examination of the results for the sensitizers indicate that reactive chemicals target nucleophilic amino acids residing in specific microenvironments of the 3D protein structure that are conducive to reactivity. This observation has important implications for the development of hapten-peptide binding assays. It is envisaged that the data from such assays will be integrated with outputs from other in vitro assays in the future to give a prediction of the sensitisation potential of novel chemicals.
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Haptics is an emerging technology that allows touch-enabled interaction with virtual objects. Analogous to the use of computer graphics for rendering of a three-dimensional (3D) scene to give the user a visual description of the scene, it is possible to use computer haptics to let the user touch objects in the 3D scene. This is normally accomplished by having the haptics engine sending either force vectors or positional information to a haptics device, a robotic arm, that the user manipulates. The purpose of this paper is to give an overview of this technology, describe haptic devices and haptic application programming interfaces. We will also illustrate the use of haptics technology by describing a few industrial and medical applications.
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To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P <.007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P <.04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case; P <.008, Mann-Whitney test). The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
Article
Objective: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. Summary Background Data: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. Methods: Sixteen surgical residents (PGY 1–4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). Results: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P < .007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P < .04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case;P < .008, Mann-Whitney test). Conclusions: The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
Article
Objective: To improve the planning of hepatic surgery, we have developed a fully automatic anatomical, pathological, and functional segmentation of the liver derived from a spiral CT scan. Materials and methods: From a 2 mm-thick enhanced spiral CT scan, the first stage automatically delineates skin, bones, lungs, kidneys, and spleen by combining the use of thresholding, mathematical morphology, and distance maps. Next, a reference 3D model is immersed in the image and automatically deformed to the liver contours. Then an automatic Gaussian fitting on the imaging histogram estimates the intensities of parenchyma, vessels, and lesions. This first result is next improved through an original topological and geometrical analysis, providing an automatic delineation of lesions and veins. Finally, a topological and geometrical analysis based on medical knowledge provides hepatic functional information that is invisible in medical imaging: portal vein labeling and hepatic anatomical segmentation according to the Couinaud classification. Results: Clinical validation performed on more than 30 patients shows that delineation of anatomical structures by this method is often more sensitive and more specific than manual delineation by a radiologist. Conclusion: This study describes the methodology used to create the automatic segmentation of the liver with delineation of important anatomical, pathological, and functional structures from a routine CT scan. Using the methods proposed in this study, we have confirmed the accuracy and utility of the creation of a 3D liver model compared with the conventional reading of the CT scan by a radiologist. This work may allow improved preoperative planning of hepatic surgery by more precisely delineating liver pathology and its relationship to normal hepatic structures. In the future, this data may be integrated with computer-assisted surgery and thus represents a first step towards the development of an augmented-reality surgical system.
Article
Surgical training systems based on virtual reality (VR) and simulation techniques for tissue deformation may represent a more cost-effective and efficient alternative to traditional training methods. Additionally, VR is a technology that can teach surgeons new procedures and can determine their level of competence before they operate on patients. At Forschungszentrum Karlsruhe (FZK), a virtual reality training system for minimally invasive surgery (MIS), based on the simulation software KISMET, has been developed. An overview of the current state of development for the “Karlsruhe Endoscopic Surgery Trainer” is presented. For quick and easy creation of surgical scenes containing deformable anatomical organ models, the spline-based modeller KisMo has been developed, which generates beside the geometry also a spatial mass–spring network of the objects for the elastodynamic simulation in KISMET. The MIS trainer provides several surgical interaction modules for deformable objects like grasping, application of clips, cutting, coagulation, injection and suturing. Additionally, it is possible to perform irrigation and suction in the operation area. Active deformable objects are used for the morphodynamic simulation of the stomach and the intestines. Furthermore, a hierarchical pulse simulation in virtual arterial vessel trees has been realized, which enables the palpation of the pulse with a force-feedback device. The pulse simulation is coupled with an arterial bleeding simulation, which gets activated by injuries of arteries and stopped by application of clips. The simulation system has been applied to minimally invasive surgery training in gynaecology and laparoscopy. Special attention is addressed to elastodynamically deformable tissue models and geometric modelling techniques for graphical real-time performance.
Surgery simulation is a promising technique for training of surgical procedures. The overall goal for any surgical simulator is to allow for efficient training of the skills required and to improve learning by giving the user proper feedback. This goal is easier achieved if the training is performed in a realistic environment. Therefore functionality such as soft tissue deformation, tearing and cutting, penetration of soft tissue etc. is necessary. Furthermore, a realistic simulator must provide haptic feedback so that all senses match, that is, there should be a correspondence between what you see and what you feel with your hands. In this paper we describe a medical platform that provides all this functionality. It is based on the Reachln Magma API, which has been extended for surgery simulation. We describe the development of the platform and illustrate the use of it for the development of two different types of surgical simulators, both of which represents work in progress.
Article
Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.
Article
To show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology. Technical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances. To verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service). The operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery. Remote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide.
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The development of computerized surgical simulators in a virtual reality environment demands models for proper validation. Recent investigations have shown that a virtual reality simulator (MIST-VR) is a reliable tool for the assessment of laparoscopic psychomotor skills and that it improves the automation of the so-called fulcrum effect. Therefore, we set out to determine whether training with the MIST-VR would improve the surgical performance of surgically inexperienced medical students and to see if results obtained in the simulator would correlate with surgical performance. A total of 29 medical students were randomized into two groups. One group received preoperative MIST-VR training. Both groups then performed a simulated laparoscopic appendectomy in a pig. The operations were videotaped and examined by three independent observers. There was no significant difference in performance between the two groups. The performance with the MIST-VR correlated with the results in surgery. A method that can measure surgical skill, based on the scoring of independent observers who view videotaped performances, seems to be reliable. MIST-VR did not improve the surgical skills of the subjects, but the results with MIST-VR did predict surgical outcome.
Article
The aim of the study was to evaluate whether basic surgical skills achieved by training in LapSim, a computerbased laparoscopic simulator, could be transferred to the operating room. For this study, 24 medical students undergoing courses in surgery were randomly assigned to train with LapSim or to serve as control subjects. After they had undergone simulator training 2 h per week for 5 weeks, their basic skills in laparoscopic surgery were assessed in a porcine model. The time to perform each task was measured, and four senior surgeons independently graded the overall performance on a 9-step differential rating scale. The participants randomized to train with LapSim showed significantly better results for all tasks in both parts of the study than the untrained participants, according to the expert evaluation. Time consumption was accordingly lower in the training group in the control group. The results show that basic skills achieved by systematic training with a laparoscopic simulator such as LapSim can be transferred to the operating room.
Article
We evaluated a virtual reality shoulder arthroscopy simulator using a standardized skills-assessment algorithm in 3 specific groups with various degrees of surgical expertise. The simulator (Mentice Corp, Gothenberg, Sweden) consists of a computer-based, dual-force feedback system with video monitor. Modeled structures include cartilage, labrum, ligaments, biceps tendon, and rotator cuff. The study included 3 groups of volunteers: group 1, medical students interviewing for orthopaedic residency (n = 35); group 2, orthopaedic residents interviewing for sports medicine fellowship (n = 22); and group 3, experienced faculty at a shoulder surgery course (n = 21). Data were collected anonymously and subjects completed a standardized test protocol designed to assess accuracy and efficiency. Subjects used the probe to "touch" a sphere that appeared at various locations within the joint (11 positions total). The sphere changed location immediately on contact with the tip of the probe. The following parameters were calculated by the computer: time (from touching the first ball until touching the eleventh ball), path ratio (percent of measured path length relative to the ideal path), collisions (number of times the probe / arthroscope contacted any tissue), and injuries (collisions beyond a threshold force). Test time and path ratio differed significantly as a function of surgical experience. There was no significant difference in probe collisions between the groups. Arthroscope collisions and injuries averaged 2 or less in all of the groups. There was significant correlation between path ratio and time to complete the test in groups 1 and 2 (r =.527 and r =.827, respectively, P <.001), but not in group 3 (r =.376, P =.10). There was essentially normal distribution of time performance in groups 1 and 2. Time was shorter and more consistent in group 3, suggesting greater consistency in the experienced surgeons. These data suggest that this arthroscopy simulator facilitates discrimination of arthroscopic skills. Computer-based simulation technology provides a major opportunity for surgical skills development without morbidity and operating room inefficiency.
Article
Skills in gastrointestinal endoscopy mainly depend on experience and practice. Training on endoscopy simulators may decrease the time needed to reach competency in endoscopy. The purpose of the study was to determine whether the GI-Mentor, a virtual reality endoscopy simulator, can distinguish between beginners and experts in endoscopy and to assess whether training improves the performance of beginners. A total of 13 beginners and 11 experts (more than 1,000 procedures) in gastrointestinal endoscopy were included. The baseline assessment consisted of virtual endoscopies and skill tests. The beginners were randomly allocated to receive training (n = 7) or no training (n = 6). The training group was allowed to practice using the simulator for 2 hours per day. After 3 weeks participants were re-evaluated with two new virtual endoscopy cases and one virtual skill test. Insertion time, correctly identified pathologies, adverse events and skill test performance were recorded. The baseline assessment revealed significant differences favoring the experts for virtual endoscopies and skill tests. Significant differences in favor of experts were found for successful retroflection during esophagogastroduodenoscopy (EGD) (P < 0.005); adverse events during colonoscopy (P < 0.02); insertion time (P < 0.001); correctly identified pathologies in gastroscopy and colonoscopy (P < 0.02); and skill test performance (P < 0.01). The final evaluation showed significant differences between training and no-training groups, in favor of the training group, for the number of adverse events during virtual endoscopy (P < 0.04), for the insertion time during colonoscopy (P < 0.03); and for skill test performance (P < 0.01). The training group improved its abilities on the simulator significantly. Differences between experts and the training group were no longer seen. This virtual endoscopy simulator is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. A 3-week training improves the performance of beginners significantly. This quite fast improvement in endoscopic skills certainly cannot be seen in clinical practice; no conclusions can be made about the impact of virtual simulator training on real-life endoscopy, and this must be evaluated.
Article
To validate a flexible cystoscopy simulator by determining if it could differentiate between expert and novice cystoscopists. Seventeen subjects (10 novices with no previous endoscopic experience and seven urologists who had all carried out > 1000 flexible cystoscopies each) were asked to undertake a flexible cystoscopy task on the URO Mentor (Simbionix, Israel) virtual reality (VR) machine. In the task used the bladder mucosa has 10 flags (numbered 1-10) at key positions in the bladder; by visualizing each of the 10 flags and photographing them the subject will have indirectly visualized the entire mucosa. Subjects were asked to carry out the task 10 times, to allow their rate of acquisition of skill to be assessed. The total time taken for the task and the number of flags visualized were used as measures of performance. The experienced urologists were significantly better at flexible cystoscopy than the medical students on the first trial for the mean number of flags seen (9.57 vs 8.0, P = 0.01) and the mean time to complete the task (2.33 vs 4.89 min, P = 0.03). At the 10th trial there was still a significant difference for the time taken, between the medical students and the urologists (2.33 vs 0.81 min, P = 0.01) but not for the number of flags seen (9.2 vs 9.6, P = 0.46). The medical students improved between the first and the 10th attempt, being significantly quicker for trial 10 than trial 1 (P = 0.005). However, although the medical students appeared to see more flags (8.0 vs 9.2) this was not significant (P = 0.05). The urologists did not differ in the number of flags visualized between the first and 10th trial, although they were significantly quicker in completing the task (P = 0.02). The urologists were significantly faster in trial 2 than trial 1, but no faster thereafter (P = 0.04). Using the URO Mentor simulator, it was possible to assess the level of experience of flexible cystoscopy, and therefore the system has construct validity. As in the real situation there is a period of learning during which the subject becomes familiar with the computer/machine/human interface, the task and the handling of the instruments. These results support the view that there is a role for VR simulators in urological training.
Article
This study was undertaken to establish construct validity of the Xitact LS500, a virtual reality laparoscopic cholecystectomy simulator. The primary research statement is: "The clip-and-cut task on the Xitact LS500 virtual reality laparoscopic cholecystectomy simulator mimics the surgical procedure of the clipping and cutting of the cystic duct and artery during the laparoscopic cholecystectomy adequately." According to the level of experience of the surgeon, an "expert group opinion" was formed resulting from 37 surgeons having performed over 100 laparoscopic cholecystectomies, and a "novice group opinion" was formed resulting of 37 surgeons having no experience at all with performing laparoscopic cholecystectomy. Participants received an instructed hands-on "tour" on the Xitact simulator and performed three formal simulation runs. The "novice group" is younger and more surgeons are female. Performance scores in the "expert" group are significantly higher on the second (p value 0.011) and third (p value 0.005) run, compared to the novices' scores. Experts are significantly faster on completion of all three runs. There is an increase in score over runs in both groups, which is statistically significant in the "expert group." Less than one-third of surgeons in either group are able to correctly predict their performance score as generated by Xitact. Both "experts" and "novices" feel it is useful to train with Xitact LS500 in the surgical curriculum. Three hypotheses, formulated to operationalize the primary research statement, could be answered affirmatively. Although further validation studies are needed, the Xitact LS500 simulator seems to be able to discriminate between expert and novice surgeons in this research setting, and thus the construct for this setting is considered to be valid.
Surgical simulation is a promising technique for training of laparoscopic surgery. Computer based simulation provides not only a cost effective alternative to traditional training but also a way to assess the surgeons performance. In this paper, we present a haptic simulator that allows for training and assessment of basic laparoscopic skills. The skills trained are modeled around a cholecystectomy procedure and include bi-manual dissection, clips setting, catheter insertion and cutting. The system uses accurate anatomic models of the organs involved in the procedure. This combined with effective methods for soft tissue deformation and haptic feedback, giving the surgeon a precise feeling of the interaction between organs and surgical instruments, provides a realistic training environment. The system has been designed with procedural training in mind and by putting together the individual tasks it will be possible to train on performing a complete cholecystectomy procedure.
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