Virtual Reality, Simulators and Virtual Reality, Simulators and Surgical TrainingSurgical Training

W. Thomas Lawrence, MPH, MDW. Thomas Lawrence, MPH, MDUniversity of Kansas Medical CenterUniversity of Kansas Medical Center

AACPS PresidentAACPS President--ElectElect

What is a Simulator?What is a Simulator?•• A laboratory device that enables the A laboratory device that enables the

operator to reproduce under test operator to reproduce under test conditions phenomena likely to occur in conditions phenomena likely to occur in actual performance actual performance –– Webster’s Dictionary ( seventh ed.)Webster’s Dictionary ( seventh ed.)

•• A training and feedback device in which A training and feedback device in which learners practice tasks and processes in learners practice tasks and processes in lifelike circumstances using models or lifelike circumstances using models or virtual realityvirtual reality

Some Methods of Simulation Used Some Methods of Simulation Used in Medical Education for Some Timein Medical Education for Some Time

•• Other StudentsOther Students–– Commonly Used in Medical School to Learn IV Commonly Used in Medical School to Learn IV

and/or NG Placementand/or NG Placement•• CadaversCadavers

–– Commonly Used for Practicing Surgical Commonly Used for Practicing Surgical ProceduresProcedures

•• Animal ModelsAnimal Models–– Used For Developing Microsurgical SkillsUsed For Developing Microsurgical Skills

•• Models or MannequinsModels or Mannequins–– Teach ACLS SkillsTeach ACLS Skills

Limitations of Current Simulation Limitations of Current Simulation TechniquesTechniques

•• Other StudentsOther Students–– Can Be PainfulCan Be Painful

•• CadaversCadavers–– Incorrect PhysiologyIncorrect Physiology--No BleedingNo Bleeding–– Incorrect Incorrect HapticsHaptics

•• AnimalsAnimals–– Anatomy May Not Be AccurateAnatomy May Not Be Accurate–– Animal Rights Activists have ConcernsAnimal Rights Activists have Concerns

•• MannequinsMannequins–– Incorrect Incorrect HapticsHaptics and Physiologyand Physiology

Why Do We Need Better Simulators Now?Why Do We Need Better Simulators Now?•• Increased Concerns Regarding Patient SafetyIncreased Concerns Regarding Patient Safety

–– Traditional See One, Do One, Teach One May Traditional See One, Do One, Teach One May Not Be the Safest Teaching Method for PatientsNot Be the Safest Teaching Method for Patients

–– 98,000 Die Annually Due to Medical Errors98,000 Die Annually Due to Medical Errors

•• Need to Teach Full Complement of Surgical Need to Teach Full Complement of Surgical Skills in More Limited Time Period Due to Skills in More Limited Time Period Due to Work Hour RestrictionWork Hour Restriction

•• Patients in Hospital Less Providing Less Time Patients in Hospital Less Providing Less Time for Learner Interaction for Learner Interaction

•• Need to Efficiently Use OR time to Increase Need to Efficiently Use OR time to Increase Clinical Billing so Programs Can SurviveClinical Billing so Programs Can Survive

What is Virtual Reality?What is Virtual Reality?

•• Term Coined by Term Coined by JaronJaron Lanier in the late 1980’sLanier in the late 1980’s•• Defined as a HumanDefined as a Human--Computer Interface that Computer Interface that

Simulates Realistic Environments while Simulates Realistic Environments while Enabling Participant InteractionEnabling Participant Interaction–– Has to Provide Sense of Immersion in the Has to Provide Sense of Immersion in the

EnvironmentEnvironment

•• Provides Most Realistic SimulationProvides Most Realistic Simulation

•• Link SimulatorLink Simulator-- Developed by Edward Link Developed by Edward Link ––Son of Piano ManufacturerSon of Piano Manufacturer

•• Training of Pilots to fly by instrument Training of Pilots to fly by instrument control control

•• Surgeons Behind Pilots in the Development Surgeons Behind Pilots in the Development and Utilization of Surgical Simulatorsand Utilization of Surgical Simulators

Advantages of SimulatorsAdvantages of Simulators•• No Harm to PatientsNo Harm to Patients•• Teaching Technique not Dependent on Teaching Technique not Dependent on

Patient AvailabilityPatient Availability–– Can Provide Exposure to Rare PathologyCan Provide Exposure to Rare Pathology–– Can Assure Ability to Effectively Manage Rare Can Assure Ability to Effectively Manage Rare

EmergenciesEmergencies

•• Can Be Utilized in Less Technologically Can Be Utilized in Less Technologically Advanced Medical Environments (Third Advanced Medical Environments (Third World) to Provide Surgical TrainingWorld) to Provide Surgical Training

What is ‘Virtual Reality’?What is ‘Virtual Reality’?--Not Just One ThingNot Just One Thing

•• Tool That Allows Student to Carry Out Surgical Tool That Allows Student to Carry Out Surgical Procedure or Technique on a Virtual PatientProcedure or Technique on a Virtual Patient–– Particularly Applicable to Laparoscopic TechniquesParticularly Applicable to Laparoscopic Techniques

•• Animated Model of a Patient on Which Procedures Animated Model of a Patient on Which Procedures Are SimulatedAre Simulated–– Court Cutting’s Simulations of Cleft ProcedureCourt Cutting’s Simulations of Cleft Procedure

•• Clinical Scenario Described or Demonstrated and Clinical Scenario Described or Demonstrated and Student Responds with Evaluation and/or TreatmentStudent Responds with Evaluation and/or Treatment–– Develops and Evaluates Patient Management SkillsDevelops and Evaluates Patient Management Skills–– Develops and Evaluates Ability to Work Within Healthcare Develops and Evaluates Ability to Work Within Healthcare

SystemSystem

•• Simulate an Environment Simulate an Environment egeg ERER

Other Uses Less Applicable to EducationOther Uses Less Applicable to Education

•• TelesurgeryTelesurgery-- Operating on Patients Operating on Patients Separated from the SurgeonSeparated from the Surgeon

•• Robotic SurgeryRobotic Surgery–– RobodocRobodoc Used to Mill Femoral ShaftUsed to Mill Femoral Shaft–– DaVinciDaVinci Device for Urologic Surgery etc.Device for Urologic Surgery etc.

•• Surgeon Controls a RobotSurgeon Controls a Robot•• Robot Improves Upon Surgeon’s Skills by Robot Improves Upon Surgeon’s Skills by

Reducing TremorReducing Tremor

Need Computerized Need Computerized Models on Which Models on Which

to Workto Work

What Can Simulators Be Used For?What Can Simulators Be Used For?•• Teaching and Developing Competence in Surgical Teaching and Developing Competence in Surgical

TechniquesTechniques•• Evaluating Surgical Skills Using Defined Metrics in Evaluating Surgical Skills Using Defined Metrics in

a Defined Environmenta Defined Environment–– Need High InterNeed High Inter--rater reliabilityrater reliability–– Probably More Accurate than Traditional OR EvaluationsProbably More Accurate than Traditional OR Evaluations

•• Demonstrating Surgical Techniques in Models of Demonstrating Surgical Techniques in Models of Patients in Videos Patients in Videos egeg Court CuttingCourt Cutting

•• Evaluating and Teaching Cognitive Patient Evaluating and Teaching Cognitive Patient Management SkillsManagement Skills

•• Proving Competence in a Particular ProcedureProving Competence in a Particular Procedure

Simulation of Nasal ReconstructionSimulation of Nasal Reconstruction

What Simulators Are Currently What Simulators Are Currently Being Utilized?Being Utilized?

•• Minimally Invasive Surgical Trainer (MIST) Minimally Invasive Surgical Trainer (MIST) VR Device, VR Device, EndotowerEndotower and Computer and Computer Enhanced Laparoscopic Training System Enhanced Laparoscopic Training System (CELTS) for Laparoscopic Techniques(CELTS) for Laparoscopic Techniques

•• Vascular Intervention System TrainingVascular Intervention System Training•• EndoscopicEndoscopic Training DevicesTraining Devices•• Epidural injection SimulatorsEpidural injection Simulators•• IV Insertion SimulatorsIV Insertion Simulators•• Ophthalmologic SimulatorsOphthalmologic Simulators•• OthersOthers

Train IV InsertionTrain IV Insertion

MicrosurgeryMicrosurgerySimulationSimulation

Virtual Reality Training Improves Virtual Reality Training Improves Operating Room Performance: Results Operating Room Performance: Results of a Randomized, Double Blinded Studyof a Randomized, Double Blinded Study

Seymour et Seymour et al:Annal:Ann SurgSurg 236:458, 2002236:458, 2002•• 16 Yale Surgical Residents Randomized to either 16 Yale Surgical Residents Randomized to either

receive training on MIST VR simulator or not after receive training on MIST VR simulator or not after Baseline AssessmentsBaseline Assessments

•• One Half Underwent a Supervised Training Session One Half Underwent a Supervised Training Session on the MIST VR System Simulating a on the MIST VR System Simulating a CholecystectomyCholecystectomy

•• Residents Trained Until They Were Competent in Residents Trained Until They Were Competent in Required Manipulations with Both HandsRequired Manipulations with Both Hands

•• All Performed All Performed LaparascopicLaparascopic CholecystectomyCholecystectomy with with a Blinded Surgeon Investigator Which was a Blinded Surgeon Investigator Which was VideotapedVideotaped

Virtual Reality Training Improves Virtual Reality Training Improves Operating Room Performance (cont)Operating Room Performance (cont)

•• VR Trained Residents 29% Faster VR Trained Residents 29% Faster •• Gall Bladder Injury and Burn to Gall Bladder Injury and Burn to NontargetNontarget

tissue 5x More Likely in Nontissue 5x More Likely in Non--VR TrainedVR Trained•• NonNon--VR Trained Residents 9x More Likely to VR Trained Residents 9x More Likely to

Demonstrate Lack of ProgressDemonstrate Lack of Progress•• NonNon--VR Trained Made 6x More Errors VR Trained Made 6x More Errors

Including Liver Injury, Incorrect Plane of Including Liver Injury, Incorrect Plane of Dissection and Attending Takeover (Tissue Dissection and Attending Takeover (Tissue Tearing Not Noted in Either Group)Tearing Not Noted in Either Group)

Challenges for Virtual Reality Challenges for Virtual Reality SystemsSystems

•• Accurate Accurate HapticsHaptics–– Provide Feel of Natural TissueProvide Feel of Natural Tissue–– Provide Normal Provide Normal ViscoelasticityViscoelasticity of Tissueof Tissue–– Provide Accurate Simulations of BleedingProvide Accurate Simulations of Bleeding

•• Represent Immediate and Delayed Represent Immediate and Delayed PostsurgicalPostsurgicalResults of InteractionResults of Interaction

•• Providing Accurate Simulation of Entire Providing Accurate Simulation of Entire Environment Environment egeg OR, EROR, ER

•• Provide Accurate Simulation of Activities Provide Accurate Simulation of Activities Requiring a Team of IndividualsRequiring a Team of Individuals

•• Develop Tools that Can Be Utilized on a PC at Develop Tools that Can Be Utilized on a PC at Reasonable ExpenseReasonable Expense

Possible Future UsesPossible Future Uses•• Screen Resident Applicants for Surgical Screen Resident Applicants for Surgical

AptitudeAptitude–– Alternative to Carving EarsAlternative to Carving Ears–– Early Identification of Those With Limited Early Identification of Those With Limited

AptitudeAptitude•• Currently May Not Be Noted Until PGY 3Currently May Not Be Noted Until PGY 3--44

•• Board Certification ProcessBoard Certification Process•• Train and Validate Competency in New Train and Validate Competency in New

Procedures by Established PractitionersProcedures by Established Practitioners–– Required for New Carotid Required for New Carotid StentStent