Effects of Repetition of Technical Skills Independent of External Instruction on Surgical Performance Using Virtual Reality Surgical Simulator NeuroTouch 10th SANS - March 1st, 2016 Dr. Gmaan Alzhrani, MBBS, MA ed. Norah Abdulaziz Alarifi Dr. Hamed Azarnoush, PhD Dr. Fahad Alotaibi, MBBS, MSc Dr. Abdulrahman Sabbagh, M.D., FRCS(C) Alexander Winkler-chwartz, MBBS Dr. Susanne Lajoie Dr. Rolando Del Maestro, M.D., Ph.D., FRCS(C), FACS, DBNS, DABPNS Neurosurgical Simulation Research Centre, Department of Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montréal, Canada Department of Educational and Counseling Psychology, McGill University National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia Alfaisal University, College of Medicine, Riyadh, Saudi Arabia Introduction • Surgical training o Teacher-centered approach o “Education by random opportunity” • Virtual reality surgical simulation o Skill acquisition o Skill assessment Cosman, P. H., Cregan, P. C., Martin, C. J., & Cartmill, J. A. (2002). Virtual reality simulators: current status in acquisition and assessment of surgical skills. ANZ journal of surgery, 72(1), 30-34. Human, T. E. I., Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). Institute of medicine. Washington, DC. Purpose of the Study • To assess whether procedural repetition would result in improvement of neurosurgical technical skills performance using a set of specific metrics independent of external instruction using NeuroTouch/NeuroVR simulation platform Methods 1. Participants • A group of 31 participants: • 16 board certified neurosurgeons • 15 neurosurgery residents o 3 R1, 2 R2, 2 R3, 2 R4, 3 R5, 3 R6 • No participants had any experience using NeuroTouch or other simulators. Methods 2. NeuroTouch/Neuro VR • A virtual reality surgical simulator with a haptic feedback a. Stereoscope b. Simulated tools c. Foot pedals Figure 1. (A) The NeuroTouch simulator platform equipped with stereoscopic viewer, display screen, bimanual force feedback handles, and activator pedals. (B) Mannequin head with haptic device, which provides force feedback of the simulated ultrasonic aspirator. (C) View of operating scene with participant using simulated d. Haptics ultrasonic aspirator to resect 1 of 3 simulated tumors in scenario 4. Adapted from AlZhrani, G., Alotaibi, F., Azarnoush, H., Winkler-Schwartz, A., Sabbagh, A., Bajunaid, K., ... & Del Maestro, R. F. (2015). Proficiency performance benchmarks for removal of simulated brain tumors using a virtual reality simulator neurotouch. Journal of surgical education, 72(4), 685-696. Methods 3. Scenarios • 18 consecutive tumor of different complexities Methods 4. Metrics Safety Quality Efficiency Brain Volume Ultrasonic Aspirator Removed Total Tip Path Length Ultrasonic Aspirator Tumor Percentage Duration For Task Maximum Force Removed Completion Applied Ultrasonic Aspirator Frequency of Pedal Sum of Forces Utilized Activation Alotaibi, F. E., AlZhrani, G. A., Sabbagh, A. J., Azarnoush, H., Winkler-Schwartz, A., & Del Maestro, R. F. (2015). Neurosurgical assessment of metrics including judgment and dexterity using the virtual reality simulator NeuroTouch (NAJD Metrics). Surgical innovation, 1553350615579729. Methods 5. Data Analysis • Repeated Measure ANOVA • The independent variable is the 18 repetitions each participant did during the trial • The dependent variables include the metrics assessed Results: Brain Volume Removed T1 (M = .10, SD = .03) T18 (M = .09, SD = .03) Performance curve for neurosurgery group (neurosurgery staff, junior, and senior residents) demonstrating a decrease in the amount of brain volume removed with repetitions. MB = Medium Black; HB = Hard Black; SB = Soft Black; ST = Soft Tissue; MT = Medium Tissue; HT = Hard Tissue; HW = Hard White; MW = Medium White; SW = Soft White. Results: Sum of Forces Utilized T1 (M = 114.4, SD = 66.2) T18 (M = 99.6, SD = 62.7) Performance curve for neurosurgery group (neurosurgery staff, junior, and senior residents) demonstrating a decrease in the sum of force utilized during tumor resection. MB = Medium Black; HB = Hard Black; SB = Soft Black; ST = Soft Tissue; MT = Medium Tissue; HT = Hard Tissue; HW = Hard White; MW = Medium White; SW = Soft White. Results: Total Tip Path Length T1 (M = 1487.5, SD = 639.5) T18 (M = 1445.9, SD = 551.7) Performance curve for neurosurgery group (neurosurgery staff, junior, and senior residents) demonstrating a decrease in the total tip path length with repetitions. MB = Medium Black; HB = Hard Black; SB = Soft Black; ST = Soft Tissue; MT = Medium Tissue; HT = Hard Tissue; HW = Hard White; MW = Medium White; SW = Soft White. Results: Duration of Task Completion T1 (M = 115.8, SD = 32.9) T18 (M = 107.1, SD = 31.0) Performance curve for neurosurgery group (neurosurgery staff, junior, and senior residents) demonstrating a decrease in the duration for task completion. MB = Medium Black; HB = Hard Black; SB = Soft Black; ST = Soft Tissue; MT = Medium Tissue; HT = Hard Tissue; HW = Hard White; MW = Medium White; SW = Soft White. Safety Quality Efficiency Brain Volume Ultrasonic Aspirator Removed Total Tip Path Length Ultrasonic Aspirator Tumor Percentage Duration For Task Maximum Force Removed Completion Applied Ultrasonic Aspirator Frequency of Pedal Sum of Forces Utilized Activation Improved Unaffected Discussion • Capacity for improvement with repetition in 4 of the 7 of the metrics studied. o Two involving safety metrics o Two involving the efficiency metrics • External instruction to guide the performance may be important in all metrics but particularly involving metrics concerned with safety (e.g. total maximum force applied) and quality (e.g. percentage of tumor removed). Conclusion • Virtual reality simulation in neurosurgical training is a new approach to understanding manual performance and provides insights into new concepts of training • This study is one of many focused on understanding ‘expert’ neurosurgical performance. o Proficiency Performance Benchmarks for Removal of Simulated Brain Tumors using NeuroTouch a Virtual Reality Simulator o Assessing bimanual performance in brain tumor resection withNeuroTouch, a virtual reality simulator o Neurosurgical Assessment of Metrics including Judgment and Dexterity (NAJD) Using the Virtual Reality Simulator NeuroTouch THANK YOU Neurosurgical Simulation National Research Council Research Center (Canada) team • Dr. Rolando Del Maestro, M.D., Ph.D., • Denis Laroche, Meng FRCS(C), FACS, DBNS, DABPNS • Nusrat Choudhury, MEng • Dr. Gmaan Alzhrani, MBBS, MA ed. • Valerie Pazos, PhD • Dr. Hamed Azarnoush, PhD • Dr. Robert Dirado, PhD • Dr. Fahad Alotaibi, MBBS, MSc • Dr. Abdulrahman Sabbagh, M.D., FRCS(C) • Dr. Alexander Winkler-chwartz, MD • Susanne P. Lajoie, PhD • Jawad Fares • Marta Baggiani.