JS Tsang, QMH Joint Hospital Grand Round 26 th April 2014
Dec 17, 2015
Halsted’s apprenticeship model◦ Random exposure◦ Biased assessment
Working time restrictions◦ Europe – EWTD (58->56->48hrs)◦ Hong Kong
Patient safety concerns
Trend in restructuring of surgery training
Interaction with computer-generated 3D model through an interface device
Well established in aviation
Training in safe environment
Develop Teamwork
Surgical simulation 1993 - Satava
Satava RM. Virtual reality surgical simulator. Surg Endosc 1993;7(3):203-5
Minimally invasive surgery
Endovascular surgery◦ Peripheral vascular disease (PVD)◦ Carotid stenosis◦ Aortic aneurysm
Steep learning curve – catastrophic for failure
EVA 3S trial – Carotid stenting 9.6% vs CEA 3.9% (peri-operative stroke rate)
Essential in training curriculumMas J et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis NEJM 2006; 355:1660
Realistic
Safe – patient + trainee
Objective assessment
Structured training
Rehearsal◦ Case◦ Team rehearsal
SAPPHIRE trial1 – CAS not inferior to endarterectomy
Increasing popularity
High-risk procedure – Stroke, death
Use of VR to improve learning curve
1.Yadav JS et al. Protected carotid-artery stenting versus endarterectomy in high risk patients. N Engl J Med 2004;351:1493-501
Dayal et al
Participants: Novice n=16 vs Experienced n= 5
Pre-training graded procedure
All received 2hrs simulation training
Results: significant improvements in Novice◦ Procedural time (PT)◦ Fluoroscopic time (FT)◦ Catheter and guide wire manipulation
Conclusion: Improve trainee performance
Dayal R et al. Computer simulation as a component of catheter-based training. J Vasc Surg 2004; 40(6):1112-17.
Participants: Untrained n=16 vs experienced n=13
Initial pre-test
Randomised into simulation training (60mins) vs no training
Final test
Results: ◦ significant improvement in PT after training in both untrained and experienced◦ Most improvement with Untrained subjects
Conclusion:◦ Performance correlated with previous experience◦ Novice may benefit most from VR training
Hsu JH et al. Use of computer simulation for determining endovascular skill levels in a carotid stenting model. J Vasc Surg 40(6):1118-25.
Participants: 20 experienced cardiologists
All received simulation training◦ 1.5 days of didactic and simulation training
Results: ◦ Significant improvements in PT, FT, contrast volume and
catheter handling time
Conclusion:◦ Learning curve with improved performance demonstrated on VR
simulator
Patel AD et al. Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography.J Am Coll Cardiol 2006; 47(9):1796-802.
Construct validity – ◦ differentiate novice and experienced subjects
Significant improvements in performance◦ Novice trainees
Aggarwal et al –
Renal angioplasty and stenting
20 vascular consultants◦ 11 inexperienced (<10 cases)◦ 9 experienced (>50 cases)
All received simulation training
Results: ◦ significant improvements in inexperienced - PT and contrast vol◦ Similar performance to experienced group after training
◦ Conclusion:◦ VR simulation helpful in early learning curve
Aggarwal R et al. Virtual reality simulation training can improve inexperienced surgeons’ endovascular skills. Eur J Vasc Endovasc Surg 2006;31(6):588-93.
Nine vascular trainees from different states
Iliac stenting
Simulation training x2 days with didactic tutorials
Results:◦ PT - 54% faster◦ FT and contrast volume decreased◦ Time to recognise and manage complications improved
Conclusion:◦ VR simulation offers realistic practice without risk to patients
Dawson DL et al. Training with simulation improves residents’ endovascular procedure skills. J Vasc Surg 2007; 45(1):149-54
Participants - 20 residents
Randomised - VR training vs no VR training
All performed 2 graded “real” peripheral angioplasty after 2 hours
Results:◦ Simulation subjects scored higher – procedural steps and global
rating scale◦ Advantage persisted for second “real” test
Conclusion:◦ Simulation - valid tool for training residents and fellows◦ May benefit retraining of vascular surgeons
N = 15
Rehearsal (within 24hrs) then actual CAS◦ Interventionalist + team members rehearsal
Recorded for analysis◦ Technical and non -technical skills
Results: ◦ 11/15 patients – identical endovascular tool use◦ 13/15 patients – identical fluoroscopic angles◦ 30% patients – simulator did not predict difficult, stenotic artery◦ Subjective evaluation score 4/5 – realism, technical +
communication issues
Willaert et al. BJS 2012;99:1304-13
N= 9 with abdominal aortic aneurysms
Pre-op rehearsal (within 24hrs) then real EVAR
Results:
◦ PT shorter in simulation vs live EVAR◦ FT, contrast volume, no. of angiographies – similar◦ 7/9 patients - C-arm angulation changed significantly
after rehearsal◦ Subjective questionnaire score 4/5: realism, usefulness in
rehearsal
Desender L et al. EJVEVS 2013;45:639
Seymour et al1 – laparoscopic cholecystectomy
Randomised surgical trainees to VR vs standardised training
VR group – fewer intra-op errors
Grantcharov et al2
◦ VR group – faster, better improvement in error and economy of movements
1. Seymour et al. Virtual reality training improves operating room performance: results of a randomised , double-blinded study. Ann Surg 2002;236:458-63
2. Grantcharov et al. Randomised clinical trial of virtual reality simulation of laparoscopic skills training. Br J Surg 2004;91:146-50
Ahlberg et al
Randomised trainees, surgeons and gastroenterologists
VR training vs control group
Results: VR group better caecal intubation◦ Shorter time◦ Less discomfort
Ahlberg et al. Virtual reality colonoscopy simulation: a compulsory practice for future colonoscopist? Endoscopy 2005;37:1198-204
‘see one do one’ – no longer feasible
VR simulation – realistic environment
Safe and offers ‘permission to fail’
Objective assessment and training◦ Structured and Competency based program
“Mission rehearsal” allows pre-operative planning
Studies – small series but encouraging
Improved performance Construct validity Shortens learning curve
VR simulation – endovascular surgical training◦ Adjunct to didactic training + clinical exposure