From OR to VR: Virtual reality takes on surgical training
Students and residents learning minimally invasive surgery have a new center for training, courtesy of John A. Savino, M.D., and Donald Risucci, Ph.D.
By Susan Hoffner
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John A. Savino, left professor and chairman of the Department of Surgery, and Donald A. Risucci, Ph.D., director of the Surgical Skills Center, have teamed up to put virtual reality to the test: To what level can surgeons perfect their skills? |
Fastest route
The vision for a surgical skills laboratory had been forming in the mind of John A. Savino, M.D., professor and chairman of the Department of Surgery, for a number of years. The idea came to him even before he took the helm from Louis R.M. Del Guercio, M.D., professor emeritus of surgery, who retired in 2001 after nearly 25 years. "We wanted to have a place where surgeons with all levels of experience could come to hone their skills and learn new ones," explains Dr. Savino. "This center will provide the safest and fastest route to putting the most advanced minimally invasive methods into practice, which has been our goal all along." He heralds MIS techniques as "the future of surgery." The skills are particularly suited to learning through computer simulation because as he explains, "Surgeons performing these types of procedures on actual patients are already viewing the surgical field on a monitor."
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Laura Choi, M.D., completing a one-year fellowship in minimally invasive surgery offered by the Department of Surgery, finishes the suturing exercise with high marks at the Surgical Skills Center in Westchester Medical Center. |
One of the first devices used in the training of minimally invasive procedures is the box trainer. The rectangu- lar Plexiglas box has three holes through which two surgical instruments and a camera are placed, in much the same way that tools are passed through small incisions into a patient. "Box trainers accurately simulate the confining, rigid environment that limits the surgeon's range of motion in actual surgery," explains Donald A. Risucci, Ph.D., associate professor of surgery and director of the center. "It is a low-tech apparatus, but some surgical educators believe box trainers offer better simulation than some of the more advanced equipment. It is actually a bit controversial for that reason."
Enter virtual reality
At the other end of the spectrum are two sophisticated computer terminals that could be dubbed the "crown jewels" of the skills lab. They are the LapSim short for laparoscopic simulator, one of the latest virtual reality trainers, and the minimally invasive surgery trainer, or MIST, which perfects visual perception skills with a set of abstract exercises. First appearances are deceiving; with the monitors turned off both units are rather unimpressive. But if you press the start-up button on the virtual reality trainer, launch the LapSim Basic Skills TM software, and select one of a dozen or so task modules, everything changes. Realistic organ-like objects and tissue hover on screen, glistening and pulsating, as one imagines that only the human equivalent can.
A turn at the controls gives the eerie feeling of peering deep inside a human body - up close and very per- sonal. Computer simulation exercises run the gamut from beginning mod- ules on camera and instrument navi- gation and coordination, to more advanced tasks like applying clips and suturing, which involve a foot pedal for cutting to activate cauterization. There is even a precision and speed module, described by the manufacturer as "light-heartedÉwith serious intentÉ.navigation practice in a game-like context."
Scorecards rate docs
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Training module on LapSim displays the on-screen command, "Place the stitch within the circle," putting residents' suturing and cauterization techniques to the test at the new Surgical Skills Center. |
"One striking advantage to LapSim and MIST is the ability to preprogram individualized exercises for students and to collect data scores," explains Dr. Risucci, whose unusual back- ground of surgery, psychology and educational research make him uniquely suited to direct the skills laboratory. He and Dr. Savino are on a mission to develop research that will quantify the success of these new teaching modalities.
"Some preliminary data on the effectiveness of surgical training via computer simulation is out there but much more needs to be done," says Dr. Risucci, who held an academic appointment at Cornell University Medical College as assistant professor of psy- chology in surgery prior to joining the College faculty in 2002. At the time he also served in an administrative role as assistant chairman for education and research in the department of surgery at North Shore University Hospital. Dr. Risucci's career has traversed a some- what accidental and unusual twist of fate, beginning as a doctoral student in applied psychological research, and later as a faculty member in psychology at Hofstra University in Queens, N.Y. He then focused on neuropsychological research, but now has landed squarely in surgery - specifically, in the forefront of surgical education. Dr. Risucci was recently elected secretary of the executive committee of the Association for Surgical Education, which represents more than 190 medical schools and institutions in the U.S. and Canada in promoting the art and science of education in surgery.
Different strokes
Benefiting the most from the new lab and research are those contemplating surgery as a specialty in medical school, attendings wishing to improve their techniques and others who have decided it's finally time to learn new ones. Third-year medical students will get first crack at MIS skills training dur- ing their required surgery rotation, while fourth-years taking a surgical sub- specialty rotation will find further opportunities there. Additionally, fourth-years will be able to sign up for a new surgical elective with a significant MIS component coupled with skills enhancement. Even interested first-years get a taste of the new lab when Dr. Savino and his faculty coach them through special presentations they will give before the student Surgery Club. Still, it will be the surgical residents who utilize the lab most, spending numerous hours in the facility during the five years of their residencies. The junior residents, PGY-1 and 2, will make good use of the 12-hour didactic CD- ROM-based module Laparoscopy 101, while PGY-4 and PGY-5 residents will develop speed and accuracy toward the end of their residencies. There also are three surgeons enrolled in a one-year MIS fellowship who are looking to develop finesse in the lab.
The advantages of using computer simulation in training are enormous. Dr. Savino cites the 1998 report by the Institute of Medicine of the National Academy of Sciences entitled "To Err is Human," which revealed dismal statistics on hospital deaths related to human error. "The report charged us to improve procedural accuracy and performance," he says. "This is one way we will achieve the goals we have set.
"Minimally invasive surgery is no longer the future, it is here now - and there is no turning back. More than 60 percent of surgeries are done this way now. In 5 years it will be 80 percent. Once unveiled, the technique will only grow in popularity. Patients obviously want it. Hospitals want it. The government, private insurers and managed care companies want it. With advances such as ultrasonic technology replacing electrical current for cauterization, plus developments in fiber optics and safer instrumentation, the benefits are continuing to accrue. Doctors are obligated to provide it."
MIS techniques are not ergonomically friendly for doctors, but that too will eventually change, Dr. Savino predicts. "MIS is a skill that must be learned and early perception development is needed. These skill sets are advanta- geous for a wide range of physicians, not just surgeons. We have urologists performing nephrectomies, gynecolo- gists performing hysterectomies, even interventional cardiologists doing angioplasties and stents. All of these and others will be able to utilize the skills enhancement laboratory."
Perfecting maneuvers through repeated practice, in a learning environment where there is little pressure and the stakes are not as high as they are in a clinical setting, can only be a good thing for all those involved - doctor, patient and family.