Journal of Surgical Research 145, 80–86 (2008)

Training Opportunities and the Role of Virtual Reality Simulation inAcquisition of Basic Laparoscopic Skills

Rajesh Aggarwal, M.R.C.S.,1 Indran Balasundaram, M.R.C.S., and Ara Darzi, M.D.

Department of Biosurgery and Surgical Technology, Imperial College London, London, United Kingdom

Submitted for publication December 27, 2006

doi:10.1016/j.jss.2007.04.027

Background. Within the past decade, there has beenincreasing interest in simulation-based devices fortraining and assessment of technical skills, especiallyfor minimally invasive techniques such as laparos-copy. The aim of this study was to investigate theperceptions of senior and junior surgeons to virtualreality simulation within the context of current train-ing opportunities for basic laparoscopic procedures.

Methods. A postal questionnaire was sent to 245 con-sultants and their corresponding specialist registrar(SpR), detailing laparoscopic surgical practice andtheir knowledge and use of virtual reality (VR) surgi-cal simulators.

Results. One hundred ninety-one (78%) consultantsand 103(42%) SpRs returned questionnaires; 16%(10/61) of junior SpRs (year 1– 4) had performed more than50 laparoscopic cholecystectomies to date comparedwith 76% (32/42) of senior SpRs (year 5– 6) (P < 0.001);90% (55/61) of junior SpRs and 67% (28/42) of seniorSpRs were keen to augment their training with VR(P � 0.007); 81% (238/294) of all surgeons agreed thatVR has a useful role in the laparoscopic surgical train-ing curriculum.

Conclusions. There is a lack of experience in indexlaparoscopic cases of junior SpRs, and laparoscopicVR simulation is recognized as a useful mode ofpractice to acquire technical skills. This should en-courage surgical program directors to drive the inte-gration of simulation-based training into the surgicalcurriculum. © 2008 Elsevier Inc. All rights reserved.

Key Words: virtual reality; laparoscopy; training;questionnaire; simulation.

1 To whom correspondence and reprint requests should be ad-dressed at Department of Biosurgery and Surgical Technology, Im-perial College London, 10th Floor, Queen Elizabeth the QueenMother Building, St. Mary’s Hospital, Praed Street, London, W2

1NY, United Kingdom. E-mail: rajesh.aggarwal@imperial.ac.uk.

800022-4804/08 $34.00© 2008 Elsevier Inc. All rights reserved.

INTRODUCTION

The process of acquiring skills to practice surgeryindependently has remained largely unchanged for thepast century [1]. Trainees repeatedly practice withinthe operating theater, under the guidance of an expe-rienced surgeon. Training and progression dependsupon the patient case mix, workload, and subjectiveassessment by the tutor. Reductions in working hours,ethical considerations of training on patients, andemerging specialized surgical techniques require novelapproaches in training to ensure existing competenciesare met [2]. Surgical simulation has been proposed as ameans of achieving this task [3–6].

Virtual reality (VR) technology has been used suc-cessfully in the military, aviation, and nuclear industryfor many years [7]. Furthermore, numerous studieshave demonstrated the benefits of VR in surgical train-ing [8–11]. Although VR simulation was developed foruse in training surgical skills over a decade ago, thereremains a failure of dissemination of this technologyinto daily practice. Reasons such as lack of familiarity,poor reliability, prohibitive costs, the need for frequentsoftware upgrades, inadequate validation of effective-ness, and reluctance of faculty to allow time for its usehave been suggested as causes for poor uptake of VRsimulation tools [12].

Despite the benefits of VR and the current evidencebacking its use, there remains a lack of knowledge andconsensus regarding the incorporation of this new tech-nology into the surgical curriculum. This study aims toassess the current opinions and attitudes of those whohave the power to advocate change in the trainingcurriculum—consultants, and those who will be train-ing in any potential new curriculum—specialist regis-

trars (SpRs).

81AGGARWAL, BALASUNDARAM, AND DARZI: ROLE OF VIRTUAL REALITY SIMULATION

MATERIALS AND METHODS

A postal questionnaire was sent to 245 consultant surgeons witha specialist interest in laparoscopic surgery in the four Londonregions (North West, North East, South West and South East),followed by a similar questionnaire to their associated SpRs. EveryNational Health Service (NHS) hospital in this area was identifiedusing the NHS website (www.nhs.uk). The hospital switchboardtelephone numbers were obtained and the theater nurse in chargecontacted. Following an explanation of the study aims to the theaternurse, the names of consultants who regularly performed laparo-scopic surgery was obtained.

Two questionnaires were sent, one addressed to the consultant byname, and a second addressed as ‘surgical registrar to consultant’.These were sent by post, and each included a self addressed envelopefor return of the responses. If no response was received within twoweeks, a further copy of the questionnaire was sent.

The consultant’s questionnaire had three sections (Appendix 1).The first was concerned with surgical experience: years since quali-fying as a consultant, total number of laparoscopic cholecystectomies(LC) performed and the number of LC performed in the past 12months. The second section covered the consultants’ SpR work load.Consultants were asked whether their SpRs had the opportunity toperform LCs under supervision, and the anticipated case load peryear. The final section was concerned with the experience of VR simu-lation, i.e., whether they had seen and used VR, and whether VRsimulation had a useful role to play in laparoscopic surgical skillstraining (marked on a Likert scale from 1 � not useful to 5 � veryuseful).

The SpR questionnaire (Appendix 2) followed a similar structureto that described above. The initial section requested informationregarding laparoscopic experience. The second section was concernedwith competency—how many LC they feel they need to complete tooperate independently and how many LC they should perform peryear to maintain competency. The final section requested informationregarding experience with VR, as for the consultant questionnaire.

Statistical analysis used the �2 test, with P � 0.05 deemed signif-icant.

RESULTS

For the purposes of this study, results from consult-ants were analyzed separately from those of SpRs. TheSpRs were further subdivided into training years 1 to 4(junior trainees) and years 5 to 6 (senior trainees).

FIG. 1. Training opportunities for SpRs in laparoscopic cholecys-tectomy according to level of experience. (Color version of figure is

available online.)

From the 245 questionnaires sent, 191 (78%) consult-ants replied, while 103 (42%) SpRs returned the ques-tionnaire; of these 61 (59%) were junior SpRs and 42(41%) were senior SpRs.

Ninety-five percent (181/191) of consultants had per-formed more than 100 LC in total and 84% (161/191)had performed more than 20 LC in the past 12 months.Although not all consultants replied to the question,83% (143/173) of consultants stated that they providedopportunities for years 1 and 2 SpRs to perform LCunder supervision, 94% (163/174) for years 3 and 4SpRs, and 96% (160/166) for years 5 and 6 SpRs toperform LCs (Fig. 1). Sixteen percent (10/61) of juniorSpRs (year 1–4) had performed more than 50 LC todate compared to 76% (32/42) of senior SpRs (year 5–6).This difference was statistically significant (P � 0.001).

All SpRs were asked to define numbers of LCs re-quired to be competent in the procedure. This is showngraphically in Fig. 2, and demonstrates a wide varietyof responses. The majority of SpRs, especially thosehaving performed over 20 procedures, denote “greaterthan 50 LCs” as a marker of operative competence.

Fifty-one percent (98/191) of consultants had seen alaparoscopic VR simulator and 25% (48/191) had hadsome hands-on experience of the tool. Of the seniorSpRs, 62% (26/42) had seen and 36% (15/42) had useda VR simulator. The junior SpRs had slightly less ex-perience of VR than their senior counterparts, 52%(32/61) of them having seen and 30% (18/61) havingused a laparoscopic VR simulator (Fig. 3).

Ninety percent (55/61) of junior SpRs were keen toaugment their training with VR, though only 67% (28/42) of senior SpRs were enthusiastic to do the same(Fig. 4; P � 0.007). However, across the board of allresponses, 81% (238/294) of surgeons agreed that VRhas a useful role in the laparoscopic surgical trainingcurriculum (marked as scores of 3, 4, or 5 on the Likertscale). The range of responses divided according toconsultant and SpRs was equivalent, as shown in Fig.

FIG. 2. Number of cholecystectomies performed by registrars(x-axis). Bars indicating how many they feel need to be performed togain competence in the procedure. (Color version of figure is avail-able online.)

5a and b.

82 JOURNAL OF SURGICAL RESEARCH: VOL. 145, NO. 1, MARCH 2008

DISCUSSION

Simulation provides a realistic reflection of the realworld where the learner can practice the concept of “de-liberate practice”. This allows the learner to attempt awell defined task at a set difficulty level where opportu-nities for repetition and correction of errors is permitted[13, 14]. Simulators can be used to train, test, analyze,and research the skills of trainees and trainers. Thetrainee can practice effectively through a hierarchy oflearning, from simple skills to tasks and then completeprocedures in a risk-free environment [15]. The simulatoralso provides immediate objective feedback to questions,decisions, actions, and performance during learning,which consequently enables proficiency testing, leadingto the development of proficiency based practice [13, 14].

From the results of this study, it is apparent that themajority of junior SpRs are inexperienced in perform-ing the index laparoscopic procedure of cholecystec-tomy. Although 83% of years 1 and 2 SpRs and 94% ofyears 3 and 4 SpRs were provided with opportunities toperform LC under supervision, only 16% of juniortrainees (year 1–4) had performed greater than 50 LC.The senior SpRs had greater experience of laparoscopicsurgery, with 76% of them having performed morethan 50 LC to date. This may account for the fact thata significantly greater proportion of junior SpRs werekeen to augment their training with VR, though a largemajority of the respondents agreed that there is arole for VR as part of a training curriculum. However,the low response rate of SpRs to the questionnaire is alimitation to the interpretation of this data.

The current perception, supported by the results ofthis study, is of VR simulation as a tool for acquisitionof basic laparoscopic skills. Advances within the past18 months have led, and shall continue to lead, to thedevelopment of simulators that enable more advancedprocedures to be performed, with the added benefit ofrealistic force feedback. Notwithstanding this fact, itmay not be necessary for the simulated task to accu-rately resemble the real task. A study by Grober et al.

FIG. 3. Percentages of surgeons who have seen and/or used a virtualreality surgical simulator. (Color version of figure is available online.)

demonstrated that training using high fidelity models

(anesthetized rats) was equivalent to that on low-fidelity synthetic bench-top models [16].

Current research also supports the use of VR simula-tion for training of surgeons in the skills laboratory, butalso that this transfers to the operating room [4, 11]. Ourresults demonstrated that senior trainees were less likelyto use VR to augment their training. This may be due tothe fact that the questionnaire focused upon laparoscopiccholecystectomy, and there may have been more interestfrom senior trainees regarding advanced laparoscopicprocedures such as colon resection. With the advance-ment of technology and the improvement of current sim-ulators, VR has the potential to recreate more complexand more realistic operations, which can be applicable tothe training programs of senior surgeons.

Two previous questionnaire studies have analyzed theopinions of trainers and trainees toward VR. An Ameri-can study published in 2001 revealed that 58% of generalsurgery program directors had seen and 19% had used aVR surgical simulator [12]. Ninety-two percent believedthat there is a need for skills training outside the oper-ating room and 83% agreed upon the role for VR technol-ogy to satisfy this need. The senior surgeons also believed61% of residents would participate in VR training butsurprisingly only 49% responded that the faculty wouldsupport such training. A further study questioned ortho-paedic surgeons who believed that a surgical simulatorcould have useful applications in arthroscopic surgery[17]. However, only 3% of those responding had used asurgical VR simulator and, contrary to their hypothesis,recently qualified surgeons were less likely to agree thatVR-based training is important.

Integrating VR simulation technologies into the cur-rent training curriculum involves a paradigm shift inthe previous approach toward training practices and,therefore, current perceptions need to be changed [18].A pure apprenticeship model can no longer be applica-ble, and surgical training needs to be augmented withsupplementary methods to compensate for the currentdrivers for change within the delivery of healthcare. Sim-ulators must be integrated into a comprehensive curric-ulum and not considered as a stand-alone system [19].Current working schedules already place a great deal ofdemand on the trainee’s time, with patient care, theater

FIG. 4. Percentage of trainees interested in augmenting theirtraining with virtual reality simulation. (Color version of figure is

available online.)

83AGGARWAL, BALASUNDARAM, AND DARZI: ROLE OF VIRTUAL REALITY SIMULATION

time, clinics, and ward duties. Therefore, time allocatedto self study and training is given a lower priority.

VR has already been shown to improve surgicaltrainees’ manual dexterity and, within the wider pic-ture, is not only necessary to train on technical skills,but also within fully contextualized environments such

FIG. 5. (A) The role of VR in training according to consultant sversion of figure is available online.)

as the operating theater, consulting room, and endos-

copy suite [20, 21]. This can lead to the development ofa simulation-based training curriculum that goeshand-in-hand with clinical progression, enabling train-ees and trainers to make the most out of the time spentwithin real clinical environments. Ultimately, it is pos-sible that this will also reduce the number of unneces-

eons. (B) The role of VR in training according to registrars. (Color

urg

sary errors that occur within healthcare.

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