JS Tsang, QMHJoint Hospital Grand Round

26th April 2014

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

Skills transfer to real operating environment

Chaer RA et al. Ann Surg 2006; 244:343-52

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

Mission/ Procedure rehearsal

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

Simulated procedure + theatre Real procedure + theatre

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

JS Tsang, QMHJoint Hospital Grand Round

26th April 2014