Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 35-39

Virtual reality simulator face validity for topographic real situation of inflated abdomen


1 Department of Urology, Istanbul Cerrahi Hospital, Nisantasi University College of Health Sciences, Istanbul, Turkey
2 Department of Urology, Hisar Intercontinental Hospital, Galata University, Istanbul, Turkey
3 Department of Medical Education, School of Medicine, Marmara University, Istanbul, Turkey
4 Department of Urology, Taksim Teaching and Research Hospital, Istanbul, Turkey

Date of Submission16-Aug-2021
Date of Decision16-Aug-2021
Date of Acceptance08-Sep-2021
Date of Web Publication26-May-2022

Correspondence Address:
Basri Çakiroglu
Saray Mah.Siteyolu Cad. No. 7 34768, Umraniye, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_30_21

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  Abstract 


Objective: The aim of this study is to investigate the face validity of LapSIM® (haptic feedback Xitact™ IHP, Mentice AB, Sweden) for the topographic real condition of the inflated abdomen in upper urinary tract laparoscopic interventions. Materials and Methods: The present study was conducted with 30 urologists with experience in transperitoneal laparoscopic renal surgery. Surgeons were divided into three groups: novices, intermediate experience, and experts. After performing the tasks, the participants were then asked to finish a five-item questionnaire regarding the face validity of the simulator. Participants answered questions with ratings from 1 (not realistic/useful) to 5 (very realistic/useful). Results: The mean age of the study group was 38.33 ± 5.45 (29–47) years. The mean years of experience of the doctors were 4.27 ± 1.89 (1–7) years. All the variables showed significant differences from the ideal value of 5. We also tested whether the medians differed from 3, and the restrained body posture of the surgeon, the monitor position, and the trocar position not show significance with one-sided P value of P = 0.825, P = 0.992, and P = 0.265, respectively. Conclusion: Although the LapSIM® virtual reality simulator provides face validity for the topographic real condition of the inflated abdomen, it should be improved.

Keywords: Face validity, laparoscopy, LapSIM, simulator, surgeon


How to cite this article:
Tas T, Çakiroglu B, Akdeniz E, Hazar IA, Balci C. Virtual reality simulator face validity for topographic real situation of inflated abdomen. Hellenic Urology 2021;33:35-9

How to cite this URL:
Tas T, Çakiroglu B, Akdeniz E, Hazar IA, Balci C. Virtual reality simulator face validity for topographic real situation of inflated abdomen. Hellenic Urology [serial online] 2021 [cited 2022 Oct 4];33:35-9. Available from: http://www.hellenicurologyjournal.com/text.asp?2021/33/2/35/346056




  Introduction Top


For competence in laparoscopic surgical practice, knowledge, reasoning, and training are required as well as skill.[1] Challenging urological laparoscopic interventions have created the need for training models as in other branches.[2],[3],[4] Simulators, animal models, and cadaveric models are used in laparoscopic manual skill training in urology.[5],[6] Box trainers (BTs) and virtual reality simulators (VRSs) are frequently used in training centers.[7]

Virtual reality training has become one of the mainstays of surgical training outside the operating room.[8] Conventional BTs do not aim to simulate operations exactly. VRSs are created to simulate one to one. VRSs are designed as a virtual environment in which basic laparoscopic tasks can be performed. The use of video and instrumentation in laparoscopy training has provided VRS with a unique field as a teaching tool. After the developments in software technology in recent years, the reality in the image has been increased. The system has models with and without haptic feedback. Haptic feedback has been shown to improve the fidelity, realism, and thus the training effect of VRSs.[9]

LapSIM® is one of the VRSs with the most validation studies. The aim of this study is to investigate the face validity of LapSIM® (haptic feedback Xitact™ IHP, Mentice AB, Sweden) for the topographic real condition of the inflated abdomen in the upper urinary tract laparoscopic interventions.


  Materials and Methods Top


The study was conducted with 30 urologists with experience in transperitoneal laparoscopic renal surgery. Surgeons were divided into three groups: novices with 20–50 primary surgeries (n = 7), intermediate experience with 50–100 primary surgeries (n = 14), and experts (n = 9) with more than 100 primary surgeries.

Simulator

The LapSIM® used in our study is a VRS that allows basic laparoscopic skills and some procedures to be applied.[10],[11] LapSIM® basic skills module training program (Haptic LapSIM® Surgical Science AB, Sweden) was used in the study. The system consisted of an 18-inch Thin Film Transistor (TFT) monitor, a laparoscopic interface module (Immersion Inc., San Jose, CA), a box, and a foot pedal. The software was dual processor Pentium IV, Microsoft Windows XP operating system, and video card 256 MB RAM and Geforce [Figure 1]. The box system consisted of two systems for hanging the hand tool and an unrounded space. The system and all modules were compatible with haptic feedback.
Figure 1: LapSIM® virtual reality simulator (Surgical Science AB) with haptic feedback Xitact™ IHP, Mentice AB, Sweden. IHP: Instrument haptic ports

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Exercises

LapSIM® basic skills training system consists of 11 modules [Figure 2]. Each module of the simulator training has three phases as easy, intermediate, and difficult. It was requested to complete tasks involving 11 basic skill modules such as camera navigation, instrument navigation, coordination, grasping, cutting, clip applying, lifting and grasping, fine dissection, seal and cut, suturing, precision, and speed. The short course is completed approximately 60 min.
Figure 2: LapSIM® basic skills training suturing and knot models

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After performing the tasks, the participants were then asked to finish a five-item questionnaire regarding the face validity of the simulator. Participants answered questions with ratings from 1 (not realistic/useful) to 5 (very realistic/useful) [Table 1].
Table 1: Posttask questionnaire and questions: ratings from 1 (not realistic/useful) to 5 (very realistic/useful)

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Statistical analyses

The variables were described with mean (standard deviation), median, first quantile (Q1), third quantile (Q3), and minimum and maximum values. The medians of restrained body posture of the surgeon, monitor position, trocar position, tissue distance, and limited field of movement and motional capability were tested whether they were less than the ideal (a perfectly realistic compared to real laparoscopic cases) value of 5 and also from 4 to 3 using the one-sample one-sided Wilcoxon-signed rank test. The boxplots for each variable were also displayed using the jittered observations. Kruskal–Wallis test was employed to compare doctors classified with respect to their experiences in terms of their opinions about the VRS. P < 0.05 was considered significant. R statistics program was used for all calculations.


  Results Top


Thirty doctors were included in the study. The mean age of the study group was 38.33 ± 5.45 (29–47) years. The mean years of experience of the doctors were 4.27 ± 1.89 (1–7) years.

The medians of restrained body posture of the surgeon (3.06 [0.45]), monitor position (3.23 [0.50]), trocar position (2.93 [0.52]), tissue distance (2.70 [0.47]), and limited field of movement and motional capability (2.63 [0.49]) were tested whether they were less than the ideal value of 5 and the results are given in table. All the variables showed significant differences from the ideal value of 5. We also tested whether the medians differed from 3 and the restrained body posture of the surgeon, the monitor position, and the trocar position did not show significance with one-sided P values of P = 0.825, P = 0.992, and P = 0.265, respectively [Table 2]. The table show whether the opinions of doctors about the properties of the VRS changed according to their experience level [Table 3].
Table 2: Descriptive statistics

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Table 3: Whether the opinions of doctors about the properties of the virtual reality simulator changed according to their experience level

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The boxplots of each variable are given in [Figure 3]. From the boxplots, it was seen that monitor position, the restrained body posture of the surgeon and trocar position observations were centered around the median 3; however, for tissue distance and limited field of movement and motional capability, many observations are below the median level 3.
Figure 3: Boxplots for variables (Box position: Restrained body posture of the surgeon, feel: tissue distance, and space: Limited field of movement and motional capability)

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  Discussion Top


The restrained body posture of the surgeon, the monitor position, and the trocar position were seen as close imitations of the real environment. LapSIM® showed face validity in 3 of 5 parameters evaluated in our study. Based on the participants; feedback, LapSIM® was considered to be moderately realistic. Doctors' opinions did not differ significantly due to their level of experience.

The restrained body posture of the surgeon representative

In our study, laparoscopists reported that LapSIM® is partially representative in terms of the surgeon's mandatory posture in transperitoneal laparoscopy of the upper tract procedures. The mean value in all three of novices, intermediate experience, and experts has been determined to be above 3. Surgeons generally stated that due to the more comfortable posture, it may partially give the same fatigue. LapSIM® partially presents the humanoid structure that can give this posture condition and the condition that muscle groups should be accustomed to.

The position of monitor and devices

In our study, it attracted attention as the closest imitation by taking the highest mean value. According to experience, the mean value was found to be above 3 in all three groups. Surgeons reported that the monitor position partially represents the actual situation.

The trocars entry slots

Surgeons reported that trocars entry slots were partially representative of the real situation. However, unlike the other two groups, expert surgeons have an average of <3. Depending on the type of surgery, the distance between the trocars and the angles they make during operation vary. In LapSIM®, the fact that the distances of the trocars cannot be adjusted to each other, and although the upper tract attempts make an angle close to parallel to the ground, working with an angle close to 45° may have been effective in this results.

Surgeons reported that tissue distance and limited field of movement and motional capability were not representative. It has been reported that the area to be studied and the trocars do not meet the support point, i.e., the tissue depth, in laparoscopic interventions, and that the manipulations are performed much more easily in LapSIM®, which has a larger working area.

Shetty et al. assessed the face validity of medical students, surgical residents (postgraduate years 1–5), fellows, and attending participants with a questionnaire. The curriculum improved my camera handling skills, the curriculum should be required for novices before assisting in the operating room, the feedback from the program is accurate, the curriculum is relevant to surgery, the curriculum is a valid training tool, and the curriculum is a valid testing tool. In this study, it was reported that LapSIM® camera navigation shows construct and face validity.[12] Schreuder et al. evaluated facial validity using a questionnaire consisting of 27 statements with novice (medical students), intermediate (residents), and expert (gynecologists and some senior residents who all performed more than 100 laparoscopic) participants. It has been reported that there is a significant difference between subjects with different laparoscopic experience, and therefore, construct validity for the laparoscopic simulator can be established.[13]

Van Dongen et al. reported that LapSIM® provided construct validity by showing statistically significantly higher scores than novices for both overall score and efficiency, speed and precision parameters in experienced surgeons and surgical residents.[14] Woodrum et al. reported that LapSIM® showed construct validity, but some performance parameters did not differentiate between groups.[15] In a study conducted by Kovac et al. after completing 15 junior and senior residents and three skill tasks (lifting and grasping, cutting and clip application) in LapSIM®, construct validity could not be demonstrated for the total time, path length, angular path length, and tissue handling parameters.[16]

Although virtual reality training shows that it improves general skills such as suturing or cutting, there is limited predictive validity study evaluating whether they are ready to work on human subjects after training. Hogle et al. reported in their study with 21 surgical residents that basic LapSIM® training programs did not have predictive validity in many areas.[17] Radical nephrectomy performances of 12 urology residents in the pig model after LapSim training were evaluated by two surgeons and showed poor predictive validity.[18]

There is no widely accepted or recommended humanoid model for laparoscopic simulation. We think that the humanoid model pretentious VRS should simulate an inflated abdomen. In this state, it was wanted to be investigated in terms of face validity. Experienced surgeons were questioned by questionnaire, since it was thought that topographic measurements of the working area in VRS application could not be taken by us. Since easy and moderate cases such as cortical renal cyst resection, ureterolithotomy, and nephrectomy (benign) are the first operations recommended for those who start laparoscopy, the study was designed based on transperitoneal kidney intervention.

Although LapSIM® is one of the VRSs with one of the largest validation studies, literature is limited. In our study, the scenario in the real operation was evaluated with five parameters. It is aimed to present LapSIM® face validity new data to literature. Face validity is the extent to which the simulator is identical to real-life scenarios.[19] In our study, all the variables showed differences from the ideal value of 5 (all P < 0.001).


  Conclusion Top


Although the LapSIM® VRS provides face validity for the topographic real condition of the inflated abdomen, it should be improved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Istanbul Provincial Health Directorate, SIMMERK, supported this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Hogle NJ, Widmann WD, Ude AO, Hardy MA, Fowler DL. Does training novices to criteria and does rapid acquisition of skills on laparoscopic simulators have predictive validity or are we just playing video games? J Surg Educ 2008;65:431-5.  Back to cited text no. 17
    
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