Design, Development and Validation of a Take-Home Simulator for Fundamental Laparoscopic Skills: Using Nintendo Wii® for Surgical Training
Ravia Bokhari MD*, Jyoti Bollman MD*, Kanav Kahol PhD^+, Marshall Smith MD+, Ara Feinstein MD*, John Ferrara MD*
*Phoenix Integrated Surgical Residency, Phoenix, Arizona USA 85016
+Simulation and Education Training (SimET) Center
Banner Good Samaritan Medical Center, Phoenix, Arizona USA 85016
^Human Machine Symbiosis Lab, Department of Biomedical Informatics, Arizona State University, Phoenix, Arizona, USA 85004
Introduction
One of the fundamental goals of surgical residency is to train surgeons that are technically capable of performing complex procedures. New technologies and novel treatment mechanisms are developing at a rapid pace, presenting residents with a dynamic and increasingly high performance environment. In laparoscopy, ambidexterity and proficiency of fine hand movements to control laparoscopic instruments are crucial for surgical expertise [1]. Despite this increasing complexity, traditional surgical residencies almost exclusively depend on operating room experience for surgical skills acquisition. The problem is compounded by recent work hour limitations which decrease the amount of time available for robust technical training.
In response to this need, surgical simulators have emerged at the forefront of methodologies employed for technical skills preparation [2]. The adoption of a Fundamentals of Laparoscopy simulation training module by the American Board of Surgery illustrates the integration of simulation into surgical training [www.fls.org]. Surgical simulators have become more realistic with each generation their value has been confirmed in several validation studies [3-6]. Simulator use is limited, however, because they are expensive and reduced work hours limit the amount of time residents can spend in simulation labs [7].
An innovative method to address this challenge lies in the development of take-home simulators. Using these portable, affordable simulators, residents can practice skills at home or in call rooms and then perform skills testing in a simulation center. Several challenges need to be addressed for this to be a viable option. The first challenge is to evaluate if such a program would indeed produce acceptable learning rates when compared to conventional approach of close monitoring of residents during skills training. Previous studies have confirmed that take-home simulators can provide a valid method of teaching skills [8]. Second, take-home trainers need to be affordable to be a viable option. Conventional simulators can cost several thousands of dollars and are not a practical choice. Off-the-shelf gaming platforms are state-of-the-art computing devices capable of high end graphics at an affordable rate. Three of the premier commercially available gaming models are: the XBOX 360® (www.xbox.com), PlayStation3® (www.playstation.com) and the Nintendo Wii® (www.nintendowii.com). They have online capabilities and allow for remote monitoring of users which has been shown to have a positive impact on medical education [9]. Most importantly, they are all priced below $300. Given their technological capabilities and affordability, it is reasonable to consider commercial gaming systems for the development of take-home simulators.
Prior studies have demonstrated that surgeons who grew up playing video games performed better on laparoscopic simulation drills [10]. Rosser et al. found that surgeons who previously played more than 3hrs/wk of video games and those that currently played video games made fewer errors during laparoscopic simulation [11]. Two approaches can be employed to develop take-home simulators using commercial gaming devices. The first option would be to develop games that are specifically targeted towards surgeons. This would allow designers to fully exploit the powers of the consoles to simulate virtual surgery and develop algorithms to measure surgical proficiency. However, this approach is complicated by the shear amount of resources and cost required for developing games. The second, and more realistic, approach is to offer surgical training through readily available games. The advantage of this approach is that there is no costly development required for surgical training. However, games need to be carefully selected for suitability. In related work, we have developed a scientific methodology to choose the appropriate games for surgical training [14].
We chose the Nintendo Wii® device (copyright Nintendo of America, Inc.) as a surgical simulator because theWiiMote®(Nintendo Wii® remote) employs natural hand movements for game control and does not require translation of hand movements through buttons like traditional game controllers. We developed a scientific methodology that verified this device along with the game Marble Mania® to have a high correlation with surgical hand movement [data not published]. We hypothesize that the Nintento Wii® device can be modified into a take-home simulator and lead to improvement of surgical skills.
Materials and Methods
All experiments were conducted with the approval of the Banner Good Samaritan Institutional Review Board. Custom adaptations for the WiiMote® were developed to simulate the look and feel of surgical instruments. The remote was modified to simulate a laparoscopic instrument and was placed through a trocar-like attachment to limit gross movement similar to laparoscopic procedures, where instruments can only move within the confines of a port. (Figure 1).
Figure 1. Setup. The WiMmote with the developed add-ons to mimic laparoscopic tools.
A prospective, controlled trial was carried out to validate the training capability of Nintendo Wii® with Marble Mania® through the interface developed for the experiment. After informed consent, a total of 21 right handed general surgery residents participated in the study. Fourteen residents were assigned to the experimental group and the remaining seven were placed in the control group. The experimental group practiced with the Wii game Marble Mania®. Each level of the game was repeated four times in random order, twice with the dominant and twice with the non-dominant hand. The residents completed 50 levels of the game with increasing difficulty of fine motor control. Following this training, they performed an electrocautery task on the ProMIS® simulator with both hands sequentially. Their performance was compared to the control group residents who did not practice with the Wii® and directly performed the electrocautery procedure. The ProMIS® simulator has been described in previously published studies[14, 15]. We measured proficiency through time taken to complete tasks, glove based hand movement proficiency and number of errors made during the electrocautery procedure identified by independent observers. The hand movement proficiency was calculated through a custom algorithm validated in several previous studies [7, 13, 16]. Using ANOVA statistical methods the two groups of surgical residents were compared. Ambidexterity was measured by comparing dominant and non-dominant hand performance on the Wii in the experimental group only.
Results
Compared to controls, Wii® trained residents took (p<0.05) less time (0.25 + 0.07 SD v 0.63 + 0.1 SD), made (p<0.05) fewer errors (0.1 + 0.02 SD v 0.29 + 0.05 SD) and were (p<0.05) more proficient in hand movements (0.65 + 0.09 SD v 0.39 + 0.04 SD) (Figure 2) during the transfer electrocautery task.
The learning curves of the dominant (right) and non-dominant hand on the Wii game Marble Madness are illustrated in Figure 3. During the initial iterations the dominant hand scores are significantly higher than non-dominant scores (p<0.03 r=0.07 for the first 15 repititions) but towards the completion of training the scores were comparable (p<0.89 r=0.92 for the last 15 repititions). During the midpoint of training, the non-dominant hand outperformed the dominant, but this was not statistically significant.
Figure 2. Performance of control group and experimental group on a simulated electrocautery task
Figure 3. Analysis of Ambidexterity in the Experimental Group.
Discussion
Given the restraints of the 80-hour work week and a heavy clinical workload, it is difficult to provide residents ample time to practice in the simulation center. Having an enjoyable learning tool that leads to improved surgical skills would be a significant asset to surgical residency programs. Video games are inherently entertaining for multiple reasons: they are fun, competitive and low-stress for most. The Nintendo Wii® is commercially available at a modest price (approx $200), and some residents may already own the device. A game that closely mimics surgical movements, such as Marble Mania® can be purchased for minimal additional expense (approx. $30). Gaming systems can easily be placed in call rooms and may be an attractive opportunity for residents to practice fine motor skills during free time.
It is important to choose games in a controlled manner to ensure maximum benefit and limit negative factors. Surgeons have warned that indiscriminate video game playing as well as expecting all video games to be beneficial in improving surgical skills is unrealistic [17]. Also, it is important to note that prolonged, repetitive and incorrect use of video game remotes can result in injuries [18]. Although there is no substitute for surgical training in the operating room, the Ninteno Wii® serves as a useful adjunct when used appropriately.
There are some unanswered questions that arise from our findings. In our study, we compare the two groups in laparoscopic simulation skill, not to actual operating room skill. Future studies may evaluate this directly. It is unclear if the skills gained from practicing with the Nintendo Wii® are long-lasting. Additionally, it may be worthwhile to evaluate if using the Nintendo Wii® immediately before a surgical procedure would increase efficiency and possibly lead to decreased operating times. Kahol et al have previously reported that performing simple simulated exercises prior to surgery can improve performance during surgery. They describe this as the “warm-up effect”[15]. Future studies will evaluate if off-the-shelf games can serve as effective warm-up devices. Finally, as gaming technology advances, it remains to be seen if future iterations of home gaming systems will be even more effective for training surgeons.
Conclusion
Our results validate the Nintendo Wii® gaming system, along with the Marble Mania® video game, as an effective laparoscopic simulation device. Given its affordability, availability and the inherent attraction of video games, the Nintendo Wii® can be utilized as an effective take-home surgical simulator.
References
[1] J. C. Hall, Ellis.C, and Hamdorf.J, "Surgeons and cognitive processes," British Journal of Surgery, vol. 90, pp. 10-16, 2002.
[2] R. Aggarwal, Moorthy, K., and Darzi, A., "Laparoscopic skills training and assessment," British Journal of Surgery, vol. 91, pp. 1549-1558, 2004.
[3] R. Brydges, A. Kurahashi, V. Brümmer, L. Satterthwaite, R. Classen, and A. Dubrowski, "Developing Criteria for Proficiency-Based Training of Surgical Technical Skills Using Simulation: Changes in Performances as a Function of Training Year," Journal of the American College of Surgeons, vol. 206, pp. 205 - 211, 2008.
[4] R. Aggarwal, S. A. Black, J. R. Hance, A. Darzi, and N. J. W. Cheshire, "Virtual Reality Simulation Training can Improve Inexperienced Surgeons' Endovascular Skills," European Journal of Vascular and Endovascular Surgery, vol. 31, pp. 588-593, 2006.
[5] A. G. Gallagher, N. McClure, J. McGuigan, I. Crothers, and J. Browning, "Virtual reality training in laparoscopic surgery: a preliminary assessment of Minimally Invasive Surgical Trainer Virtual Reality (MIST VR)," Endoscopy, vol. 31, pp. 310 – 313, 1999.
[6] T. P. Grantcharov, "Virtual reality simulation in training and assessment of laparoscopic skills," European Clinics in Obstetrics and Gynaecology, vol. 2, pp. 197-200, 2006.
[7] K. Kahol, M. Leyba, M. Deka, V. Deka, S. Mayes, M. Smith, J. Ferrara, and S. Panchanathan, "The Effect of fatigue on psychomotor and cognitive skills," American Journal of Surgery, vol. 195, pp. 195-204, 2008.
[8] K. Kahol, J. Uccelli, M. Smith, and J. Ferrara, "TR 1001344: The effectiveness of unstructured learning of skills in surgery," Arizona State University, Phoenix, AZ 2010.
[9] R. McLean, B. Richards, and J. Wardman, "The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?," Medical Journal of Australia, vol. 187, pp. 174-7, 2007.
[10] S. Meterissian, M. Liberman, and P. McLeod, "Games as teaching tools in a surgical residency," Med Teach., vol. 29, pp. 258-60, 2007.
[11] J. C. Rosser, Jr., P. J. Lynch, L. Cuddihy, D. A. Gentile, J. Klonsky, and R. Merrell, "The Impact of Video Games on Training Surgeons in the 21st Century," Arch Surg, vol. 142, pp. 181-186, 2007.
[12] D. Diapers, Task Analysis for Human-Computer Interaction: Ellis Horwood, 2004.
[13] K. Kahol, C. Krishnan, V. Balasubramanian, S. Panchanathan, M. Smith, and J. Ferrara, "Measuring movement expertise in surgical tasks," in Proceedings of the 14th annual ACM international conference on Multimedia. Santa Barbara, CA, USA: ACM, 2006.
[14] K. Kahol, V. N. Balasubramanium, C. N. Krishnan, S. Panchanathan, M. Smith, and J. Ferrara, "Measuring movement expertise in surgical tasks," presented at 14th Annual ACM International conference on Multimedia Santa Barbara, CA, 2006.
[15] K. Kahol, R. Satava, J. Ferrara, and M. Smith, "The effect of short term pre-trial practice on surgical proficiency in simulated environments: A Randomized Trial of the “Pre-operative Warm-up” Effect," Journal of American College of Surgeons, vol. 208, pp. 255-268, 2009.
[16] K. Kahol, T. McDaniel, M. Smith, J. Ferrara, and S. Panchanathan, "The effect of real-time visualization of skill on surgical training," presented at Medicine Meets Virtual Reality, Long Beach, CA, 2007.
[17] M. J. Curet, "The Impact of Video Games on Training Surgeons in the 21st Century-Invited Critique," Archives of Surgery, vol. 142, pp. 186, 2007.
[18] A. L. Zapata, A. J. P. Moraes, C. Leone, U. Doria-Filho, and C. A. A. Silva, "Pain and musculoskeletal pain syndromes related to computer and video game use in adolescents," European Journal of Pediatrics, vol. 165, pp. 408-414, 2006.