Medical
Laparoscopy
Surgical Simulator: The LaparoscopyVR Virtual-Reality System
The LapVR Surgical Simulator uses the latest advances in technology, appropriate interactive 3D models, haptic force feedback, and performance tracking and evaluation to help decrease the learning curve in laparoscopic surgery.
The LapVR was designed by
- Reviewing the Fundamentals of Laparoscopic Surgery (FLS) curricula endorsed by the Society of American Gastrointestinal Endoscopic Surgeons’ (SAGES)
- Receiving input from surgeons at world renown institutions
- Conducting in-depth research on training needs
This high-fidelity surgical trainer comes packaged as a complete system with:
- Selected software module(s)
- Two trocars with interchangeable simulated tool tip
- An endoscopic camera with 0, 30, and 45 degree lenses
- High-speed optical tracking technology to accurately monitor tool motion
- Height adjustable cart, monitor swing, and foot pedal
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Training Outcomes
Through use of the surgical simulator's Essential Skills module, users may develop some of the technical skills and dexterity needed for laparoscopic surgery. Further, users may develop:
- Proficiency with both dominant and nondominant hand
- Improved hand-eye coordination within 3D virtual reality simulation by improving depth perception and visual-spatial cognition
- An ability to transfer the virtual reality experience of tool and camera navigation to the real life procedure
- Competence in the use of different camera lens angles
- Confidence in the use of laparoscopic surgical instruments before venturing into real patient scenarios
Each skill in the surgical simulator's Essential Skills module provides end-of-practice feedback that can be used to identify strengths and areas needing improvement. For each practice session, a summarized assessment is recorded. This assessment can be used by instructors for designing individualized surgical instruction plans.
Camera Navigation Skill
The Camera Navigation Skill helps develop proficiency in navigating the camera during laparoscopic surgery. The module requires appropriate maneuvering through all planes of the cavity. Experience is obtained by navigating with 0, 30, and 45 degree lens angles to locate objects and hold focus on the object for a predetermined length of time. Practice with this skill helps develop the ability to maintain a steady lens for visualization and image capture.
Peg Transfer Skill
The Peg Transfer Skill involves reaching for and grasping a simulated peg with an appropriately modeled instrument, and placing it into a predetermined hole in the simulated pegboard. Pegs can vary in number, shape, size, and location. This skill helps develop precise coordination of dominant and nondominant hands, and sharpened depth perception and visual-spatial cognition within the simulated environment.
Cutting Skill
The surgical simulator's Cutting Skill requires applying appropriate traction with one hand while using the other to cut with scissors. The cutting pattern will vary in size and shape, and the boundary area can be decreased for a more difficult cutting environment or increased for novice users. This skill provides practice in holding a tissue taut in order to improve cutting ease.
Clipping Skill
The surgical simulator's Clipping Skill requires the user to correctly place two clips to stop blood flow on a simulated vessel. Once blood flow is stopped, the module requires cutting between the clips. The vessels will appear in varying locations on the X, Y, and Z planes, with obstacles in front of the vessel to hinder view. This requires the user to lift the obstacle and find the vessel for clipping.
Needle Driving Skill
The Laparoscopic Needle Driving Skill involves orienting and driving a curved needle through a block with tissue-like properties. This skill reinforces the use of both hands in orienting the needle for driving and for retrieving the needle from the block. A tag of suture is available for use in the orientation part of the skill. As the levels progress, the boundary of the work area decreases, the targets become smaller, and the block position changes orientation to present added challenges to the novice user. An unprotected needle near the walls or ceiling of the work area may generate a haptic sensation that the user will feel through the tool handle, teaching the user to be aware of the position of the needle at all times.
Knot Tying Skill
The Knot Tying Skill requires the user to tie various types of surgical knots in a length of suture that has been driven through a tissue-like material. Each throw of the suture, whether crossing over or behind the other length, is recognized by the software, supplying the user with important feedback. Complexity is added by varying suture length, tying with or without a needle, and tissue and suture strength. As the levels progress, the work area will decrease in size. An unprotected needle near the walls or ceiling of the work area may generate a haptic sensation that the user feels through the tool handle.
Adhesiolysis Module
The surgical simulator's lysis of adhesions module requires appropriate safe bowel manipulation with one hand while using the other to cut adhesions using scissors or a cautery tool. The adhesions will vary in thickness and location requiring activity in all planes. The concept of traction in cutting is reinforced, as well as the concept of holding a tissue taut in order to improve cutting ease.
Running the Bowel
The goals for the LapVR Surgical Simulator's RtB Module are to develop technical and cognitive skills and dexterity for inspection, manipulation, and measurement of the bowel. These are procedural skills commonly needed during trauma, general, OB/GYN, bariatric, and colon and rectal surgery.
The RtB procedural skill allows for a student to use different two-handed techniques such as hand-over-hand and side-by-side. The LapVR RtB module is the only simulation with bowel mesentery. The presence of mesentery adds an extra layer of realism for manipulating and measuring the bowel while avoiding injury.
Running the Bowel Training Objectives
The RtB surgical simulation module builds laparoscopic skills, helping the user:
- Learn to choose from different measuring options
- Improve dexterity in the hand-over-hand and side- to- side techniques
- Learn to Inspect bowel for pathology
- Gain familiarity with tools commonly used on the bowel including a laparoscopic bowel stapler
- Identify areas of strength and those needing improvement by using an automated end-of-practice assessment
- Obtain confidence in performing laparoscopic RtB surgical procedures before introduction to real patient scenarios
Virtual Laparoscopy Suturing and Knot Tying Module
The LapVR surgical simulator's Suturing and Knot Tying Module includes procedural skill training in stitching and tying, as well as essential skill training in needle driving and knot tying. The module comes with needle driver trocar handles and the new pistol grip handles that include a trigger mechanism. Both handles are equipped with QuickChange adapters allowing fast and easy tool changes.
The Suturing and Knot Tying Procedural Skill provides training in simple-interrupted, continuous, horizontal mattress suturing, and loop ligation.
See the Essential Skills module for needle driving and knot tying skills.
Simple-Interrupted Stitch
The Simple Interrupted Stitch procedural skill requires the user to close an enterotomy in a simulated bowel using a series of interrupted stitches. The user must tie each stitch using a proper knot. Each throw of suture — whether crossed in front of or behind the other length of suture — is recognized by the software, giving the user important feedback. This is a free-play exercise with the option for the administrator to include a visual aid/overlay to assist in proper suture placement. The bowel will show blanching and bruising from rough handling. Complexity is added by adjusting parameters for enterotomy size, bowel/tissue integrity, and suture strength.
Continuous Stitch
The Continuous Stitch procedural skill requires the user to close an enterotomy in a simulated bowel using a continuous stitch. A pre-tied anchor knot is present and may be used to maneuver the bowel. After introducing the needle, the user is to place the first stitch at the apex of the enterotomy opposite the pre-tied knot and work toward it. The pre-tied knot is intended to be used to tie the final knot of the continuous stitch. The throws of the suture — whether crossed in front of or behind the other length of suture — are recognized by the software, giving the user important feedback. This is a free-play exercise with the option for the administrator to include a visual aid/overlay to assist in proper suture placement. The bowel will show blanching and bruising from rough handling. Complexity is added by adjusting parameters for enterotomy size, bowel/tissue integrity, and suture strength.
Horizontal Stitch
The Horizontal Stitch procedural skill requires the user to close a small enterotomy in a simulated bowel using a single horizontal stitch. This stitch consists of two deep simple-interrupted stitches placed side by side and tied together. The throws of the suture — whether crossed in front of or behind the other length of suture — are recognized by the software, giving the user important feedback. This is a free-play exercise with the option for the administrator to include a visual aid/overlay to assist in determining proper suture placement. The bowel will show blanching and bruising from rough handling. Complexity is added by adjusting parameters for bowel/tissue integrity and suture strength.
Loop Ligation
The Loop Ligation procedural skill requires the user to ligate an actively bleeding vessel using a delivery catheter with a preformed loop snare. The user must position the grasper inside the loop, then grasp the blood vessel. The vessel is then held while the snare is positioned. The trigger mechanism in the laparoscopic handle is used to tighten the snare’s one-way slip knot to form a hemostatic ligature. The administrator may select to have a target visible on the vessel. If no target is selected, this is a free-play exercise. Blood loss during the procedure is tracked onscreen. The blood vessels in the simulation are subject to damage from rough handling.
Training Objectives
The Cholecystectomy surgical simulation module builds skills, helping the user:
- Practice careful dissection of the peritoneal sheath and underlying tissues that surround the cystic duct and cystic artery
- Learn placement of clips on the cystic duct and cystic artery
- Avoid damage to the common bile duct
- Prepare for procedures with common anatomical deviations
- Dissect the gallbladder away from the liver bed using various techniques while avoiding injury
- Discuss the indications, contraindications, and complications of laparoscopic cholecystectomy
- Improve technical and cognitive abilities required for laparoscopic cholecystectomy
- Identify areas of strength and those needing improvement using an automated end-of-practice assessment
- Obtain confidence in performing laparoscopic cholecystectomy before introduction to real patient scenarios
Laparoscopic Cholecystectomy 2.0
The goals for the LapVR Surgical Simulator's Cholecystectomy 2.0 Module are to develop technical and cognitive skills and dexterity for laparoscopic cholecystectomy. This surgical simulation module also provides valuable feedback that can be used for evaluation and improvement.
Surgical simulation training using the LapChole module provides practice in laparoscopic instrument use, camera navigation, identification of key landmarks of the gall bladder and surrounding structures, and adjustments needed when encountering anatomical deviations.
The surgical simulation module helps develop the skills needed for selective dissection of the gall bladder including identifying, dissecting, securely clipping, then cutting the cystic duct and cystic artery, and finally dissecting the gall bladder away from the liver bed.
See detailed screenshots of Lap Chole 2.0
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Leakage of bile due to gallbladder damage from cautery |
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Calot’s Triangle is pre-dissected for practice of clipping and cutting |
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Two layer peritoneal sheath covering Calot’s Triangle |
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Beginning dissection of the outer layer of the peritoneal sheath covering Calot’s Triangle |
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Peritoneal transparency view of a gallbladder with a double artery |
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The dissection has been completed and the cystic artery and cystic duct may now be clipped and cut |
Training Objectives
The goals for the LapVR Surgical Simulator's OB/GYN module are to develop technical and cognitive skills and dexterity for three major laparoscopic OB/GYN surgical procedures.
The OB/GYN surgical simulation module builds laparoscopic skills, helping the user:
- Practice common OB/GYN surgical procedures
- Perform conservative and emergent procedures for tubal pregnancy
- Learn to choose the surgical method most appropriate for the patient
- Practice various methods of surgical intervention, clipping, cutting, electrosurgery, and retrieval
- Improve technical and cognitive abilities required for laparoscopic OB/GYN surgical procedures
- Review an end-of-practice assessment, identifying areas of strength and those needing improvement
- Obtain confidence in performing laparoscopic OB/GYN surgical procedures before introduction to real patient scenarios
- Learn to choose the correct and most efficient approaches to handling anatomical deviations
Since 1970, the frequency of ectopic pregnancy has increased six-fold, now occurring in 2% of all pregnancies.(1) Ectopic pregnancy is the leading cause of maternal mortality in the first trimester and accounts for up 15% of all maternal deaths.(2)
(1) Sepilian, Vicken P. 2007. Ectopic Pregnancy. Emedicine. http://www.emedicine.com/med/topic3212.htm (accessed August 23, 2007).
(2) Tenore, Josie L. 2000. Ectopic Pregnancy. American Family Physician. http://www.aafp.org/afp/20000215/1080.html (accessed August 23, 2007).
Ectopic Pregnancy Surgical Intervention
For each of the LapVR surigcal simulator's OB/GYN procedures, various cases, with a multitude of parameters, are available for user customization. As an example, the degree of fragility of the blood vessels that will lead to easier and quicker bleeding during surgery is an adjustable parameter.
Tubal Occlusion
Tubal occlusion is the second preferred method of birth control, next to oral contraceptives. The LapVR OB/GYN module allows the user to practice with cutting, clipping, and electrosurgery and with various patient cases.
Salpingo-Oophorectomy
Salpingo-oophorectomy, the removal of the fallopian tubes and ovaries, is performed to treat ovarian or other gynecological cancers or infections caused by pelvic inflammatory disease.
Administration
LapVR surgical simulator’s Administration module sets out a suggested curriculum. It also lets training administrators:
- Edit skills and procedures
- Set task parameters
- Create and assign courses to meet the needs of individuals and groups
- Review and report on user performance
- Import, export, e-mail, and print
| Watch the demo videos | |
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Introduction (00:27 wmv) |
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Curriculum (2:00 wmv) |
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Users and Groups (2:03 wmv) |