The role of haptic feedback in achieving surgical simulation training proficiency By Marina Yiasemidou   Under the Supervision of Mr Bijendra Patel, MS, FRCS, FRCS (Gen Surg) Academic Department of Upper GI Surgery Institute of Cancer Barts and the London School of Medicine and Dentistry Queen Mary University MSc Surgical Skills and Sciences

VR Surgical Simulators Lap mentor Lap mentor express Haptics refers to the sense of touch (from Greek ἅπτω = "I fasten onto, I touch“)

Aim of study Evaluate the role of haptic feedback in achieving surgical simulation training proficiency.

Innovation of study In the current study: Typical learning curve The exact conditions of surgical simulation training are taken into account. Participants: junior doctors, surgical trainees Validated laparoscopic cholecystectomy curriculum Assesses performance in basic, procedural tasks and full procedure. Validated curriculum - learning curve Assessing performance throughout entire learning curve.

Materials and Methods Inclusion criteria Exclusion Criteria Participants: 18 Surgical Skills and Sciences Master students (M:F 11:7) Inclusion criteria Exclusion Criteria Being a surgical SHO level doctor Having seen or assisted in 10 or more laparoscopic cholecystectomies. Having fulfilled the validated laparoscopic cholecystectomy simulation training curriculum Having performed a laparoscopic cholecystectomy Having previous experience in simulation training.

Materials and Methods Curriculum

Materials and Methods Basic tasks Task 5: Clipping and Grasping Task 6: Two handed maneuver

Materials and Methods Procedural tasks Full procedure Dissection of cystic duct and artery Achieving a critical view Procedural Task 4 Gall Bladder Separation from liver bed Full procedure The full procedure of laparoscopic cholecystectomy Real patient imaging test results Anatomical variations Complication Management Tactile response

Materials and Methods Study design 2 teams of 9 1st team fulfilled curriculum on haptic 2nd on non haptic All participants were blinded to proficiency level metrics

How aim of the study was met Statistical Analysis Step 1 – Evaluating the role of haptic feedback in the time required to reach proficiency level No of repetitions needed to reach proficiency for each of the tasks mentioned above were compared between the two machines. Step 2 – Evaluating the role of haptic feedback in skills acquired as these were recorded in a quantitative manner Mean value of total time, total no of movements and total path length for each task/procedure was calculated for each operator. Results were again compared between the two machines. Independent sample t-test or Mann-Whitney test were used according to the results of the Shapiro-Wilk normality test.

Results Step1 Task/Procedure Mean value of attempts-non haptic Mean value of attempts- haptic p-value Basic task 5 7.44 12 0.122 Basic task 6 8.56 16.22 0.026 Procedural task 3 13.11 11.33 0.533 Procedural task 4 7.22 10.67 0.082 Full procedure 8.67 8.22 0.851

Results Step2 Task Mean value of parameter for non haptic Mean value of parameter for haptic p-value B5 Mean total time 139.58 156.67 0.113 Mean total number of movements 180.06 194.06 0.795 Mean total path length 626.50 650.96 0.954 B6 142.56 182.08 0.080 169.06 235.17 0.155 540.59 674.81 0.197 P3 596.78 461.61 0.07 494.22 433.39 0.20 919.15 895.59 0.974 P4 626.91 807.93 0.007 616.45 733.26 0.077 1179.91 1302.05 0.242 FP 608.83 553.27 0.019 583.74 630.93 0.145 1207.37 1262.36 0.101

Discussion Haptic feedback has no impact on the training time required to reach proficiency level of basic task 5, procedural task 3, 4 and full procedure. Consistent with results of previous studies (1-3) Prolongs the time required to reach basic task 6 proficiency level. ?Increases the difficulty of the particular task - mechanics of the particular task.

Discussion Haptic feedback has no advantageous effect on the skills gained during training on basic laparoscopic tasks. Time taken to complete procedural tasks and FP No effect for task 3 Prolongs the time needed to complete procedural task 4. Reduces the time needed to complete the full procedure. ?Learning curve effect. Effects only total time taken to complete a task or the full procedure, no effect on other parameters related with safety and complication rates Contradictory results (prolongs time for P4, reduces for FP) - impossible to establish a set relation. High/low haptic demand mechanichs Open to lap: Reduced haptic feedback in real life operations More advanced haptic feedback features should be sought Experienced surgeons and technicians cooperation Expert validity questionnaire should be developed

Discussion Limitations of study Strengths of study Two different supervisors overlooked the two teams. ?Sample size High number of repetitions for each task provides strong statistical evidence. Studies of identical design: No power calculation, similar number of participants. ?Number of task repetitions for step 2 Aim-proficiency level Same acquaintance/experience Examines the role of haptic feedback within a validated curriculum, exact environment that is used in. Data was collected prospectively Examines the role of haptic feedback not only in time taken to train but also in skills acquired as these were measured and documented in a quantitative manner. Examines the role of haptic feedback in training laparoscopy novices to whom surgical simulation training is mostly addressed to.

Conclusion The effect of haptic feedback on simulation training of novices appears to be limited. Does not appear to speed up the learning process in either basic or procedural tasks nor in the full procedure of laparoscopic cholecystectomy. Skills acquired as these were measured and documented in a quantitative manner, do not appear to be enhanced in any way by the presence of haptic feedback with one exception, total time taken to complete full procedure. The importance of this is debatable as it has no effect what so ever on the other two safety and complication rate related metrics for any of the tasks or the full procedure

References 1. Sanne M. B. I. Botden, Fawaz Torab, Sonja N. Buzink Jack J. Jakimowicz The importance of haptic feedback in laparoscopic suturing training and the additive value of virtual reality simulation Surg Endosc (2008) 22:1214–1222 2. Lucian Panait, Ehab Akkary, Robert L. Bell, Kurt E. Roberts, Stanley J. Dudrick, and Andrew J. Duffy. The Role of Haptic Feedback in Laparoscopic Simulation Training Journal of Surgical Research 156, 312–316 (2009) 3. Salkini MW, Doran CR, Kiehl N, Broderick TJ, Donovan JF, Gaitonde K. The role of haptic feedback in laparoscopic training using the LapMentor II. J Endourol. 2010 Jan;24(1):99-102.

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