1. 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

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

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

4. 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.

5. 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.

6. Materials and Methods Curriculum

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

8. 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

9. 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

10. 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.

11. 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

12. 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
0.242 FP
608.83
553.27
0.019
583.74
630.93
0.145
0.101

13. 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.

14. 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

15. 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.

16. 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

17. 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 Jan;24(1):

18. The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man. –George Bernard Shaw
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