Publications

THE UNIVERSITY OF ILLINOIS AT CHICAGO

ACCURACY OF VENTRICULOSTOMY CATHETER PLACEMENT USING A HEAD- AND HAND-TRACKED HIGH-RESOLUTION VIRTUAL REALITY SIMULATOR WITH HAPTIC FEEDBACK

The mean distance (+/- standard deviation) from the final position of the catheter tip to the Monro foramen was 16.09 mm (+/- 7.85 mm).

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Objective:

The purpose of this study was to evaluate the accuracy of ventriculostomy catheter placement on a head- and hand-tracked high-resolution and high-performance virtual reality and haptic technology workstation.

Methods:

Seventy-eight fellows and residents performed simulated ventriculostomy catheter placement on an ImmersiveTouch system. The virtual catheter was placed into a virtual patient's head derived from a computed tomography data set. Participants were allowed one attempt each. The distance from the tip of the catheter to the Monro foramen was measured.

Results:

The mean distance (+/- standard deviation) from the final position of the catheter tip to the Monro foramen was 16.09 mm (+/- 7.85 mm).

Conclusions:

The accuracy of virtual ventriculostomy catheter placement achieved by participants using the simulator is comparable to the accuracy reported in a recent retrospective evaluation of free-hand ventriculostomy placements in which the mean distance from the catheter tip to the Monro foramen was 16 mm (+/- 9.6 mm).

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THE UNIVERSITY OF TEXAS

A NOVEL VIRTUAL REALITY SIMULATION FOR HEMOSTASIS IN A BRAIN SURGICAL CAVITY: PERCEIVED UTILITY FOR VISUOMOTOR SKILLS IN CURRENT AND ASPIRING NEUROSURGERY RESIDENTS

This simulation module may be suitable for resident training, as well as for the development of career interest and skill acquisition; however, validation for this type of simulation needs to be further developed.

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Objective:

To understand the perceived utility of a novel simulator to improve operative skill, eye-hand coordination, and depth perception.

Methods:

We used the ImmersiveTouch simulation platform (ImmersiveTouch, Inc., Chicago, Illinois, USA) in two U.S. Accreditation Council for Graduate Medical Education-accredited neurosurgical training programs: the University of Chicago and the University of Texas Medical Branch. A total of 54 trainees participated in the study, which consisted of 14 residents (group A), 20 senior medical students who were neurosurgery candidates (group B), and 20 junior medical students (group C). The participants performed a simulation task that established bipolar hemostasis in a virtual brain cavity and provided qualitative feedback regarding perceived benefits in eye-hand coordination, depth perception, and potential to assist in improving operating skills.

Results:

The perceived ability of the simulator to positively influence skills judged by the three groups: group A, residents; group B, senior medical students; and group C, junior medical students was, respectively, 86%, 100%, and 100% for eye-hand coordination; 86%, 100%, and 95% for depth perception; and 79%, 100%, and 100% for surgical skills in the operating room. From all groups, 96.2% found the simulation somewhat or very useful to improve eye-hand coordination, and 94% considered it beneficial to improve depth perception and operating room skills.

Conclusions:

This simulation module may be suitable for resident training, as well as for the development of career interest and skill acquisition; however, validation for this type of simulation needs to be further developed.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

CONCURRENT AND FACE VALIDITY OF A CAPSULORHEXIS SIMULATION WITH RESPECT TO HUMAN PATIENTS

A prototype version of the ImmersiveTouch® virtual reality simulator was applied to capsulorhexis, the creation of circular tear or "rhexis" in the lens capsule of the eye during cataract surgery.

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Abstract

A prototype version of the ImmersiveTouch® virtual reality simulator was applied to capsulorhexis, the creation of circular tear or "rhexis" in the lens capsule of the eye during cataract surgery. Virtual and live surgery scores by residents were compared. The same three metrics are used in each mode: circularity of the rhexis, duration of surgery (sec), and number of forceps grabs of the capsule per completed rhexis (fewer is better). The average simulator circularity score correlated closely with the average live score (P = 0.0002; N = 4), establishing "concurrent validity" for this metric. Individuals performed similarly to each other in both modes, as shown by the low standard deviations for average circularity (virtual 0.92 ± 0.04; live 0.88 ± 0.04). By contrast, the standard deviations are high for the other two metrics, capsulorhexis duration (virtual 96.91 ± 44.23 sec; live 94.42 ± 65.74 sec, N = 8) and number of forceps grabs (virtual 10.66 ± 4.81; live 10.31 ± 5.23, N = 8). Nevertheless, the simulator was able to demonstrate that the surgeons with wide variations in total duration and number of capsular grabs in 2 to 4 trials of simulated surgery also had similar variations in live surgery, so that the simulator retains some realism or "face validity."

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

ALLEGHANY GENERAL HOSPITAL PENNSYLVANIA

THE UNIVERSITY OF CHICAGO

THE UNIVERSITY OF ARIZONA

LEARNING RETENTION OF THORACIC PEDICLE SCREW PLACEMENT USING A HIGH-RESOLUTION AUGMENTED REALITY SIMULATOR WITH HAPTIC FEEDBACK

With a 12.5% failure rate, a two-proportion z-test yielded P= 0.08.

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Objective:

To evaluate the learning retention of thoracic pedicle screw placement on a high-performance augmented reality and haptic technology workstation.

Methods:

Fifty-one fellows and residents performed thoracic pedicle screw placement on the simulator. The virtual screws were drilled into a virtual patient’s thoracic spine derived from a computed tomography data set of a real patient.

Results:

With a 12.5% failure rate, a two-proportion z-test yielded P= 0.08. For performance accuracy, an aggregate Euclidean distance deviation from entry landmark on the pedicle and a similar deviation from the target landmark in the vertebral body yielded P=0.04 from a two-sample t-test in which the rejected null hypothesis assumes no improvement in performance accuracy from the practice to the test sessions, and the alternative hypothesis assumes an improvement.

Conclusions:

The performance accuracy on the simulator was comparable to the accuracy reported in literature on recent retrospective evaluation of such placements. The failure rates indicated a minor drop from practice to test sessions, and also indicated a trend (P=0.08) towards learning retention resulting in improvement from practice to test sessions. The performance accuracy showed a 15% mean score improvement and over 50% reduction in standard deviation from practice to test. It showed evidence (P=0.04) of performance accuracy improvement from practice to test session.

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THE UNIVERSITY OF TEXAS

NEUROSURGERY SIMULATION IN RESIDENCY TRAINING: FEASIBILITY, COST, AND EDUCATIONAL BENEFIT

The systematic implementation of a simulation curriculum in a neurosurgery training program is feasible, is favorably regarded, and has a positive impact on trainees of all levels, particularly in junior years.

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Objective:

To create a neurosurgery simulation curriculum encompassing basic and advanced skills, cadaveric dissection, cranial and spine surgery simulation, and endovascular and computerized haptic training.

Methods:

A curriculum with 68 core exercises per academic year was distributed in individualized sets of 30 simulations to 6 neurosurgery residents. The total number of procedures completed during the academic year was set to 180. The curriculum includes 79 simulations with physical models, 57 cadaver dissections, and 44 haptic/computerized sessions. Likert-type evaluations regarding self-perceived performance were completed after each exercise. Subject identification was blinded to junior (postgraduate years 1-3) or senior resident (postgraduate years 4-6). Wilcoxon rank testing was used to detect differences within and between groups.

Results:

One hundred eighty procedures and surveys were analyzed. Junior residents reported proficiency improvements in 82% of simulations performed (P < .001). Senior residents reported improvement in 42.5% of simulations (P < .001). Cadaver simulations accrued the highest reported benefit (71.5%; P < .001), followed by physical simulators (63.8%; P < .001) and haptic/computerized (59.1; P < .001). Initial cost is $341,978.00, with $27,876.36 for annual operational expenses.

Conclusions:

The systematic implementation of a simulation curriculum in a neurosurgery training program is feasible, is favorably regarded, and has a positive impact on trainees of all levels, particularly in junior years. All simulation forms, cadaver, physical, and haptic/computerized, have a role in different stages of learning and should be considered in the development of an educational simulation program.

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THE UNIVERSITY OF TEXAS

THE UNIVERSITY OF ILLINOIS AT CHICAGO

NEUROSURGICAL TACTILE DISCRIMINATION TRAINING WITH HAPTIC-BASED VIRTUAL REALITY SIMULATION

Virtual computer-based simulators with integrated haptic technology may improve tactile discrimination required for microsurgical technique.

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Objective:

To determine if a computer-based simulation with haptic technology can help surgical trainees improve tactile discrimination using surgical instruments.

Methods:

Twenty junior medical students participated in the study and were randomized into two groups. Subjects in Group A participated in virtual simulation training using the ImmersiveTouch simulator (ImmersiveTouch, Inc., Chicago, IL, USA) that required differentiating the firmness of virtual spheres using tactile and kinesthetic sensation via haptic technology. Subjects in Group B did not undergo any training. With their visual fields obscured, subjects in both groups were then evaluated on their ability to use the suction and bipolar instruments to find six elastothane objects with areas ranging from 1.5 to 3.5 cm2 embedded in a urethane foam brain cavity model while relying on tactile and kinesthetic sensation only.

Results:

A total of 73.3% of the subjects in Group A (simulation training) were able to find the brain cavity objects in comparison to 53.3% of the subjects in Group B (no training) (P  =  0.0183). There was a statistically significant difference in the total number of Group A subjects able to find smaller brain cavity objects (size ≤ 2.5 cm2) compared to that in Group B (72.5 vs. 40%, P  =  0.0032). On the other hand, no significant difference in the number of subjects able to detect larger objects (size ≧ 3 cm2) was found between Groups A and B (75 vs. 80%, P  =  0.7747).

Conclusions:

Virtual computer-based simulators with integrated haptic technology may improve tactile discrimination required for microsurgical technique.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

PERCUTANEOUS SPINAL FIXATION SIMULATION WITH VIRTUAL REALITY AND HAPTICS

The experiments showed evidence (P = .04) of performance accuracy improvement from the first to the second percutaneous needle placement attempt.

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Objective:

To evaluate the learning effectiveness in terms of entry point/target point accuracy of percutaneous spinal needle placement on a high-performance augmented-reality and haptic technology workstation with the ability to control the duration of computer-simulated fluoroscopic exposure, thereby simulating an actual situation.

Methods:

Sixty-three fellows and residents performed needle placement on the simulator. A virtual needle was percutaneously inserted into a virtual patient's thoracic spine derived from an actual patient computed tomography data set.

Results:

Ten of 126 needle placement attempts by 63 participants ended in failure for a failure rate of 7.93%. From all 126 needle insertions, the average error (15.69 vs 13.91), average fluoroscopy exposure (4.6 vs 3.92), and average individual performance score (32.39 vs 30.71) improved from the first to the second attempt. Performance accuracy yielded P = .04 from a 2-sample t test in which the rejected null hypothesis assumes no improvement in performance accuracy from the first to second attempt in the test session.

Conclusions:

The experiments showed evidence (P = .04) of performance accuracy improvement from the first to the second percutaneous needle placement attempt. This result, combined with previous learning retention and/or face validity results of using the simulator for open thoracic pedicle screw placement and ventriculostomy catheter placement, supports the efficacy of augmented reality and haptics simulation as a learning tool.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

THE LOYOLA UNIVERSITY OF CHICAGO

NORTHWESTERN UNIVERSITY OF CHICAGO

SUMMA HEALTH SYSTEM OH

PGY 4 CAPSULORHEXIS PERFORMANCE METRICS ON THE SENSIMMER "PHACO SIMULATOR" AND DURING PHACOEMULSIFICATION-A PAIRED CONTROL STUDY

PGY4 residents who completed comparable numbers of surgical cases showed considerable variability during surgery in duration of capsulorhexis and in number of forceps grabs.

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Objective:

In an attempt to follow the fast-evolving advances in retinal surgery, we feel there is an unmet need for advanced surgical simulator training in vitreoretinal interface diseases. The integration of retinal images from the 3D optical coherence tomography (OCT) volume scans, which could serve as a disease template, is a further step to bring surgical simulation closer to reality. This report for the first time describes the integration of OCT images into a virtual reality surgical simulator.To compare capsulorhexis performance metrics between the Sensimmer phaco simulator and live surgery performed by PGY 4 residents.

Methods:

Three performance metrics were developed: time to complete capsulorhexis; number of capsular grabs per completed rhexis; and circularity of capsulorhexis. Circularity index was ratio of average radius at 45 deg intervals to maximal radius in capsulorhexis trajectory. Twelve PGY 4 residents from 4 training programs were recruited. Performance metrics were extracted from 3 video recordings of non-complicated cataract surgery cases from each resident; and during the same time frame on the simulator from these simulator-naïve residents who were given brief simulator training prior to testing in 2 to 4 trials. Averages, standard deviations and correlations using a two-sample t-test were calculated.

Results:

Average simulator completion time was 96.91 ± 44.23 sec and it was 94.42 ± 65.74 sec during surgery. Mean number of grabs on the simulator was 10.66 ± 4.81 and during surgery it was 10.31 ± 5.23. Circularity index of capsulorhexis on the simulator was 0.92 ± 0.04 and in surgery it was 0.88 ± 0.04 . Although average completion times and number of grabs on the simulator were comparable between the two groups, there was considerable variability between individual residents. Surgeons who showed the greatest variability on the simulator for these two metrics appeared to show increased variability during surgery while those residents that demonstrated less variability on the simulator showed reduced variability during actual surgery. For all surgeons, there was a high correlation between the circularity index on the simulator and in surgery (p=0.0002).

Conclusions:

PGY4 residents who completed comparable numbers of surgical cases showed considerable variability during surgery in duration of capsulorhexis and in number of forceps grabs. The simulator was able to identify this variability. Average performance measures of a group may be misleading and may not reflect surgical performance of an individual resident. Rhexis circularity with simulator correlated best with surgical performance suggesting that this metric may be useful. Additional training tools and techniques were needed to try to reduce performance variability in residents-in-training.

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THE UNIVERSITY OF CHICAGO1

PRACTICE ON AN AUGMENTED REALITY/HAPTIC SIMULATOR AND LIBRARY OF VIRTUAL BRAINS IMPROVES RESIDENTS' ABILITY TO PERFORM A VENTRICULOSTOMY

Simulator practice with a library of virtual brains representing a range of anatomies and difficulty levels may improve performance, potentially decreasing complications due to inexpert technique.

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Methods:

Using computed tomographic scans of actual patients, we developed a library of 15 virtual brains for the ImmersiveTouch system, a head- and hand-tracked augmented reality and haptic simulator. The virtual brains represent a range of anatomies including normal, shifted, and compressed ventricles. Neurosurgery residents participated in individual simulator practice on the library of brains including visualizing the 3-dimensional location of the catheter within the brain immediately after each insertion. Performance of participants on novel brains in the simulator and during actual surgery before and after intervention was analyzed using generalized linear mixed models.

Results:

Simulator cannulation success rates increased after intervention, and live procedure outcomes showed improvement in the rate of successful cannulation on the first pass. However, the incidence of deeper, contralateral (simulator) and third-ventricle (live) placements increased after intervention. Residents reported that simulations were realistic and helpful in improving procedural skills such as aiming the probe, sensing the pressure change when entering the ventricle, and estimating how far the catheter should be advanced within the ventricle.

Conclusions:

Simulator practice with a library of virtual brains representing a range of anatomies and difficulty levels may improve performance, potentially decreasing complications due to inexpert technique.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

THE UNIVERSITY OF CHICAGO

Role of cranial and spinal virtual and augmented reality simulation using ImmersiveTouch modules in neurosurgical training

Recent studies have shown that mental script-based rehearsal and simulation-based training improve the transfer of surgical skills in various medical disciplines.

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Abstract:

Recent studies have shown that mental script-based rehearsal and simulation-based training improve the transfer of surgical skills in various medical disciplines. Despite significant advances in technology and intraoperative techniques over the last several decades, surgical skills training on neurosurgical operations still carries significant risk of serious morbidity or mortality. Potentially avoidable technical errors are well recognized as contributing to poor surgical outcome. Surgical education is undergoing overwhelming change, as a result of the reduction of work hours and current trends focusing on patient safety and linking reimbursement with clinical outcomes. Thus, there is a need for adjunctive means for neurosurgical training, which is a recent advancement in simulation technology. ImmersiveTouch is an augmented reality system that integrates a haptic device and a high-resolution stereoscopic display. This simulation platform uses multiple sensory modalities, re-creating many of the environmental cues experienced during an actual procedure. Modules available include ventriculostomy, bone drilling, percutaneous trigeminal rhizotomy, and simulated spinal modules such as pedicle screw placement, vertebroplasty, and lumbar puncture. We present our experience with the development of such augmented reality neurosurgical modules and the feedback from neurosurgical residents.

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THE UNIVERSITY OF CHICAGO

THE UNIVERSITY OF ILLINOIS AT CHICAGO

THE UNIVERSITY OF TEXAS

SENSORY AND MOTOR SKILL TESTING IN NEUROSURGERY APPLICANTS: A PILOT STUDY USING A VIRTUAL REALITY HAPTIC NEUROSURGICAL SIMULATOR

Our study represents a first step in the direction of an objective, standard, computer-scored test of motor and haptic ability.

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Objective:

To develop a method of testing sensory-motor skill using objective and reproducible virtual reality simulation.

Methods:

We designed a set of tests on a 3-dimensional surgical simulator with head and arm tracking, colocalization, and haptic feedback: (1) "trajectory planning in a simulated vertebra," ie, 3-dimensional memory and orientation; "hemostasis in the brain," ie, motor planning, sequence, timing, and precision; and "choose the softest object," ie, haptic perception. We also derived a weighted combined score for all tasks.

Results:

Of the 55 consecutive applicants to a neurosurgery residency approached, 46 performed at least 1 task, and 36 performed all tasks. For the trajectory planning task, the distance from target ranged from 3 to 30 mm, with 25 of 36 in the 6- to 18-mm range. In the motor planning test, the duration between cauterization attempts ranged between 5 and 22.5 seconds, peaking at 10 to 12.5 seconds in 15 of 36 participants. In the haptic perception test, linear regression demonstrated increased variability in performance with increasing difficulty of task (R = 0.6281). In all tests, performance followed a roughly bell-shaped curve. The combined weighted score of all tests demonstrated a better bell curve distribution, with scores ranging from 0.275 to 0.71 (mean, 0.47; median, 0.4775; SD, 0.1174).

Conclusions:

Our study represents a first step in the direction of an objective, standard, computer-scored test of motor and haptic ability.

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JOHNS HOPKINS UNIVERSITY

THE UNIVERSITY OF ILLINOIS AT CHICAGO

KING KHALED EYE HOSPITAL

THE USE OF A VIRTUAL REALITY SURGICAL SIMULATOR FOR CATARACT SURGICAL SKILL ASSESSMENT WITH 6 MONTHS OF INTERVENING OPERATING ROOM EXPERIENCE

Four variables (circularity, accuracy, fluency, and overall) were tested by the simulator and graded on a 0–100 scale.

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Objective:

To evaluate a haptic-based simulator, MicroVisTouch™, as an assessment tool for capsulorhexis performance in cataract surgery. The study is a prospective, unmasked, nonrandomized dual academic institution study conducted at the Wilmer Eye Institute at Johns Hopkins Medical Center (Baltimore, MD, USA) and King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia).

Methods:

This prospective study evaluated capsulorhexis simulator performance in 78 ophthalmology residents in the US and Saudi Arabia in the first round of testing and 40 residents in a second round for follow-up.

Results:

Four variables (circularity, accuracy, fluency, and overall) were tested by the simulator and graded on a 0–100 scale. Circularity (42%), accuracy (55%), and fluency (3%) were compiled to give an overall score. Capsulorhexis performance was retested in the original cohort 6 months after baseline assessment. Average scores in all measured metrics demonstrated statistically significant improvement (except for circularity, which trended toward improvement) after baseline assessment. A reduction in standard deviation and improvement in process capability indices over the 6-month period was also observed.

Conclusions:

An interval objective improvement in capsulorhexis skill on a haptic-enabled cataract surgery simulator was associated with intervening operating room experience. Further work investigating the role of formalized simulator training programs requiring independent simulator use must be studied to determine its usefulness as an evaluation tool.

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THE UNIVERSITY OF BOSTON

THE OHIO STATE UNIVERSITY

THE UNIVERSITY OF CHICAGO

MAYO CLINIC ROCHESTER

VIRTUAL REALITY-BASED SIMULATION TRAINING FOR VENTRICULOSTOMY: AN EVIDENCE-BASED APPROACH

VR ventriculostomy placement as part of the CNS simulation trauma module complements standard training techniques for residents in the management of neurosurgical trauma.

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Objective:

To enhance neurosurgical resident training for ventriculostomy placement using simulation-based training.

Methods:

A course-based neurosurgical simulation curriculum was introduced at the Neurosurgical Simulation Symposium at the 2011 and 2012 CNS annual meetings. A trauma module was developed to teach ventriculostomy placement as one of the neurosurgical procedures commonly performed in the management of traumatic brain injury. The course offered both didactic and simulator-based instruction, incorporating written and practical pretests and posttests and questionnaires to assess improvement in skill level and to validate the simulators as teaching tools.

Results:

Fourteen trainees participated in the didactic component of the trauma module. Written scores improved significantly from pretest (75%) to posttest (87.5%; P < .05). Seven participants completed the ventriculostomy simulation. Significant improvements were observed in anatomy (P < .04), burr hole placement (P < .03), final location of the catheter (P = .05), and procedure completion time (P < .004). Senior residents planned a significantly better trajectory (P < .01); junior participants improved most in terms of identifying the relevant anatomy (P < .03) and the time required to complete the procedure (P < .04).

Conclusions:

VR ventriculostomy placement as part of the CNS simulation trauma module complements standard training techniques for residents in the management of neurosurgical trauma. Improvement in didactic and hands-on knowledge by course participants demonstrates the usefulness of the VR simulator as a training tool.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

THE UNIVERSITY OF CHICAGO

WEILL CORNELL NEW YORK

VIRTUAL REALITY CEREBRAL ANEURYSM CLIPPING SIMULATION WITH REAL TIME HAPTIC FEEDBACK

Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs.

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Objective:

To develop and evaluate the usefulness of a new haptic-based virtual reality simulator in the training of neurosurgical residents.

Methods:

A real-time sensory haptic feedback virtual reality aneurysm clipping simulator was developed using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery.

Results:

Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery.

Conclusions:

Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

VIRTUAL REALITY IN NEUROSURGICAL EDUCATION: PART TASK VENTRICULOSTOMY SIMULATION WITH DYNAMIC VISUAL AND HAPTIC FEEDBACK

Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle.

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Objective:

Mastery of the neurosurgical skill set involves many hours of supervised intraoperative training. Convergence of political, economic, and social forces has limited neurosurgical resident operative exposure. There is need to develop realistic neurosurgicalsimulations that reproduce the operative experience, unrestricted by time and patient safety constraints. Computer-based, virtual realityplatforms offer just such a possibility. The combination of virtual reality with dynamic, three-dimensional stereoscopic visualization, and hapticfeedback technologies makes realistic procedural simulation possible. Most neurosurgical procedures can be conceptualized and segmented into critical task components, which can be simulated independently or in conjunction with other modules to recreate the experience of a complex neurosurgical procedure.

Methods:

We use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create avirtual anatomic volume.

Results:

Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user's head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed byneurosurgical faculty, residents, and medical students.

Conclusions:

We have developed a realistic, haptics-based virtual reality simulator for neurosurgical education. Our first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures.

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KING KHALED EYE HOSPITAL

THE UNIVERSITY OF ILLINOIS AT CHICAGO

VIRTUAL REALITY SIMULATOR FOR VITREORETINAL SURGERY USING INTEGRATED OCT DATA

A customized peeling algorithm with full controllability was developed to simulate the peeling of the ERM and ILM.

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Objective:

In an attempt to follow the fast-evolving advances in retinal surgery, we feel there is an unmet need for advanced surgical simulator training in vitreoretinal interface diseases. The integration of retinal images from the 3D optical coherence tomography (OCT) volume scans, which could serve as a disease template, is a further step to bring surgical simulation closer to reality. This report for the first time describes the integration of OCT images into a virtual reality surgical simulator.

Methods:

For the purpose of the study we used random, previously acquired patients’ images from the database of the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. Eyes with epiretinal membrane (n=3) and macular hole (n=2) were imaged using the RTVue instrument (Optovue, Freemont, CA, USA). The image raw data were downloaded, exported with no patient identifier, and used for 3D rendering in MicroVisTouch. The study adhered to the tenets of the Declaration of Helsinki in clinical research.

We then designed a computer-based simulator for epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling procedures with the idea to develop a high performance haptics-, physics-, and graphics-enabled simulator. The study was conducted on the MicroVisTouch surgical simulator. High fidelity haptic feedback is rendered to provide the sense of real surgery sensations. Opening and closing of the forceps is governed by a pressure sensor attached to the Geomagic Touch haptic device. The deformable retina is modeled from volumetric data generated from the OCT scan (Optovue) using position-based dynamics with improved performance over traditional mass-spring models.

Results:

A customized peeling algorithm with full controllability was developed to simulate the peeling of the ERM and ILM. Figure 2 shows an example of a successful integration of an OCT image from a real patient with vitreoretinal interface abnormality which will serve as a template for ERM removal practice. The surface membranes can be distinguished from retinal tissue on the integrated OCT scan. A combination of vertex and fragment shaders is adopted to provide improved realism on graphical/visual effect. The forceps are used for surgical simulation and the user is instructed to apply enough pressure to the sensor in order for the membrane not to slip out of the forceps.

Several metrics can be used to assess surgical performance. The circularity score measures how perfect the circle of removed ERM or ILM is with respect to an ideal peel. The accuracy score indicates the number of times the retina is touched by the forceps. The fluency score indicates the number of times the forceps are closed to grab the membrane. These all can be used as part of surgical skills evaluation both at initial performance and subsequent sessions.

Conclusions:

In summary, the concept introduced here can be utilized to practice image-based vitreoretinal surgery using OCT scans from real patients. Contrary to other surgical simulators which use a standardized pre-operative starting condition, the integration of retinal imaging into a surgical simulator will allow students to be challenged with numerous different conditions. We believe this innovation will contribute to enhancing preclinical surgical experience in vitreoretinal surgery.


THE UNIVERSITY OF TEXAS

THE UNIVERSITY OF ILLINOIS AT CHICAGO

THE UNIVERSITY OF CHICAGO

VIRTUAL REALITY SPINE SURGERY SIMULATION: AN EMPIRICAL STUDY OF ITS USEFULNESS

Computer-based simulation appears to be a valuable teaching tool for non-experts in a highly technical procedural task such as pedicle screw placement that involves sequential learning, depth perception, and understanding triplanar anatomy.

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Objective:

This study explores the usefulness of virtual simulation training for learning to place pedicle screws in the lumbar spine.

Methods:

Twenty-six senior medical students anonymously participated and were randomized into two groups (A = no simulation; B = simulation). Both groups were given 15 minutes to place two pedicle screws in a sawbones model. Students in Group A underwent traditional visual/verbal instruction whereas students in Group B underwent training on pedicle screw placement in the ImmersiveTouch simulator. The students in both groups then placed two pedicle screws each in a lumbar sawbones models that underwent triplanar thin slice computerized tomography and subsequent analysis based on coronal entry point, axial and sagittal deviations, length error, and pedicle breach. The average number of errors per screw was calculated for each group. Semi-parametric regression analysis for clustered data was used with generalized estimating equations accommodating a negative binomial distribution to determine any statistical difference of significance.

Results:

A total of 52 pedicle screws were analyzed. The reduction in the average number of errors per screw after a single session of simulation training was 53.7% (P  =  0.0067). The average number of errors per screw in the simulation group was 0.96 versus 2.08 in the non-simulation group. The simulation group outperformed the non-simulation group in all variables measured. The three most benefited measured variables were length error (86.7%), coronal error (71.4%), and pedicle breach (66.7%).

Conclusions:

Computer-based simulation appears to be a valuable teaching tool for non-experts in a highly technical procedural task such as pedicle screw placement that involves sequential learning, depth perception, and understanding triplanar anatomy.

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THE UNIVERSITY OF ILLINOIS AT CHICAGO

VIRTUAL REALITY TRAINING IN NEUROSURGERY: REVIEW OF CURRENT STATUS AND FUTURE APPLICATIONS

Fully immersive technology is starting to be applied to the practice of neurosurgery. In the near future, detailed VR neurosurgical modules will evolve to be an essential part of the curriculum of the training of neurosurgeons.

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Methods:

A PubMed review of the literature was performed for the MESH words "Virtual reality, "Augmented Reality", "Simulation", "Training", and "Neurosurgery". Relevant articles were retrieved and reviewed. A review of the literature was performed for the history, current status of VR simulation in neurosurgery.

Results:

Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and credential surgeons as technically competent. The number of published literature discussing the application of VR simulation in neurosurgery training has evolved over the last decade from data visualization, including stereoscopic evaluation to more complex augmented reality models. With the revolution of computational analysis abilities, fully immersive VR models are currently available in neurosurgery training. Ventriculostomy catheters insertion, endoscopic and endovascular simulations are used in neurosurgical residency training centers across the world. Recent studies have shown the coloration of proficiency with those simulators and levels of experience in the real world.

Conclusions:

Fully immersive technology is starting to be applied to the practice of neurosurgery. In the near future, detailed VR neurosurgical modules will evolve to be an essential part of the curriculum of the training of neurosurgeons.

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