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Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (5): 755-763    DOI: 10.31083/j.ceog.2020.05.4988
Original Research Previous articles | Next articles
Comparison of laparoscopic surgical skills acquired on a virtual reality simulator and a box trainer: an analysis for obstetrics-gynecology residents
M. Varras1, *(), C. Loukas2, N. Nikiteas2, V.K. Varra3, F.N. Varra4, E. Georgiou2
1Fifth Department of Obstetrics and Gynecology, ‘Elena Venizelou’ General Maternity Hospital, Athens, Greece
2Simulation Center, Medical Physics Laboratory, School of Medicine, National and Kapodistrian University of Athens, Greece
3Department of Pharmacy, University of Patras, Greece
4Department of Pharmacy, Frederick University, Nicosia, Cyprus
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Abstract  

Background/Aims: It is well known that laparoscopic surgery requires the demonstration of a different set of technical skills when compared to open surgery. Laparoscopic training using simulators has been shown to accelerate learning in an efficient and standardized manner. Significant research has been conducted for skills acquisition in abdominal surgery, but in the field of gynecologic laparoscopy the relevant studies are limited. The aim of this study was to compare the training efficacy of virtual reality (VR) simulators and box-trainers (BTs) for skills acquisition in gynecologic surgery, and also to study the transferability of these skills in the performance of more advanced gynecologic operations. Methods: Twenty residents in obstetrics-gynecology with minimal laparoscopic experience were randomized into two equal groups to be trained on either a VR simulator (Group-A) or a BT (Group-B). Group-A was trained on basic tasks (clipping, peg transfer, and cutting), whereas Group-B was trained on ovarian cystectomy and salpingotomy using custom training models. After training, the two groups were assessed on the performance of two laparoscopic gynecologic procedures on a VR simulator (salpingotomy and salpingectomy). Performance metrics included time, instrument pathlength, and various task-specific errors. Results: Both groups demonstrated significant performance improvement in all training tasks, for all but one of the metrics (p < 0.05). After training, both groups had improved performance in the laparoscopic operations using the VR simulator, but this trend was not statistically significant in any metric considered (p > 0.05). Similarly, the post-training performance between the two groups was not statistically different (p > 0.05). Conclusions: Basic skills training on either a VR simulator or BT results in equivalent but not statistically significant performance improvement with more advanced gynecologic laparoscopic tasks on a VR simulator.

Key words:  Virtual reality simulator      Box-trainer      Gynecologic surgical training      Ectopic pregnancy      Salpingotomy      Salpingectomy     
Submitted:  23 September 2018      Accepted:  04 February 2019      Published:  15 October 2020     
*Corresponding Author(s):  M. Varras     E-mail:  mnvarras@otenet.gr

Cite this article: 

M. Varras, C. Loukas, N. Nikiteas, V.K. Varra, F.N. Varra, E. Georgiou. Comparison of laparoscopic surgical skills acquired on a virtual reality simulator and a box trainer: an analysis for obstetrics-gynecology residents. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(5): 755-763.

URL: 

https://ceog.imrpress.com/EN/10.31083/j.ceog.2020.05.4988     OR     https://ceog.imrpress.com/EN/Y2020/V47/I5/755

Figure 1.  — Various steps from the salpingotomy (top) and salpingectomy (bottom) procedures performed on the VR simulator.

Figure 2.  — The three VR training tasks performed by Group A.

Figure 3.  — Various steps from the two training tasks (top: cystectomy, bottom: salpingotomy), performed by Group B on the BT.

Table 1  — Group A, ‘Clipping’: Training results (mean ± standard deviation), and correlation coefficient w.r.t. to the number of repetitions performed (VR simulator). Bold numbers indicate significance.
First two repetitions Last two repetitions p-values Correlation coefficient p-values
Number of clips applied 4.60 ± 2.68 4.10 ± 0.45 0.42 -0.02 0.77
Number of clips dropped 0.85 ± 0.23 0.07 ± 0.26 0.01 -0.18 < 0.01
Total instrument pathlength (m) 2.45 ± 1.50 1.62 ± 0.64 0.04 -0.36 < 0.01
Completion time (s) 149 ± 65 89 ± 40 < 0.010 -0.46 < 0.01
Table 2  — Group A, ‘Peg transfer’: Training results (mean ± standard deviation), and correlation coefficient w.r.t. to the number of repetitions performed (VR simulator). Bold numbers indicate significance.
First two repetitions Last two repetitions p-values Correlation coefficient p-values
Number of pegs dropped 1.10 ± 0.85 0.42 ± 0.63 0.02 -0.22 < 0.01
Total instrument pathlength (m) 6.47 ± 1.36 4.41 ± 0.57 < 0.01 -0.27 < 0.01
Completion time (s) 184 ± 80 104 ± 30 < 0.01 -0.51 < 0.01
Table 3  — Group A, ‘Cutting’: Training results (mean ± standard deviation), and correlation coefficient w.r.t. to the number of repetitions performed (VR simulator). Bold numbers indicate significance.
First two repetitions Last two repetitions p-values Correlation coefficient p-values
Percentage cutting out of boundary area 0.70 ± 1.38 0.47 ± 0.67 0.04 -0.29 < 0.01
Number of unsuccessful cutting attempts 5.90 ± 6.67 1.80 ± 2.71 0.02 -0.19 0.01
Total instrument pathlength (m) 7.43 ± 2.12 4.25 ± 2.15 0.04 -0.33 < 0.01
Completion time (s) 294 ± 147 166 ± 67 < 0.01 -0.53 < 0.01
Table 4  — Group B, ‘Ovarian cystectomy’: Training results (mean ± standard deviation), and correlation coefficient w.r.t. to the number of repetitions performed (Box Trainer). Bold numbers indicate significance.
First two repetitions Last two repetitions p-values Correlation coefficient p-values
Minimal damage of the cystic wall (yes=1/no=2) 1.95 ± 0.22 1.60 ± 0.30 0.04 -0.40 < 0.01
Success for a 7-cm longitudinal
incision on the ovarian cortex (y=1/n=2)
1.45 ± 0.21 1.10 ± 0.27 0.04 -0.18 0.04
Maximum deviation from the labelled line (mm) 1.57 ± 0.95 1.50 ± 0.98 0.58 -0.14 0.10
Total instrument pathlength (m) 13.42 ± 7.22 9.66 ± 5.05 0.03 -0.22 0.01
Completion time (s) 480 ± 110 320 ± 136 0.02 -0.19 0.04
Table 5  — Group B, ‘Salpingotomy’: Training results (mean ± standard deviation), and correlation coefficient w.r.t. to the number of repetitions performed (Box Trainer). Bold numbers indicate significance.
First two repetitions Last two repetitions p-values Correlation coefficient p-values
Success of longitudinal
incision (y=1/n=2)
1.53 ± 0.51 1.26 ± 0.45 0.17 -0.24 0.03
Total instrument pathlength (a.u.) 10.98 ± 5.66 4.30 ± 2.11 < 0.01 -0.65 < 0.01
Completion time (s) 382 ± 183 136 ± 65 < 0.01 -0.66 < 0.01
Table 6  — Pre-training vs. post-training performance results (mean ± standard deviation), for each group, for the salpingotomy assessment task performed on the VR simulator.
Pre-training Post-training p-values
Group A
Time for cautery used (s) 38.51 ± 30.44 33.61 ± 32.17 0.91
Total blood loss (cc) 69.40 ± 31.06 60.64 ± 18.24 0.18
Incision length (cm) 2.42 ± 0.46 2.26 ± 0.67 0.35
Total instrument pathlength (m) 6.60 ± 2.85 6.57 ± 4.32 0.43
Completion time (s) 260 ± 141 222 ± 120 0.85
Group B
Time for cautery used (s) 50.24 ± 33.89 28.89 ± 19.60 0.74
Total blood loss (cc) 67.56 ± 28.12 62.45 ± 22.34 0.68
Incision length (cm) 2.68 ± 0.98 2.33 ± 0.52 0.63
Total instrument pathlength (m) 6.29 ± 2.13 7.64 ± 4.89 0.85
Completion time (s) 276 ± 114 252 ± 164 0.48
Table 7  — Pre-training vs. post-training performance results (mean ± standard deviation), for each group, for the salpingectomy assessment task performed on the VR simulator.
Pre-training Post-training p-values
Group A
Time for cautery used (s) 157.79 ± 90.65 119.66 ± 71.36 0.31
Total blood loss (cc) 585.27 ± 341.84 405.87 ± 210.23 0.17
Adhesions ripped (%) 2.84 ± 3.76 2.60 ± 1.65 0.85
Adhesions lysed (%) 97.40 ± 7.54 94.30 ± 18.02 0.62
Total instrument pathlength (m) 20.37 ± 8.09 19.75 ± 9.52 0.43
Completion time (s) 732 ± 292 650 ± 318 0.87
Group B
Time for cautery used (s) 131.81 ± 56.47 159.55 ± 88.46 0.41
Total blood loss (cc) 505.97 ± 279.15 398.05 ± 211.47 0.34
Adhesions ripped (%) 2.68 ± 0.98 2.33 ± 0.52 0.84
Adhesions lysed (%) 99.40 ± 0.97 99.80 ± 0.63 0.28
Total instrument pathlength (m) 20.33 ± 7.27 22.31 ± 9.72 0.61
Completion time (s) 810 ± 306 726 ± 277 0.53
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