Chapter 8 This study investigates the operation room results of novice surgical residents after participating in the Eindhoven Virtual Reality laparoscopic cholecystectomy training course. During this tailored course, both basic and procedural VR skills training tasks are integrated, resulting in a multi-modality approach which is a novelty in procedural teaching. Surgical novice residents were compared with controls who have had none or some (animal) training, but were considered able to start with the procedure by their superiors. In fact, the constitution of our case-control group refers much to the common, unstructured clinical practice of today. As in the traditional apprenticeship model, it is the expert surgeon who decides if a resident is ready to start operating on patients –or not. Groups were demographically comparable except for the parameter ´number of laparoscopic cholecystectomies performed´ (Table 1). In the case-control group, there is even somewhat more clinical experience present. However, as defined by the selection criteria, this is limited to a maximum of 3 clinical procedures. Therefore, participants in both groups must be considered well at the beginning of the learning curve. [1, 9]. The fact that among the controls, significantly more clinical experience is present, does not seem to contribute much to their performance outcome, as observers agree (no significant differences between observers on outcome parameters (Table 3). Rating scales were constructed for the observers, as this is regarded as the most reliable and valid method for observers to assess performance during a laparoscopic cholecystectomy [10]. Observers judge the over-all performance in the experimental group to be clearly superior. One observer also feels the pattern of movement in terms of fluency to be significantly better in this group, compared to the performers in the control group (Table 5). The parameter ´sumscore´, used to estimate performance outcome in earlier validation studies of the Xitact simulation software, seems to be correlate highly to observers´ judgement (Table 4). Indeed, scores are highly correlated and therefore sumscore is thought to be a reliable estimate for observers´ final judgement. As for the parameter ´time´, it cannot be said that there is a significant difference between groups (Table 5). This is probably due to the large dispersion in outcome, e.g. large confidence interval. However, as depicted in figure 4, linking observers´ judgement to time needed for completion of the clip-and-cut task, there is less dispersion in procedural time within the experimental group, suggesting more efficient performance. As for the participants, they enjoyed and valued the course highly, in terms of the statements presented (Fig. 1 and Table 2). Participants´ rated the Xitact developed and validated clip-and-cut scenery highest (Fig. 2). [3, 11]. A few limitations to the methods of this study must be addressed. Participants were not randomly assigned to either group. In fact, residents in the experimental group were analysed against the background of a group of controls trained according to ´current clinical practice in The Netherlands´, e.g. declared fit to perform the procedure according to the opinion of their own clinical supervisor. As there were no baseline recordings -using VR simulation- available for both the experimental and the control group on the assessed ´clip-and-cut´ procedure, it cannot be firmly stated that participants are equally skilled upon inclusion. Although inclusion criteria restricted clinical experience to a maximum of four procedures, and in fact, controls were more experienced beforehand, their outcome is significantly worse.
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