1. JS Tsang, QMH Joint Hospital Grand Round 26 th April 2014

2.  Halsted’s apprenticeship model ◦ Random exposure ◦ Biased assessment  Working time restrictions ◦ Europe – EWTD (58->56->48hrs) ◦ Hong Kong  Patient safety concerns  Trend in restructuring of surgery training

3.  Interaction with computer-generated 3D model through an interface device  Well established in aviation  Training in safe environment  Develop Teamwork  Surgical simulation 1993 - Satava Satava RM. Virtual reality surgical simulator. Surg Endosc 1993;7(3):203-5

4.  Minimally invasive surgery  Endovascular surgery ◦ Peripheral vascular disease (PVD) ◦ Carotid stenosis ◦ Aortic aneurysm  Steep learning curve – catastrophic for failure  EVA 3S trial – Carotid stenting 9.6% vs CEA 3.9% (peri-operative stroke rate)  Essential in training curriculum Mas J et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis NEJM 2006; 355:1660

7.  Realistic  Safe – patient + trainee  Objective assessment  Structured training  Rehearsal ◦ Case ◦ Team rehearsal

8.  SAPPHIRE trial 1 – CAS not inferior to endarterectomy  Increasing popularity  High-risk procedure – Stroke, death  Use of VR to improve learning curve 1.Yadav JS et al. Protected carotid-artery stenting versus endarterectomy in high risk patients. N Engl J Med 2004;351:1493-501

9.  Dayal et al  Participants: Novice n=16 vs Experienced n= 5  Pre-training graded procedure  All received 2hrs simulation training  Results: significant improvements in Novice ◦ Procedural time (PT) ◦ Fluoroscopic time (FT) ◦ Catheter and guide wire manipulation  Conclusion:  Improve trainee performance Dayal R et al. Computer simulation as a component of catheter-based training. J Vasc Surg 2004; 40(6):1112-17.

10.  Participants: Untrained n=16 vs experienced n=13  Initial pre-test  Randomised into simulation training (60mins) vs no training  Final test  Results: ◦ significant improvement in PT after training in both untrained and experienced ◦ Most improvement with Untrained subjects  Conclusion: ◦ Performance correlated with previous experience ◦ Novice may benefit most from VR training Hsu JH et al. Use of computer simulation for determining endovascular skill levels in a carotid stenting model. J Vasc Surg 40(6):1118-25.

11.  Participants: 20 experienced cardiologists  All received simulation training ◦ 1.5 days of didactic and simulation training  Results: ◦ Significant improvements in PT, FT, contrast volume and catheter handling time  Conclusion: ◦ Learning curve with improved performance demonstrated on VR simulator Patel AD et al. Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography. J Am Coll Cardiol 2006; 47(9):1796-802.

12.  Construct validity – ◦ differentiate novice and experienced subjects  Significant improvements in performance ◦ Novice trainees

13.  Aggarwal et al –  Renal angioplasty and stenting  20 vascular consultants ◦ 11 inexperienced (<10 cases) ◦ 9 experienced (>50 cases)  All received simulation training  Results: ◦ significant improvements in inexperienced - PT and contrast vol ◦ Similar performance to experienced group after training ◦ Conclusion: ◦ VR simulation helpful in early learning curve Aggarwal R et al. Virtual reality simulation training can improve inexperienced surgeons’ endovascular skills. Eur J Vasc Endovasc Surg 2006;31(6):588-93.

14.  Nine vascular trainees from different states  Iliac stenting  Simulation training x2 days with didactic tutorials  Results: ◦ PT - 54% faster ◦ FT and contrast volume decreased ◦ Time to recognise and manage complications improved  Conclusion: ◦ VR simulation offers realistic practice without risk to patients Dawson DL et al. Training with simulation improves residents’ endovascular procedure skills. J Vasc Surg 2007; 45(1):149-54

15.  Skills transfer to real operating environment Chaer RA et al. Ann Surg 2006; 244:343-52

16.  Participants - 20 residents  Randomised - VR training vs no VR training  All performed 2 graded “real” peripheral angioplasty after 2 hours  Results: ◦ Simulation subjects scored higher – procedural steps and global rating scale ◦ Advantage persisted for second “real” test  Conclusion: ◦ Simulation - valid tool for training residents and fellows ◦ May benefit retraining of vascular surgeons

17.  Mission/ Procedure rehearsal

18.  N = 15  Rehearsal (within 24hrs) then actual CAS ◦ Interventionalist + team members rehearsal  Recorded for analysis ◦ Technical and non -technical skills  Results: ◦ 11/15 patients – identical endovascular tool use ◦ 13/15 patients – identical fluoroscopic angles ◦ 30% patients – simulator did not predict difficult, stenotic artery ◦ Subjective evaluation score 4/5 – realism, technical + communication issues Willaert et al. BJS 2012;99:1304-13

19.  N= 9 with abdominal aortic aneurysms  Pre-op rehearsal (within 24hrs) then real EVAR  Results: ◦ PT shorter in simulation vs live EVAR ◦ FT, contrast volume, no. of angiographies – similar ◦ 7/9 patients - C-arm angulation changed significantly after rehearsal ◦ Subjective questionnaire score 4/5: realism, usefulness in rehearsal Desender L et al. EJVEVS 2013;45:639

21. Simulated procedure + theatre Real procedure + theatre

23.  Seymour et al 1 – laparoscopic cholecystectomy  Randomised surgical trainees to VR vs standardised training  VR group – fewer intra-op errors  Grantcharov et al 2 ◦ VR group – faster, better improvement in error and economy of movements 1.Seymour et al. Virtual reality training improves operating room performance: results of a randomised, double-blinded study. Ann Surg 2002;236:458-63 2. Grantcharov et al. Randomised clinical trial of virtual reality simulation of laparoscopic skills training. Br J Surg 2004;91:146-50

24.  Ahlberg et al  Randomised trainees, surgeons and gastroenterologists  VR training vs control group  Results: VR group better caecal intubation ◦ Shorter time ◦ Less discomfort Ahlberg et al. Virtual reality colonoscopy simulation: a compulsory practice for future colonoscopist? Endoscopy 2005;37:1198-204

25.  ‘see one do one’ – no longer feasible  VR simulation – realistic environment  Safe and offers ‘permission to fail’  Objective assessment and training ◦ Structured and Competency based program  “Mission rehearsal” allows pre-operative planning

26.  Studies – small series but encouraging  Improved performance  Construct validity  Shortens learning curve  VR simulation – endovascular surgical training ◦ Adjunct to didactic training + clinical exposure

27. JS Tsang, QMH Joint Hospital Grand Round 26 th April 2014