LETTER TO THE EDITOR Multi-Input Simulation in Surgical Training: Discussing the Role of Virtual Reality To the Editor: e read with great interest the article published in Annals of Surgery titled, “‘Blowing Up the Barriers’ in Surgical Training: Exploring and Validating the Concept of Distributed Simulation,” by Kassab et al.1 The authors describe for the first time what they call distributed simulation (DS) as a portable, flexible, and low-cost training module. This model is based on the idea of a simple and easily reproducible simulated environment to prepare a laparoscopic surgeon for “the real job.” This study has great merit and introduces an underestimated variable in surgical simulation: the environment. The missing step in all the studies about surgical simulation is the demonstration of the virtual reality (VR) training ability to improve the performance during surgery. One reason for this failure could be the lack of all the external stimuli beyond surgical skills at the console or at the training box, influencing the outcome. Authors stress, at different times, the portability of the system and the low cost of this kind or training. The design of the study provides evaluation from only 2 blinded expert raters on an extremely small number of subjects, with a statistical power that is not declared but has to be lower than 70%. Given these facts, why was not a multicenteric, open-label study preferred for this validation? This could be a strong point in favor of system portability and reproducibility and maybe avoid some limitations related to the use of OSATS from only 2 raters. Kassab et al decided to name this integrated multitasking simulation “distributed simulation.” The major concern is about the term DS: in computer engineering, VR simulation is divided into local simulation systems, in which the entire model is simulated by a
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single program, and the DS system, with submodels simulated by distinct programs (“federates”). Federates are run on distinct hosts, which could be spatially separated. Briefly, DS is an unambiguous definition for the scientific community, used to define a network of terminals involved in a VR environment. We believe that DS (in its original meaning) will be in the future part of the VR armamentarium helping the surgeon, for its well-studied properties of scalability (a facility to scale up for the increased computational requirements of complex system simulation, ie, dividing between different hosts in different times a multitasking procedure), aggregation, reusability (use simulation systems available in separate sites and aggregate them into a more complex system), and parallelism [collecting in the same action every different professional in the operating room (OR) team, ie, surgeon, assistant, scrub nurse, circulating nurse]. These concepts seem to be so far from the surgeon’s mind today, but in the future, a better knowledge about VR and simulation can reasonably be expected. For this reason, if the system proposed by Kassab et al will be developed and distributed with this name (DS), ambiguities will be generated in scientific literature. Our suggestion is to explain the origin of this name, finding a solution to avoid misunderstandings. Gaming systems for VR as headmounted displays are available on the market that are portable and for a competitive price. Moreover, almost anything can be converted into a sensing device for simulation in VR: a box trainer can be connected to the head-mounted screen, becoming part of the virtual environment such as an airplane console or a treadmill for the military training. The advantages are easy to figure out: telepresence, teaching and evaluating different teams at the same time, metric objective evaluation on a computer-generated scenarios, possibility to introduce unforeseen situation and related troubleshooting, and easy data storage and elaboration. The attempt to recreate a simplified OR seems to be actually anachronic, less reproducible, and more intricate than declared.
No more than 15 years ago, the trainer boxes were confined to laparoscopic laboratories of training. Today, in more and more institutions, every resident has a portable laparoscopic simulator at home to train. It is easy to assume that, following the same steps, in the near future, a more immersive and multi-input simulation will be obtained by any surgeon at home, with an audio-video interface, a modified training box, and a laptop. The statement in the discussion session, based only on postexperimental interviews, that “a willingness to become immersed and a concordance with remembered experiences of the actual OR were sufficient to transform an inflatable shell into an OR” seems to conflict against the idea of recreating a multi-input surgical environment. Actually, the evaluation of a simulation system is based on immersion and interactivity: Many VR systems available nowadays provide a comparable or better grade of immersion for an affordable price.2,3 To complete this study, could be interesting testing with a similar methodology on a larger number of subjects the comparison with a VR system, for example, introducing a third group of surgeons and a cost analysis. Federico Gheza, MD Division of General, Minimally Invasive and Robotic Surgery Department of Surgery University of Illinois at Chicago Chicago, IL [email protected]
REFERENCES 1. Kassab E, Tun JK, Arora S, et al. “Blowing up the barriers” in surgical training: exploring and validating the concept of distributed simulation. Ann Surg. 2011;254:1059–1065. 2. Dev P, Heinrichs WL, Youngblood P. CliniSpace: a multiperson 3D online immersive training environment accessible through a browser. Stud Health Technol Inform. 2011;163:173–179. 3. Doerr KU, Rademacher H, Huesgen S, et al. Evaluation of a low-cost 3D sound system for immersive virtual reality training systems. IEEE Trans Vis Comput Graph. 2007;13:204–221.
Disclosure: The author has no conflicts of interest or sources of funding related to this letter. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26101-e0019 DOI: 10.1097/SLA.0000000000000331
Annals of Surgery r Volume 261, Number 1, January 2015
www.annalsofsurgery.com | e19
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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single program, and the DS system, with submodels simulated by distinct programs (“federates”). Federates are run on distinct hosts, which could be spatially separated. Briefly, DS is an unambiguous definition for the scientific community, used to define a network of terminals involved in a VR environment. We believe that DS (in its original meaning) will be in the future part of the VR armamentarium helping the surgeon, for its well-studied properties of scalability (a facility to scale up for the increased computational requirements of complex system simulation, ie, dividing between different hosts in different times a multitasking procedure), aggregation, reusability (use simulation systems available in separate sites and aggregate them into a more complex system), and parallelism [collecting in the same action every different professional in the operating room (OR) team, ie, surgeon, assistant, scrub nurse, circulating nurse]. These concepts seem to be so far from the surgeon’s mind today, but in the future, a better knowledge about VR and simulation can reasonably be expected. For this reason, if the system proposed by Kassab et al will be developed and distributed with this name (DS), ambiguities will be generated in scientific literature. Our suggestion is to explain the origin of this name, finding a solution to avoid misunderstandings. Gaming systems for VR as headmounted displays are available on the market that are portable and for a competitive price. Moreover, almost anything can be converted into a sensing device for simulation in VR: a box trainer can be connected to the head-mounted screen, becoming part of the virtual environment such as an airplane console or a treadmill for the military training. The advantages are easy to figure out: telepresence, teaching and evaluating different teams at the same time, metric objective evaluation on a computer-generated scenarios, possibility to introduce unforeseen situation and related troubleshooting, and easy data storage and elaboration. The attempt to recreate a simplified OR seems to be actually anachronic, less reproducible, and more intricate than declared.
No more than 15 years ago, the trainer boxes were confined to laparoscopic laboratories of training. Today, in more and more institutions, every resident has a portable laparoscopic simulator at home to train. It is easy to assume that, following the same steps, in the near future, a more immersive and multi-input simulation will be obtained by any surgeon at home, with an audio-video interface, a modified training box, and a laptop. The statement in the discussion session, based only on postexperimental interviews, that “a willingness to become immersed and a concordance with remembered experiences of the actual OR were sufficient to transform an inflatable shell into an OR” seems to conflict against the idea of recreating a multi-input surgical environment. Actually, the evaluation of a simulation system is based on immersion and interactivity: Many VR systems available nowadays provide a comparable or better grade of immersion for an affordable price.2,3 To complete this study, could be interesting testing with a similar methodology on a larger number of subjects the comparison with a VR system, for example, introducing a third group of surgeons and a cost analysis. Federico Gheza, MD Division of General, Minimally Invasive and Robotic Surgery Department of Surgery University of Illinois at Chicago Chicago, IL [email protected]
REFERENCES 1. Kassab E, Tun JK, Arora S, et al. “Blowing up the barriers” in surgical training: exploring and validating the concept of distributed simulation. Ann Surg. 2011;254:1059–1065. 2. Dev P, Heinrichs WL, Youngblood P. CliniSpace: a multiperson 3D online immersive training environment accessible through a browser. Stud Health Technol Inform. 2011;163:173–179. 3. Doerr KU, Rademacher H, Huesgen S, et al. Evaluation of a low-cost 3D sound system for immersive virtual reality training systems. IEEE Trans Vis Comput Graph. 2007;13:204–221.
Disclosure: The author has no conflicts of interest or sources of funding related to this letter. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26101-e0019 DOI: 10.1097/SLA.0000000000000331
Annals of Surgery r Volume 261, Number 1, January 2015
www.annalsofsurgery.com | e19
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
