Elsevier

The Lancet

Volume 364, Issue 9444, 23–29 October 2004, Pages 1538-1540
The Lancet

Rapid Review
Virtual reality training for the operating room and cardiac catheterisation laboratory

https://doi.org/10.1016/S0140-6736(04)17278-4Get rights and content

Summary

Context

High-profile cases of medical errors in the USA and UK, and major reports from organisations such as the US Institute of Medicine and UK Senate of Surgery, have sensitised the public and medical profession. Training is a key area that must be tackled to positively affect the problem of medical errors, especially in surgery and interventional cardiology. Despite the radically novel skills required for minimally invasive surgery or interventional cardiology, current training has gone largely unchanged. At the end of the 20th century, the public and the medical profession have concluded that training on patients is no longer acceptable.

Starting point

Recently, Teodor Grantcharov and colleagues (Br J Surg 2004; 91: 146–50) did a randomised double-blind trial which showed that training by virtual reality (VR) significantly reduces objectively assessed intraoperative errors in laparoscopic cholecystectomy. They used a low-fidelity VR simulator. Much more sophisticated VR simulators exist for endoscopy, gynaecology, laparoscopy, orthopaedics, otolaryngology, robotics, and urology. There are few studies on the efficacy of these simulators in improving the safety of procedures on patients.

Where next

There needs to be more large and multicentre studies. Technical skills training for procedural based medicine continues to be an ad-hoc mentor-based experience for the trainee, with experience gained by practising on patients. The skills required now are so difficult to learn that this type of training is no longer acceptable. VR-simulator-based training does work, but further empirical evidence is required to convince the more conservative members of the medical community.

Section snippets

Virtual reality training for medical procedures

The state of the art for training in many other high-skill professions is virtual reality (VR). VR was probably best defined7 as a communication interface based on interactive three-dimensional visualisation which allows the user to interact with and integrate different sensory inputs that simulate important aspects of real-world experience. VR allows more than observation, which has important implications for teaching. First introduced to surgery in 1991,8 acceptance of VR training has been

VR training for clinical practice

One of the major advantages of VR for training technical skills is that the opportunity to train is constantly and consistently available. Another advantage is that the trainee can make mistakes without exposing the patient to risk, unlike in vivo. However, simulation as a training tool often seems to be poorly understood by users. It is widely assumed that if an individual just trains on a simulator, their technical skills improve. From an evidence-based medicine perspective, this assumption

Metrics

For some time many physicians believed that only a simulator that looked and felt like a real patient could substitute for the in-vivo clinical experience. Both VR-to-OR studies9, 10 showed this belief to be wrong—even a low-fidelity VR simulator can dramatically improve clinical performance. The fidelity of the simulation should be appropriate. For laparoscopic cholecystectomy where immediate clinical risk to the patient is low, a low-fidelity simulator trains safe skills. For work in the

Now and the future

Interventional cardiologists, radiologists, and endovascular surgeons have the opportunity to learn carotid stenting on a full procedural VR simulator.14 The complete simulation package probably represents the most advanced VR for medical simulation in the world today. The implication of having this quality of simulation and objective metrics readily available is that only physicians who clearly show proficiency on the simulator will be approved to do the procedure on patients. It also means

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