Defining a Proficiency-Based Virtual Reality Curriculum for Laparoscopic Colorectal Surgery

Vanessa N Palter, MD, Maurtis Graafland, MD, Marlies P Schijven, MD PhD, Teodor P Grantcharov, MD PhD. St. Michael’s Hospital, Toronto, On, Canada., Academic Medical Center Amsterdam, Amsterdam, The Netherlands

Introduction: Laparoscopic colorectal surgery is an advanced minimally invasive procedure with a long variable learning curve. Although task training on virtual reality simulators has been shown to transfer to the operating room, to date no virtual reality curricula have been described for advanced minimally invasive procedures such as laparoscopic colorectal surgery. The objective of this study is twofold. First, to determine the essential elements in a virtual reality technical skills curriculum for laparoscopic colorectal surgery using the Delphi consensus methodology. Second, to define expert benchmarks for the developed virtual reality technical skills curriculum.
Methods: The virtual reality system that will be utilized in the curriculum is the LapSim system (Surgical Science, Sweden). The LapSim offers a total of 27 tasks. The Delphi method was used to determine expert consensus on the tasks that are relevant to teaching the technical skills required to perform laparoscopic colorectal surgery. These tasks were compiled into an on-line survey. 20 international experts in surgical simulation were recruited to participate in the survey. The participants rated each identified LapSim task on a Likert scale from 1 to 5 detailing the degree to which they agreed or disagreed that a particular component should be included in a final technical skills curriculum. Results of the survey were sent back to participants with group averages and standard deviations until expert consensus (Cronbach’s Alpha >0.8) was reached. After consensus was reached, specific curricular tasks that over 80% of the experts rated as either “agree” or “strongly agree” on the Likert scale were included in the final curriculum. In order to define the expert benchmark scores for the identified curricular tasks, 10 experts (completed more than 100 laparoscopic colorectal procedures) were recruited. Each expert completed all curricular tasks on the “easy”, “medium” and “hard” setting of the simulator. Median expert benchmark scores relating to time and economy of movement were calculated for each curricular task on each of the 3 levels of difficulty.
Results: In the first round of the survey, Cronbach’s α was 0.715 and after the second round, consensus was reached at 0.865. Consensus was reached for 7 of the basic tasks (coordination, lifting and grasping, clipping, cutting, grasping, handling intestine and fine dissection) and for 1 advanced suturing task. Nine experts completed the curriculum in its entirety. Median expert scores were calculated for all curricular tasks. For example, for the easy level of the fine dissection task, the median expert scores were as follows: time 71.8s, right grasper path length 0.56m, left grasper path length 0.38m, left grasper angular path 116.68º, and right grasper angular path 82.45º.
Conclusions: The Delphi method allowed for expert consensus to be reached on the essential components of a virtual reality curriculum for laparoscopic colorectal surgery. Expert benchmarks were determined for all curricular tasks. Ultimately trainees will practice on the LapSim until they reach these identified expert levels of proficiency for all curricular tasks.