The merits of VR simulation in surgical training have been established. Its use has been shown to help novice surgical trainees quickly acquire and improve a basic laparoscopic skill set. Grantcharov et al. [43] studied three groups of surgeons with varying levels of laparoscopic expertise (advanced, intermediate, and novices) using the Minimally Invasive Surgical Trainer-Virtual Reality (MIST VR) , which entails six different and increasingly difficulty skill exercises, including grasping, transference, use of energy, and combinations of these tasks. Subjects in each group completed ten sessions of all tasks over a 1-month block of time. Their performance metrics were measured via time to completion of tasks, errors committed, and economy of motion utilized. Although performance scores for the beginner group were significantly lower compared to the intermediate and advanced cohorts after the first trial run, the results were not significantly different after the final session, revealing that basic laparoscopic skill attainment is possible in a relatively short period of time. In fact, the beginner group’s learning curves reached a steady stage just after seven, six, and five sessions for time, economy of motion, and error scores, respectively.

Furthermore, in a randomized, double-blinded study, Seymour et al. [44] showed that the surgical resident group who underwent basic task training using the MIST VR platform proved to perform subsequent laparoscopic cholecystectomy procedures faster and with a reduced error rate compared to the control group. This study pioneered the concept that transference of a surgical skill set from a simulation platform to an operative venue is, indeed, possible. Calatayud et al. [45] furthered this idea from a different training angle: the operative warm-up setting. In this randomized crossover study, surgical residents functioned as their own controls, and each group performed a total of two laparoscopic cholecystectomy procedures 2 weeks apart. The first group was randomized to perform the procedure without VR warm-up, followed 2 weeks later by undergoing VR warm-up exercises and subsequently performing the procedure. The second group first completed a VR surgical warm-up and performed the procedure; 2 weeks later, this group performed an additional laparoscopic cholecystectomy without the benefit of VR warm-up exercises. VR warm-up training constituted executing three exercises (object manipulation, clip application, and dissection) for 15 min using the Lapsim VR simulator just prior to the start time of the operative procedure. The results of the study revealed significantly higher operative surgical performance scores in the groups who performed laparoscopic cholecystectomy cases with prior surgical warm-up as measured by a validated objective structure of technical skills (OSATS) global rating scale. Lee et al. [46] helped to cement that surgical warm-up is a beneficial practice; this randomized crossover study included three junior urology residents, two senior urology residents, and three urology fellows. Each subject performed a total of four laparoscopic renal procedures in two sets divided by more than 1 week apart. During each session consisting of two procedures, each subject had the opportunity to either first perform warm-up exercises or directly proceed with the operative procedure; the actual order of events (i.e., warm-up vs. surgical procedure) was randomized. Surgical warm-up was composed of performing a 5 min electrocautery exercise on the LAP Mentor VR simulator as well as a 15 min laparoscopic suturing/knot tying task 1 h prior to the operative procedure. Psychomotor and cognitive data was obtained using electroencephalography (EEG), eye tracking technology, and video recording of the operative procedures. Mean psychomotor performance scores, as measured by hand movement smoothness, tool movement smoothness, and postural stability, proved to be significantly higher in the surgical warm-up group. The warm-up group also showed improved cognition during performance of renal surgery, as measured by mean attention, distraction, and mental workload scores. Furthermore, the surgical rehearsal cohort achieved significantly higher technical performance scores when evaluating its ability to mobilize the colon during an early portion of a renal procedure. However, during a later step of the procedure (retroperitonealizing the colon), surgical warm-up was not found to improve surgical task scores, thus, lending theory that warm-up may be applicable for a short period of time. Lendvay et al. [47] performed a trial designed to test whether VR surgical warm-up proved beneficial in a robotic dry lab situation. The group consisted of a total of 51 subjects across various fields (urology, gynecology, and general surgery) and training levels (residents and attendings). All subjects underwent robotic proficiency training and were subsequently randomized to either the surgical warm-up group or the control group. All subjects completed four trial runs: the initial three involved completion of the da Vinci VR rocking pegboard task while the final one comprised a robotic intracorporeal suturing exercise. In all trials, the surgical warm-up group completed a brief (3–5 min) VR pegboard warm-up task while the control group read a book for 10 min prior to the required exercise. In the first three repetitions that tested similar VR exercises, the VR warm-up group proved to show significantly improved performance metrics (task times and tool path lengths) compared to the control group. The fourth trial sitting evaluated a different and more complex VR task (robotic intracorporeal suturing) designed to test generalizability of the warm-up task; results revealed the warm-up group had a significantly decreased error rate when performing this exercise compared to the control group. The next step in robotic VR warm-up training is to assess whether it transfers dry lab skills to the operating room and impacts patient safety.

Patient-specific simulation is a technological concept/advancement that is intricately related to surgical warm-up. It allows for two-dimensional data from CT scans and MRIs to be uploaded onto a VR simulator and rendered into an interactive 3D image on the stereoscopic field. In this fashion, surgeons are given the opportunity to rehearse the planned procedure using a patient’s unique anatomical data in a VR environment, a concept similar to augmented reality. Currently, Simbionix holds the only commercially available patient-specific VR simulator (AngioMentor) designed for carotid endovascular stent placement. It has proven face, construct, and content validity and enables the user to track objective measures over time [48].

In addition to VR simulation, the robotic platform can also be effectively utilized to develop a basic robotic skill set using inanimate exercises . Jarc and Curet [49] proved the construct validity of nine ex-vivo tasks designed to test camera control, clutching, instrument manipulation, needle positioning, and suturing. In this study, advanced robotic surgeons significantly outperformed novice surgeons, as evident by quicker task completion times and performance scores. Furthermore, Raza et al. [50] used a commercially available inanimate vesicourethral anastomosis kit (Fig. 2.2) (3-Dmed) to prove content, construct, and concurrent validity in performing a vesicourethral anastomosis using the da Vinci robotic platform.

In this ever-expansive online technological age, novel avenues of surgical grading have been explored and developed. Crowdsourcing is one such method and involves seeking out responses from a large, heterogeneous cohort of people from an online community to assist in finding a solution to a problem, in this case, evaluating surgical performance; this has been termed crowd-sourced assessment of technical skills (C-SATS) . Studies involving C-SATS have recently revealed that the surgically inexperienced online community is equally effective as experienced surgeons in evaluating performance during dry lab robotic videos as well as brief animate videos performed by surgeons of varying experience levels. Surgical performance was graded using a validated surgical grading tool, the Global Evaluative Assessment of Robotic Skills (GEARS) , which evaluates the following five domains: depth perception, bimanual dexterity, efficiency, force sensitivity, and robotic control [51, 52]. While C-SATS will certainly not serve to replace a surgical trainee’s invaluable feedback from his experienced mentor, it may have a supplementary role for receiving further feedback in a timely fashion [51].

Along a similar train of thought, video-based peer evaluation via social networking is another innovative surgical evaluation grading tool. In a recent randomized control trial, a total of 41 urology and gynecology residents performed a running anastomosis exercise (Tubes simulator task) in three different sessions over 6 weeks. The 20 subjects in the intervention group received peer feedback after each session after their videos were de-identified and uploaded to a social networking site while the control group did not receive video-based peer feedback. Feedback was provided using GEARS as well as summative remarks. While mean scores for both subject groups were similar for the first session, the intervention residents scored significantly higher and completed the tasks substantially faster than the control group after the second and third sessions [53]. Consequently, this method has shown to improve simulation training performance metrics and holds promise for the evaluation and improvement of real-world robotic operative procedures.