Play to Become a Surgeon - Impact of Nintendo WII Training on Laparoscopic Skills

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Play to Become a Surgeon - Impact of Nintendo WII Training on Laparoscopic Skills
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  Play to Become a Surgeon: Impact of Nintendo WIITraining on Laparoscopic Skills Domenico Giannotti 1 , Gregorio Patrizi 1 * , Giorgio Di Rocco 1 , Anna Rita Vestri 2 , CamillaProietti Semproni 3 , Leslie Fiengo 1 , Stefano Pontone 1 , Giorgio Palazzini 1 , Adriano Redler 1 1 Department of Surgical Sciences, Faculty of Medicine and Dentistry; Sapienza University of Rome, Rome, Italy, 2 Department of Public Health and Infectious Disease,Faculty of Pharmacy and Medicine, Sapienza University of Rome, Rome, Italy, 3 Department of Radiological Sciences, Oncology and Pathology, Faculty of Medicine andDentistry, ‘‘Sapienza’’ University of Rome, Rome, Italy Abstract Background:  Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopicprocedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms isongoing. We investigated the influence of a four-week structured Nintendo H Wii TM training on laparoscopic skills byanalyzing performance metrics with a validated simulator (Lap Mentor TM , Simbionix TM ). Methodology/Principal Findings:  We performed a prospective randomized study on 42 post-graduate I–II year residents inGeneral, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and thenrandomized to group 1 (Controls, no training with the Nintendo H Wii TM ), and group 2 (training with the Nintendo H Wii TM )with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testingsession on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improvedsignificantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement inperformance (p , 0.05) for 13 of the 16 considered performance metrics. Conclusions/Significance:  The Nintendo H Wii TM might be helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room. Citation: Giannotti D, Patrizi G, Di Rocco G, Vestri AR, Semproni CP, et al. (2013) Play to Become a Surgeon: Impact of Nintendo WII Training on LaparoscopicSkills. PLoS ONE 8(2): e57372. doi:10.1371/journal.pone.0057372 Editor: Mercedes Susan Mandell, University of Colorado, United States of America Received October 3, 2012; Accepted January 22, 2013; Published February 27, 2013 Copyright: ß 2013 Giannotti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the srcinal author and source are credited. Funding: No current external funding sources for this study. Competing Interests: The authors have declared that no competing interests exist.* E-mail: g_patrizi@yahoo.com Introduction Over the past two decades video-games have become anintegral part of the new multimedia culture. Their social andcultural significance has been widely investigated and they seem tobe the basis of the so called ‘‘media competency’’ acquisition [1].Today’s video-game players include millions of individuals of allages and backgrounds. In 2010, 72% of American householdsplayed games thus fueling a multi-billion dollar industry, spending  $ 25.1 billion on video-games, hardware and accessories with $ 5.9billion in revenue [2].Despite some negative effects of excessive game playing [3], [4],several studies have confirmed that video-gaming enhances spatialattention and eye-hand coordination [5], [6].For many people videogames are the first active approach to abidimensional interface and they could increase familiarity withthe screen interfaces used in laparoscopic surgery [6]. Comparedto open surgery, laparoscopy presents different difficulties such aslimited motion range of instruments, loss of depth perception,haptic feedback and fulcrum effect [7], [8]. Considering thetechnical difficulty of laparoscopic procedures, legal issues andtime limitation, validation of appropriate trainings even outside of the operating rooms is ongoing [9], [10], [11], [12].Several studies have investigated the relationship between video-gaming and surgical skills by analyzing the impact of priorgaming experience on surgical ability [13] and the influence of asystematic video-game training on laparoscopic simulator perfor-mance [14]. Data from the literature suggests that 3D gametraining is more beneficial than 2D [15].Kolga Schlickum et al. compared a first-person 3D shootergame (Half Life, 1998, Sierra On-line, Los Angeles, California)with a bidimensional video-game (Chessmaster, 2004, Ubisoft,Montreuil-sous-Bois, France) showing that tridimensional gamesprovide a greater transfer of training effect on virtual realityendoscopic simulators [14]. Half life was chosen for the similaritieswith virtual endoscopy: in fact navigation capabilities aremandatory in both applications and the authors concluded thattransfer effect increases when increasing visual similarity. Wewondered if a similar transfer effect could also be found inlaparoscopic surgery, focusing our attention on Nintendo H Wii TM .Since a limited number of studies were conducted in this regardand with a very short training time, we investigated the influenceof a four week structured Nintendo H Wii TM training on PLOS ONE | www.plosone.org 1 February 2013 | Volume 8 | Issue 2 | e57372  laparoscopic performance, by analyzing metric effects with a validated laparoscopic simulator (Lap Mentor TM , Simbionix TM  ). Materials and Methods The study was performed in the Department of SurgicalSciences at ‘‘Sapienza’’ - University of Rome in Italy.The study was approved by the local Ethics Committee(Protocol number 808/12). All participants were enrolled on a voluntary basis and each resident gave informed consent beforeenrollment.Our research was structured in two sessions of tests on alaparoscopic simulator. Between these two sessions, participantswere randomized into two groups. One group underwent astructured training with the Nintendo Wii console, while the otherwas asked not to play any video game. The re-test session wasscheduled 28 days after session 1.61 post-graduate I–II year residents in General, Vascular andEndoscopic Surgery were assessed for eligibility. Before entering the study, all participants completed a questionnaire assessing demographics, number of previous laparoscopic procedures(camera, assistant, operator) and average number of hours perweek spent playing video-games.Inclusion criteria were lack of prior laparoscopic simulatorexperience, none or low experience in laparoscopic surgery (lessthan 5 laparoscopic procedures, all of them as camera operator),low video-game experience (less than 1 hour a week in the last 10 years).17 residents were excluded from the study because they did notmet inclusion criteria and two residents declined to participate. A total of 42 residents were then enrolled as the study subjects.Participants demographics, previous exposure to laparoscopy,exposure to laparoscopy during the study period and video gamesexperience were reported in Table 1. Participants took part inlaparoscopic procedures only as camera operators. All participants were tested in the first session on our validatedlaparoscopic simulator (Lap Mentor TM , Simbionix TM  ) and thenrandomized to group 1 (Controls, no training with the Nintendo H Wii TM  ), and group 2 (training with the Nintendo H Wii TM  ) with 21subjects in each group, according to a computer-generated list. After four weeks all residents underwent a second testing sessionon the laparoscopic simulator with the same tasks evaluated as insession 1.Between the two sessions, subjects in group 1 (control) wereinstructed not to play video-games while group 2 underwent asystematic Nintendo H Wii TM training for 60 minutes a day, fivedays a week, for four weeks. Simulator testing and Nintendo Wiitraining were conducted under supervision in a dedicated room of our Department with two Nintendo Wii consoles and onelaparoscopic simulator station. Simulator testing  All participants were tested in three basic laparoscopic skillstasks and one virtual patient case of complete cholecystectomy(Lap Chole – Full Procedure Module number 1) on a validatedlaparoscopic simulator (Lap Mentor TM , Simbionix TM  ).For each task we selected specific parameters calculated andreported by the simulator software to evaluate the subject’sperformance.Before performing the first three tasks each participant viewed astandardized screen, provided by the simulator, illustrating theprocedure. – In task 1 (0 u camera manipulation), subjects must locate 10balls and snap their photos using a 0 u camera. We recorded thetotal time in seconds to complete the procedure and theaccuracy rate in percentage calculated by dividing the numberof correct hits by the total number of camera shots. – Task 2 required eye-hand coordination: participants mustlocate 10 flashing blue and red balls and touch them with thetool of the same color. We recorded total time, accuracy ratecalculated by dividing the number of correct hits by the totalnumber of touched balls and economy of movement of right(EMRI) and left instrument (EMLI), measured in percentage,calculated by dividing the ideal path length by the relevantpath length of right/left instrument. – In task 3, designed for two handed maneuvers, participants hadto expose with two grasping tools 9 balls hidden under a jellymass and place them into an endobag. Total time, accuracy-rate, number of exposed green balls collected and economy of movement of right (EMRI) and left instrument (EMLI) wererecorded. – In task 4 participants performed a complete virtual cholecys-tectomy after a standardized oral instruction on the surgicaltechnique and a description of the patient’s medical history Table 1. Characteristics of study participants. Characteristic Group Control, n=21 Wii, n=21 p-value Age (years) 27.6 6 1.5* 26.9 6 1.3* 0.121Sex (female/male) 13/8 11/10 0.756**Right handed 21 19 0.488Previous laparoscopic procedures 2.2 6 1.2* Range 0;4 1.9 6 1.1* Range 0;4 0.311Laparoscopic procedures during thestudy period0.3 6 0.5* Range 0;1 0.2 6 0.4* Range 0;1 0.474Residents in General surgery 11(44.0) 14(56.0) 0.688**Residents in Endoscopic surgery 6(60.0) 4(40.0)Residents in Vascular surgery 4(57.1) 3(42.9)I year residents 12(44.4) 15(55.6) 0.260**II year residents 9(60.0) 6(40.0)*mean 6 sd;**Pearson’s chi-squared test; in brackets: percentage.doi:10.1371/journal.pone.0057372.t001 3D Video Games and Surgical TrainingPLOS ONE | www.plosone.org 2 February 2013 | Volume 8 | Issue 2 | e57372  reported by the simulator. All subjects selected procedurenumber 1 of Full Procedures LapChole. We evaluated the totaltime to complete virtual cholecystectomy, the efficiency of cautery (in percentage) calculated by dividing the time of cautery applied with appropriate contact with adhesions by thetotal cautery time, the safe cautery (in percentage) calculated bydividing the time of cautery applied more than 5 mm from thebiliary system and the time of cautery applied more than15 mm from the clip by the total cautery time and finally thenumber of movements of right (NMRI) and left instrument(NMLI). Nintendo H Wii TM training The Nintendo H Wii TM (Nintendo Co. Ltd, 2006, Kyoto, Japan)is a video-game console with a wireless controller, the Wii TM Remote, which is a handheld pointing device, able to detectmovement in three dimensions. Thanks to this controller, thegamers can play using physical gestures while traditional video-games require the player to press a button or to move a joystick.We chose three games (Wii TM Sports Tennis, Wii TM TableTennis and Battle at high altitude) with high demands of eye-handcoordination, movement precision, depth perception and 3D visualization, for the purpose of investigating the transfer effect of  video-games on laparoscopic simulator performance. – In Wii TM Sports Tennis (Wii TM Sports), the Wii TM Remote isswung like a racket and the player’s shots are determined bythe controller direction. This game requires prolonged visualconcentration and eye-hand coordination developing visualacuity and focus flexibility. – In Wii TM Table Tennis (Wii TM Sports Resort) there is a closeraction field with less dynamic acuity but the player has greatercontrol adding spin to the ball by twisting the Wii TM Remote. – Battle at high altitude is set in an archipelago: the player moveshis aircraft with 20 balloons attached to the tail and the goal isto stay with as many balloons as possible within 3 minutes or toburst the opponent’s balloons. This game requires precision of movements and an excellent 3D visualization rather than otherskills. All 21 participants belonging to the Wii Group underwent asystematic Nintendo H Wii TM training, using both hands, for60 minutes a day, five days a week, for four weeks. Statistical analysis Continuous variables are presented as mean 6 SD. We assessedthe normality of the data with Shapiro-Wilk test. Data of performance metrics do not follow a normal distribution andtherefore were reported as median and interquartile range.Categorical variables are presented as counts or percentage. Toevaluate the homogeneity and the differences between groups, weused the Mann-Whitney test; to evaluate the differences withingroups we used the Wilcoxon test. We calculated, for all variables,the ratio between session 2 and session 1 (index numbers), to assesstheir modification from the initial test, expressed as percentage of improvement. The probability values are 2-sided; a probability value of less than .05 was considered statistically significant. Allanalyses were carried out with SPSS software version 18.0 (SPSSInc., Chicago, Illinois). Results No significant differences were found between the Wii andcontrol group in session 1, in keeping with the homogeneity of thetwo groups for all the performance metrics evaluated. All 42subjects improved significantly from session 1 to session 2 (table 2).The control group improved significantly in all performancemetrics except for: – The accuracy rate measured in task 1 (0 u camera manipulation)and the total time to complete it (p values respectively of 0.144and 0.092). – The total number of exposed balls collected in task 3 (twohanded maneuvers), p=0.470.The Wii group improved significantly in all performancemetrics (table 2).Comparing the Wii with the control group we found significantdifferences in the improvement for all the performance metricsmeasured (p , 0.05) except in three cases (Table 2): – The total time needed to complete task 2 (eye-handcoordination), p=0.170. – The total time needed to complete task 3 (two handedmaneuvers), p=0.159. – The total number of exposed balls collected in task 3, p=0.084 Analyzing the variables as the ratio (index numbers) we canexpress the improvements, between the two groups, in percentageterms as shown in Table 3, Figures 1 and 2. Discussion Several studies have postulated a correlation between video-game experience and surgical skills. Probably in both areas thesame process of ‘‘perceptual learning’’ is involved. Video-gameplayers and surgical trainers improve their performance onsubsequent attempts using an attentional weighting: they focusmore attention on important aspects discarding the irrelevant [16].This correlation is of more than theoretical importance and opensan important debate in terms of surgical education.In recent years, technical difficulties of laparoscopic procedures,legal issues and time limitations have increased the need toperform training even outside of the operating theater [9], [10],[11], [12]. Laparoscopic simulators represent a satisfactoryresponse to this request but their high costs have limited theirspread. Video-games may be a cheap and widely availableproduct, helping to develop cognitive skills that, apparently, can betransferred in improved surgical performance.Rosser et al. tested 33 surgeons with three different video-gamesand a laparoscopic simulator, showing increased simulatorperformance in subjects with prior and current video-gamesexperience [6]. Rosemberg et al. evaluated 11 medical studentsplaying a selection of video-games and performing laparoscopictasks in a swine model. As reported in other studies they found acorrelation between video-game play and the completion time of simple laparoscopic tasks, such as object translocation, while noadvantages were identified in more complex tasks [17]. Schlickumet al. were the first to demonstrate the influence of a five-week systematic video-game training on endoscopic simulator perfor-mance even in complex tasks. They used a 3D shooter game (Half Life) chosen for the similarities with virtual endoscopy [14]. Thestudy demonstrated that transfer effect increases when increasing  visual similarity and this concept is central even in our research. 3D Video Games and Surgical TrainingPLOS ONE | www.plosone.org 3 February 2013 | Volume 8 | Issue 2 | e57372  For the training-period, we used a Nintendo H Wii TM consolewhich could reproduce the movements of laparoscopy moreclosely than conventional 2D or 3D video-games due to itsexclusive technology based on a motion-sensing interface. As inlaparoscopic surgery, the action is transferred to a 2D represen-tation on a monitor creating a 3D reconstruction in the player/surgeon’s mind. Badurdeen et al. investigated the correlationbetween Nintendo H Wii TM skills and laparoscopic skills tested withthree tasks on a webcam based laparoscopic simulator on 20participants. They concluded that medical students and juniordoctors with major Nintendo H Wii TM ability perform significantlybetter at laparoscopic tasks [18]. Although this research has showna link between Wii TM skills and laparoscopic performance, only afurther study conducted by Boyle et al. investigated whethertraining on Nintendo H console can improve laparoscopic abilityon a ProMIS TM surgical simulator. However, the study wasconducted with a rather small number of participants (22 medicalstudents) and with a very short training period (3 hours), showing asignificant improvement in only one of the performance metricsevaluated [19].Our study has provided a four week structured Nintendo H Wii TM training, focusing on games with high demand for visualconcentration and eye-hand coordination. We decided to stressthis latter aspect based on a recent study conducted by Wilson etal. on perceptual impairment and psychomotor control in virtuallaparoscopic surgery [20].Gaze analyses has shown that expert laparoscopic surgeonsmake fewer movements and spend more time fixating the targetthan novices, who divided the observation time between thetargets and tracking the tools. We therefore hypothesized thattraining with games that stimulate target focusing could improvegaze strategy and economy of movement even in laparoscopic Table 2. Descriptive statistics of all variables of the two groups (session 1 and 2). Control Group Wii GroupPerformance metric Median IQR Median IQR P-value Task 1 (Session1) Total time (s) 185.0 (142.0–207.5) 186.0 (131.5–209.5) 0.940Accuracy rate (%) 30.5 (22.4–35.7) 32.3 (21.6–36.8) 0.850Task 1 (Session 2) Total time (s) 166.0 (137.0–186.0) 136.0 (116.5–160.0) 0.021Accuracy rate (%) 32.0 (25.0–37.2) 52.4 (41.6–66.7) , 0.0001Task 2 (Session 1) Total time (s) 65.0 (54.0–72.5) 65.0 (56.0–73.5) 0.850Accuracy rate (%) 57.2 (54.8–61.8) 58.1 (53.1–65.2) 0.801EMRI (%) 37.1 (34.6–40.4) 37.8 (33.2–41.3) 0.801EMLI (%) 40.5 (38.4–44.2) 41.7 (36.7–44.9) 0.801Task 2 (Session 2) Total time (s) 54.0 (49.0–68.0) 52.0 (46.5–59.5) 0.170Accuracy rate (%) 61.0 (57.1–67.1) 82.8 (74.5–87.6) , 0.0001EMRI (%) 40.1 (37.1–44.1) 55.7 (51.3–65.7) , 0.0001EMLI (%) 44.0 (40.1–50.4) 62.8 (53.5–69.7) , 0.0001Task 3 (Session 1) Total time (s) 147.0 (103.5–168.0) 142.0 (110.0–159.0) 0.890Balls collected (n) 8.0 (7.0–8.0) 8.0 (7.0–8.0) 0.659EMRI (%) 22.5 (19.1–27.1) 22.6 (18.8–28.1) 0.940EMLI (%) 24.9 (21.2–30.0) 24.1 (19.8–31.4) 0.910Task 3 (Session 2) Total time (s) 111.0 (97.0–149.5) 100.0 (89.5–121.5) 0.159Balls collected (n) 8.0 (8.0–8.0) 8.0 (8.0–9.0) 0.084EMRI (%) 28.3 (22.7–33.5) 41.3 (32.9–50.7) , 0.0001EMLI (%) 29.4 (25.2–35.4) 47.2 (38.2–56.5) , 0.0001Task 4 (Session 1) Total time (s) 701.0 (647.0–784.5) 699.0 (622.5–797.0) 0.753Efficient cautery (%) 41.7 (38.4–45.2) 42.3 (38.5–45.4) 1.000Safe cautery (%) 61.5 (47.5–65.0) 58.4 (47.3–63.9) 0.678Perforations (n) 3.0 (2.5–4.0) 3.0 (2.0–3.5) 0.282NMRI (n) 511.0 (445.5–547.5) 489.0 (462.5–559.0) 0.860NMLI (n) 251.0 (200.0–361.0) 254.0 (202.0–356.0) 0.970Task 4 (Session 2) Total time (s) 655.0 (581.5–739.5) 565.0 (509.5–679.0) 0.027Efficient cautery (%) 45.8 (42.2–51.1) 58.8 (54.9–63.6) , 0.0001Safe cautery (%) 64.2 (52.2–69.5) 70.4 (64.6–78.6) 0.014Perforations (n) 2.0 (2.0–3.0) 1.0 (1.0–2.0) 0.001NMRI (n) 456.0 (400.0–515.5) 371.0 (329.5–417.0) 0.006NMLI (n) 240.0 (178.5–300.0) 188.0 (158.0–244.5) 0.024IQR: Interquartile range; EMRI: economy of movement of right instrument; EMLI: economy of movement of left instrument;NMRI: number of movements of right instrument; NMLI: number of movements of left instrument.doi:10.1371/journal.pone.0057372.t002 3D Video Games and Surgical TrainingPLOS ONE | www.plosone.org 4 February 2013 | Volume 8 | Issue 2 | e57372
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