A multi-modal approach to cognitive training and assistance in minimally invasive surgery
Introduction
In the last decade, technological advancements revolutionized the manner in which medical care is delivered. One area of medicine which has profited considerably from mechanical and computational innovations is the field of minimally invasive surgery (MIS). The term MIS encompasses two prominent distinct techniques: conventional laparoscopy and robotic-assisted surgery. Although similar in their approach, robotic-assisted surgery offers a variety of technological advantages, including a better visual access (e.g. robotic 3-D HD screen vs laparoscopic 2-D screen) and dexterous control (e.g. robot controlled instruments offering greater motion and precision vs laparoscopic restricted hand controlled instruments) (Kawashima, Kanno, & Tadano, 2019). Naturally, due to the two district mechanical features, both techniques rely on different set(s) of cognitive and psychomotor skills Kim, Choi, Park, and Park (2014). In this paper, we focus our application on conventional laparoscopy, considering the significant and unique cognitive challenges associated with the technique. As laparoscopy is commonly referred to as MIS in the literature, we will use the two terms synonymously throughout the article.
MIS, refers to a specialized surgical technique in the abdominal and pelvic region, whereby small incisions are made to allow the port (cannula), the camera (laparoscope) and other instrument ports (trocars) to enter the abdominal cavity. The technique involves inflating the patients abdominal wall with the gas, to allow for better visualization and a more easily navigable workspace. Small incisions are then made, to allow trocars to enter the body, through which a viewing device and other surgical instruments (e.g., graspers) are inserted. The laparoscope illuminates the internal structures and displays their real time image on a 2-D monitor viewed by the surgeons. Depending on the surgical intervention, various trocars are then inserted, allowing the long and thin surgical instruments to handle and manipulate the organs and tissue. Laparoscopy has now become widely accepted and successfully implemented MIS technique into the existing surgical practice by surgeons all around the world. As a result, around million laparoscopic procedures are currently performed annually worldwide (Global Industry Analysts, 2018).
Unlike conventional open surgery, laparoscopy reduces the physical trauma to the patient’s body and thus in return, reduces postoperative pain and complications, enables quicker recovery and improves the cosmetic results (Tan, Wolf, Ye, Hafez, & Miller, 2014). Nonetheless, the procedure itself is complex and demanding for the surgeon to acquire and master, because it creates a unique set of technical and cognitive challenges. These include lack of haptic and tactile feedback, lack of three-dimensional vision and thus diminished depth perception, conflict in hand-eye coordination, and many more (Cuevas et al., 2013, Sinha et al., 2017). Not surprisingly then, research has confirmed that laparoscopy is much more difficult to learn than is open surgery, even after some degree of training (Subramonian, DeSylva, Bishai, Thompson, & Muir, 2004). The cognitive complexities constitute towards what in medical research is termed a ‘long and steep learning curve’: Laparoscopic skills require an extended hands-on training approach, a prolonged training effort, and dedicated practice for ensuring skill mastery (Emken et al., 2004, Bansal et al., 2012). Although one may consider the importance of hands-on training in surgery as self-evident, the reality sees institutional factors such as EU working hours restrictions law, cuts in the healthcare budgets and unstructured residency curriculum, as factors keeping the resident surgeons out of the operating room (OR). Consequently, research has found that the next generation of laparoscopic surgeons admit lacking significant laparoscopic exposure and thus lacking confidence in performing laparoscopy at the end of their residency training (De Win, Everaerts, De Ridder, & Peeraer, 2015).
Realizing the exigency for trainees to acquire laparoscopic mastery outside the OR, simulation-based training tools have been introduced as patient-safe, controllable and cost-effective alternatives for gaining additional training (Zendejas, Brydges, Hamstra, & Cook, 2013). Currently, there are many different types of training simulation systems on the market, such as virtual reality simulators, box (physical) simulators, animal and human cadavers and mannequins. Nevertheless, these simulators focus primarily on acquisition of technical skills (dexterity, bi-manual in nature: e.g., grasping, cutting) and procedural skills (e.g., task execution such as suturing, rehearsing scenarios with mannequins). Although undeniably valuable skills, we know that motor-based practice alone does not guarantee surgical expertise (Hall, Ellis, & Hamdorf, 2003).
More so, when designing a training system, the individual differences in learning must be accounted for, as it is not only important to consider what the individual must learn, but also how the learning could be optimized. One strategy for maximizing the learning potential of an individual is to tailor the training curriculum according to one’s preferred learning modality. The concept of learning modalities, or learning styles, refers to the method of using specific set(s) of sensory information for learning purposes. There are three widely acceptable dimensions of modalities used to process the information into their memory storage: Visual modality (i.e. learn by seeing), auditory modality (i.e. learn by hearing) and tactile/kinesthetic modality (i.e. learning by touching and doing). Although some may be able to learn a task using all sensory modalities, others do express unusual strengths and/or weaknesses relating to specific set of senses. What is more, some modalities complement each other. For example, some visual-spatial learners are also excellent in processing auditory sequential information. In other words, they possess a full access to both modalities, and when combined, can significantly accelerate learning and thus mastery acquisition (Silvermann, 2010).
As every learner is different, the ’one size fits all’ training simulator is no longer a viable solution. In this paper, we introduce the concept of our multi-modal system for cognitive training and assistance in MIS and propose a framework to describe how a personalized and adaptive, gamified training system, could be a helpful tool for promoting expertise and mastery in MIS, in a mixed-modal fashion. Our initial efforts in conceptualising the intelligent and adaptive training system focuses on laparoscopy. The uniqueness of the proposed system lies in its gamification design, whereby cognitive skills and conditions fundamental for laparoscopy are simulated in a fun environment, allowing the user to acquire the necessary skills in a relaxing and engaging manner outside the OR. Our goal for such a simulation training is twofold: First, we will utilize knowledge from our own previous research, which systematically identified a set of visuo-spatial skills important for laparoscopic performance and training (Vajsbaher, Schultheis, & Francis, 2018), and appropriately design a computer-based training exercise which would allow for the required spatial abilities to be tested and trained (Cognitive Training). The trainer will adapt to the specific strengths and weaknesses of the user, offering a personalized training program. Second, we aim to implement a complementary auditory component, such that when and where necessary, auditory presentation of spatial information (Auditory Display) will be added to the visualization and the kinesthetic properties of the simulator.
The remainder of the paper will proceed as follows. First, we discuss the role of spatial cognition in MIS, to introduce the evidence-based approach which prompted the task-based design of our training system. Second, we provide a state of the art review relating to cognitive training simulators and auditory displays for surgical assistance. Third, we describe our approach towards developing such an adaptive multi-modal cognitive simulator for laparoscopic training.
Section snippets
Role of spatial cognition in MIS
The influential role of spatial cognition, more specifically the role of visuo-spatial ability, for laparoscopic performance and skill acquisition has been well established in the literature (Keehner, 2011, Vajsbaher et al., 2018). This is mostly due to the numerous dual-task inferences (motor and cognitive) and spatial transformation conflicts yielded by its mechanical design, coupled with the surgeon’s own innate spatial skills. For example, in open surgery, the surgeon works in line with his
Related work
Our main aims in pursuing our approach relate to three areas of research. First, research on computer-based cognitive training systems for surgeons. Second, research on the use of sound to convey information in the OR. Third, research on the use of sound to convey spatial information. In this section we review the state of the art for all three research areas.
Our approach
Mirroring the considerations outlined in Section 2.1, our approach combines an adaptive cognitive training and a cognitive assistance component. The training component is cognitive in the sense that it comprises cognitive tasks instead of mainly trying to achieve surgical surface similarity (e.g., simulating anatomy), whereby laparoscopy-specific visuo-spatial and visuo-motor skills are practiced and tested. The assistance component is an interactive auditory display that is able to guide a
Conclusion
In this paper, we introduced a novel multi-modal approach to cognitive training and assistance for application in surgery. The main contributions of our approach and its initial implementation are as follows: First, we proposed to consider training and assistance that address the same surgical cognitive challenges in an integrated fashion, which offers several advantages over a separate treatment of training and assistance. Second, we presented an initial implementation of this approach for the
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
TV and HS gratefully acknowledge funding by the German Research Foundation (DFG) through the project ‘Spatial Cognition in Surgical Practice’ (Project number: 404173918). We are also grateful to the Bremen Spatial Cognition Center for providing seed funding for this work. Special thanks to our University of Bremen students, working on the CURAT project, for their enthusiastic help in implementing the multi-component system.
References (102)
- et al.
Can everyone achieve proficiency with the laparoscopic technique? Learning curve patterns in technical skills acquisition
American Journal of Surgery
(2009) - et al.
Cognitive simulators for medical education and training
Journal of Biomedical Informatics
(2009) Improved force perception through sensory substitution
Control Engineering Practice
(1995)- et al.
Surgeon-specific factors in the acquisition of laparoscopic surgical skills
The American Journal of Surgery
(2001) - et al.
Acquiring surgical skills: A comparative study of open versus laparoscopic surgery
Journal of European Urology
(2004) - et al.
Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery
The Journal of Urology
(2014) - et al.
Visuospatial and psychomotor aptitude predicts endovascular performance of inexperienced individuals on a virtual reality simulator
Journal of Vascular Surgery
(2010) - et al.
Fls and fes: Comprehensive models of training and assessment
Surgical Clinics of North America
(2010) - et al.
Effect of visual-spatial ability on learning of spatially-complex surgical skills
The Lancet
(2002) - et al.
Sonification design for complex work domains: Dimensions and distractors
Journal of Experimental Psychology: Applied
(2009)
Laparoscopic suturing skills acquisition: A comparison between laparoscopy-exposed and laparoscopy-naive surgeons
Journal of the Society of Laparoendoscopic Surgeons
A new class of auditory warning signals for complex systems: auditory icons
Human Factors
Trends in the fundamentals of laparoscopic surgery (fls) certification exam over the past 9 years
Surgical Endoscopy
A survey of auditory display in image-guided interventions
International Journal of Computer Assisted Radiology and Surgery
Auditory feedback to support image-guided medical needle placement
International Journal of Computer Assisted Radiology and Surgery
Desktop simulator: Key to universal training?
Surgical Endoscopy
The drive-wise project: Driving simulator training increases real driving performance in healthy older drivers
Frontier Aging Neuroscience
A quality improvement study on avoidable stressors and countermeasures affecting surgical motor performance and learning
Annals of Surgery
Minimally invasive surgical skills evaluation in the field of otolaryngology
Fundamental aspects of learning minimally invasive surgical skills
Minimally Invasive Therapy & Allied Technologies
Laparoscopy training in Belgium: Results from a nationwide survey, in urology, gynecology, and general surgery residents
Advances in Medical Education and Practice
Training and assessment of laparoscopic skills
Journal of the Society of Laparoendscopic Surgeons
Spatial ability and learning the use of an angled laparoscope in a virtual environment
Studied in Health Technology Informatics
Assessing the value of the simpraxis laparoscopic cholecystectomy trainer
Journal of the Society of Laparoendscopic Surgeons
Computerised cognitive training for maintaining cognitive function in cognitively healthy people in late life
Cochrane Database of Systematic Reviews
Use of a volumetric target for image-guided surgery
Neurosurgery
Feeling the beat: premotor and striatal interactions in musicians and nonmusicians during beat perception
Journal of Neuroscience
Surgeons and cognitive processes
British Journal of Surgery
Auditory support for resection guidance in navigated liver surgery
The International Journal of Medical Robotics and Computer Assisted Surgery
Enhancing cognitive abilities with comprehensive training: A large, online, randomized, active-controlled trial
PLOS ONE
Visual working memory influences the performance in virtual image-guided surgical intervention
Surgical Endoscopy
High-level visual-spatial ability for novices correlates with performance in a visual-spatial complex surgical simulator task
Surgical Endoscopy
Visual spatial ability for surgical trainees: Implications for learning endoscopic, laparoscopic surgery and other image-guided procedures
Surgical Endoscopy
Development of visual working memory precision in childhood
Journal of Developmental Science
Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills
Surgical Endoscopy
Robots in laparoscopic surgery: Current and future status
BMC Biomedical Engineering
Spatial cognition through the keyhole: How studying a real-world domain can inform basic science–and vice versa
Topics in Cognitive Science
Cited by (5)
Three-dimensional sonification as a surgical guidance tool
2023, Journal on Multimodal User InterfacesSports competition tactical analysis model of cross-modal transfer learning intelligent robot based on Swin Transformer and CLIP
2023, Frontiers in NeuroroboticsDevelopment of a Robotic Surgery Training System
2022, Frontiers in Robotics and AI