Virtual Reality Simulators
Virtual reality simulators use computer modeling and complex programs to cause the user to believe that they are interacting with a patient, when in reality, they are interacting only with the "imagination" of the computer. The simulator has some type of physical representation with sensing instruments that inform the computer of the user's movements. The program then computes the changes that should take place within the model and projects the correct response onto the screen. Systems may include some sort of three dimensional (3D) imaging to make the environment more realistic and intuitive.
If the model has haptic (touch) feedback, it will also create the illusion that the user is coming into physical contact with the model, and the user will "feel" the patient as well as see it.
Since a VR training system is necessarily run on a computer, there is always the opportunity to collect information on trainee performance. This is a distinct advantage over non-computer-based models. User data can also be used to create critiques and to generate an individual's learning curve over time as well as to compare an individual to a cohort of peers.
Virtual reality models have one distinct drawback. It is necessary to have a computer programmer create new modules or make significant adjustments to current modules. These simulators are always limited by the number of programs that have already been written and tested.
This level of technology has just come onto the market recently, so many products are still in the developmental stage.
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Below is an alphabetical list of virtual reality simulators (with and without haptic feedback) with a brief description of the capabilities of each.
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The AngioMentor program is available to teach on 3 different platforms. The AngioMentor Ultimate is a stationary platform allows trainees to monitor changes in their virtual patient's vital signs and give appropriate medications during an angiographic procedure. Modules include carotid stenting as well as renal, SFA, iliac and coronary interventions. Each module has appropriate tools that can be manipulated in real time to perform the procedure. Case to case differences in anatomy and pathophysiology present variable challenges to trainees. AngioMentor Express is the portable platform version, and AngioMentor Mini is the desktop version.
The ARTHRO Mentor
Several endovascular fluoroscopic techniques are simulated in this trainer, including balloon angioplasty and pacemaker placement. Cases present normal and pathologic states, with complications developing if procedures are not performed correctly. Incorporation of realistic devices allows a user to become accustomed to the tools and environment as well as the procedure itself. EKGs and arterial pressures respond to trainee interventions. Realism is enhanced by the addition of haptic feedback.
The AccuTouch Endoscopic Simulator is actually a suite of simulations covering bronchoscopy, sigmoidoscopy, colonoscopy, ERCP and EGD using a flexible endoscope. Each type of endoscopy has didactic content, introductory cases and various procedures available. Haptic feedback is used to create the feeling of tissue and anatomic landmarks. Performance is reviewed after the case, and multiple sessions can be compared by the trainee or instructor for improvement over time.
Endotower is designed to introduce users to the skills needed to drive an angled laparoscopic camera / lens combination. This program would apply to physicians and residents, nurses and medical students. The virtual model is abstract, meaning there are no simulated tissues, in order to increase the application to multiple specialties, including laparoscopy, arthroscopy, urology, gynecology, and ENT. The user navigates around a 3 dimensional object in space using the 30, 45 or 70 degree angle of the camera to see around objects and into confined spaces. There is also an option to use a straight lens.
The EYESI system uses computer generated images (seen through a realistic stereo microscope), haptic feedback (sense of touch) and realistic instruments to allow trainees to practice intraocular surgery. Trainees begin with an introductory module to learn navigation, object manipulation, and equipment usage. Then they progress to the surgery module, which includes removal of membranes and injury monitoring, using realistic tissue images.
This virtual trainer for upper and lower gastrointestinal endoscopy contains partial manikins, endoscopes, and a computer screen for the visual display. The customized scopes are realistic, thus allowing training of the equipment in addition to diagnosis and procedure implementation. There are several modules available, each with many patients. Haptic feedback is incorporated. Instructional aid is available during the procedure, as well as a feedback form at the end, indicating performance level. Instructors can save a set of cases to be run together for trainees. Some of the modules use realistic computer generated images. Others focus on honing isolated skills and do not use anatomic images.
HystSim uses a real, modified hysteroscope to train basics skills / equipment, procedures such as myomectomy and endometrium ablation, and advanced topics such as intramural myoma. Supplemental information such as side views are available to help trainees understand the orientation and anatomy. As more basic levels are completed with adequate scores, more advanced modules are made available. Complications are triggered by either the user's actions or by the instructor and are managed. Feedback is provided in the form of measured metrics and recorded video for review by the trainee and instructor.
Realistic images of the intra-abdominal cavity allow training of abdominal laparoscopic procedures. Several skills and procedures can be taught on this simulator, including electrocauterization, organ maneuvering, and clipping and cutting of the cystic duct. Haptic feedback is incorporated into the tool and tissue modeling. There are several patients of both genders exhibiting varying internal anatomy. Non-anatomic modules teach isolated tasks; realistic modules incorporate the basic tasks into a full procedure on a realistic patient. Instructors can customize a series of cases for different groups. After the module is completed, feedback is given to the trainee and the output is stored for instructor review.
The LapSim system contains anatomic and non-anatomic modules for introducing trainees to the environment, tools, and skills needed for laparoscopic surgery. Trainees can select from camera navigation, grasping drills, suturing, clip application, and other basic skills in addition to more advanced procedures such as cholecystectomy or appendectomy. Performance scores are viewable by students and their instructors. Curricula, including exams, are customized for each individual or group.
The LaparoscopyVR Surgical Simulator allows trainees to practice laparoscopic skills using haptic feedback and realistic tools. There are three modules which take the trainee from basic tasks such as camera navigation and needle driving through advanced skills such as lap cholecystectomy and ectopic pregnancy. The basic module can be used to practice for the FLS (Fundamentals of Laparoscopic Surgery) test. Cases can be organized into a curriculum for individuals or for a group, with a variety of metrics being measured and recorded for each attempt at the skills.
The Mannequin Simulator Package consists of a partial torso for sensing probe insertion and manipulation, a realistic transesophageal echo probe with functioning buttons, and an on-screen real time representation of both the heart and the corresponding ultrasound image. The ultrasound plane is viewable as a plane transecting the heart, and the heart can be sectioned at the plane and viewed from both directions. Anatomical structures of interest can be highlighted both in the heart model and the ultrasound image. The Mannequin Simulator Package works in conjunction with the Anatomy Module and the Ultrasound Module to create a stepwise learning process, from basic information to clinical application.
Mediseus Epidural Simulator (Medic Vision)
This epidural simulator is designed mainly for training labor analgesia. The sense of touch is incorporated through both saline and air loss of resistance as the trainee manipulates the syringe. The simulator also contains integrated videos as part of the curriculum and access to a virtual expert throughout the program, as well as real-time feedback from the patient. Post-performance feedback includes scores on multiple factors ranked on importance and suggestions on improving performance for the next attempt. Trainees can look back at their individual scores over time to track improvement.
The MIST system combines non-anatomic and anatomic modules which allow the acquisition of skill sets that are needed in minimally invasive surgery. The skills range from single-handed object manipulation to complex tasks requiring suturing using specific knots. The trainee begins on non-anatomic models and works through anatomic tissue to 3D anatomic tissue, increasing the complexity (and the realism) of the task. Each task can be made more or less challenging, based on the level of user. Instructors can design curricula for a specific level or user. There is immediate feedback (color changes, tissue stretching, etc) as well as post-performance feedback data. Instructors can look across class results or at individual performance information.
This unit can be a standalone simulator or used in conjunction with Uro Mentor (see below). The focus is percutaneous punctures for fluoroscopy. It is appropriate for both urologists and radiologists. Haptic feedback is present for both moving through the various tissue layers and moving around ribs. The patient anatomy is variable to create multiple training opportunities. Trainees are given instruction before and during the procedure, as well as an evaluation immediately afterwards. Trainee performance data is available to the instructor for each session, as well as across many sessions (longitudinal data).
ProMis is designed to teach laparoscopic surgery skills using both physical and virtual tissue. Depending on the objectives of the session, the trainee works in either a real physical world on task trainer models or in a virtual world. Teaching points such as trocar placement, equipment in-service, or camera movement are done using the task trainer features. When moving to skills such as motion smoothness or diathermy use, the virtual world is used. Both physical and virtual training have feedback. There is a performance playback to be used either independently or with an instructor as a review. When using the virtual modules there are also measured metrics that help the trainee assess areas of competence and areas of focus for further work.
RapidFire is a minimally invasive skills training program which runs on a standard PC with the VLI interface. The program allows users to acquire a range of skills, from a basic understanding of the physical environment (equipment fulcrum effect, lack of depth perception, etc) to more complex tasks such as transferring objects between hands and placing objects accurately in space. Scores in multiple metrics are available to the trainee to help target areas needing additional attention. Sets of tasks can be assigned to a trainee and reviewed by the trainee and instructor.
Ross Robotic Surgical Simulator (Simulated Surgical Systems)
RoSS systems use dual haptic devices and three dimensional images to train users on the cognitive and motor aspects of robotic surgery. Tasks begin with nonanatomic modules such as moving balls to targets to learn basic orientation and motor skills. As the trainees become comfortable with the basic tasks, complexity increases to individual surgical skills, such as needle handling and basic electrocautery, then to advanced maneuvers, such as vessel dissection, which incorporate previously mastered basic skills. Whole procedures are at the most advanced level. Individual performance metrics are recorded and stored for each individual, to be reviewed by the instructor.
Smart Tutor was developed to keep trainees at different levels of experienced challenged at the appropriate level. It currently incorporates into Rapid Fire (see above, interface with additional applications under development) so that the task difficulty is incrementally changed as the user's metrics change. If the trainee is having difficulty in an area, the program will set easier goals until the skills have improved. As the trainee approaches mastery of the skill at that level of difficulty, then the tasks become more difficult to provide a continually challenging but not overwhelming environment.
TURPSim uses a real, modified resectoscope to teach basic skills / anatomy / equipment, the full transurethral resection of the prostate (TURP) procedure, and laser use for benign prostatic hyperplasia (BPH). The simulator also includes several complications to these procedures, either triggered by the user's actions or remotely by the instructor. Didactic content (text and movies) is provided before the module. After completion, recorded performance metrics are graded for feedback.
UltraSim Ultrasound Training Simulator (MedSim Advanced Medical Simulations)
The UltraSim consists of a generic ultrasound machine and a partial manikin. The ultrasound probe position and orientation are recorded by three-dimensional sensors within the manikin. These sensors send information to the computer within the ultrasound machine, which then projects the correct images onto the display screen. There are several modules (such as OB/Gyn and carotid doppler), each of which has a large number of cases to work through. Practice modes and evaluation modes are available.
Uro Mentor (Simbionix)
This module can be used alone or incorporated with PERC Mentor (see above). The simulator incorporates non-anatomic sessions to practice isolated skills. Once the skills have been mastered, the trainee moves onto the procedural modules, which incorporate the basic skills into a setting with a virtual patient and realistic images. Haptic feedback is incorporated into the performance of each scope and instrument. Groups of cases can be stored together as templates for various groups of trainees. Post-performance assessment is reviewed by the trainee and can be stored for review by an instructor at a later time.
VIST is designed to introduce users to endovascular interventions. A haptic feedback device (incorporating the sense of touch) is coupled to a program which produces patient interaction via real time fluoroscopic images and vital signs. Coronary stenting can be practiced, as can placing leads for pacing. A tutorial program runs in parallel to the simulation on a second monitor, enabling the user to gather necessary information as it is needed. Contrast media mixing and hemodynamic factors have been incorporated to increase the realism.
Vimedix is a virtual reality system which is used to instruct thoracic echocardiography. The trainees interact with a chest and simulated probe to produce a real-time image. Multiple probes can be used for transthoracic or transesophageal echos. The image can be altered with gain, contrast, depth of field and other settings. Heart (normal, anatomical pathophysiologies and physiological pathophysiologies), ribs, major thoracic vessels, liver and other internal structures are visible.
The VOXEL-MAN TempoSurg simulator is a tool for training and planning classical and navigated surgical access to the middle ear. The system is based on virtual 3D models of the skull base derived from high-resolution CT data. The trainee sees the virtual surgical site displayed in stereoscopic mode and controls the drill with a force feedback device. In addition, the user may navigate with three orthogonal cross-sectional views. For surgical training, a set of models derived from patient cases with labeled organs at risk is provided. Additionally, virtual bone models may be created from imported patient specific DICOM CT data. Thus, in complicated cases, interventions may be rehearsed in advance of the real procedure.