Otolaryngology - Theses
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ItemVirtual reality for the training of ear surgery( 2016)In current residency surgical training programs, residents learn by observing their mentor and practicing under his/her supervision. For patient safety, the mentor needs to ensure that residents have sufficient practice before they perform surgery on patients. Simulation, ranging from low fidelity (e.g. suture practice on rubber models) to high fidelity (e.g. cadaveric temporal bone dissection), is ideal for this purpose and cadaveric bone dissection is the gold standard of simulated training for temporal bone surgery. However, it has a few setbacks. For example, it is limited by the shortage of cadaveric temporal bones and the bones have to be discarded after drilling and cannot be reused. Also, it is difficult to ensure that residents are exposed to a wide range of temporal bones, specifically ones with rare anatomical anomalies. Another concern is that illnesses may be transmitted through contact with diseased tissues and fluids. Virtual reality surgical simulation is an alternative form of high fidelity simulation that offers risk-free, relatively low cost training environments that can be used repeatedly if necessary at the convenience of the user. Reviews have found that practicing surgical procedures on virtual reality simulators improves trainees' operative performance. One major factor contributing to the success of virtual reality surgical simulation systems is their ability to capture clinical variation. Current simulators in Ear Nose and Throat (ENT) surgery mostly use the core training methodology: starting from easier procedures and moving onto more difficult ones. However, this configuration has traditionally been based on the same anatomical model. To the author’s best knowledge, there do not exist virtual reality simulators in the field of ENT that capture anatomical variation as a basis for surgical education. The aim of this thesis was to determine whether exposure to anatomical variation in a virtual reality simulated environment leads to better surgical outcomes, to establish the foundations of a more efficient model for surgical education. To achieve this goal, several investigations were carried out. Firstly, a systematic review and meta-analyses were conducted to examine the role of virtual reality simulation based training in ENT surgery, and to investigate whether it can improve the acquisition of surgical skills. This has revealed that there is currently no literature available in this field to inform whether anatomical variation is important for improving outcomes in simulation based surgical training. Secondly, methods were developed to identify internal anatomical structure variation of temporal bones by examining the bony surface landmarks in an effort to guide the selection of specimens that exhibit differences in anatomy. To this end, correlations between internal and external landmarks were determined and mathematical models developed to predict internal structure variation given combinations of multiple external landmarks using a library of CT scans. It was observed that these correlations and mathematical models were able to predict some anatomical variations with a high level of accuracy. Thirdly, to standardize the evaluation of competence in cochleostomy, an objective assessment tool was developed and validated. Its construct validity and inter-rater reliability were established to be high through evaluations of resident and expert performances on a standardized virtual temporal bone conducted by expert assessors using the proposed tool. Lastly, a randomised controlled trial of ENT residents performing cochleostomy was conducted to determine whether anatomical variation in virtual reality simulation based training improved surgical performance. Participants were randomly allocated to two groups: the experimental group who were exposed to a six different temporal bone anatomies over a period of three weeks and the control group who were trained on one standardized temporal bone over the same period of time. At the end of the training period participants’ performance on two novel temporal bones was assessed. It was observed that ENT residents who were exposed to a range of anatomical variations performed significantly better than those trained on a single anatomical model.
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ItemValidation of virtual reality temporal bone simulators in otolaryngology training( 2010)Background: The training of surgeons is a critically important issue for the health care system. While the traditional method of surgical training continues to serve the health care system well, there are many forces both within surgery and in society that are seeking to improve the training of surgeons of the future. Virtual reality simulations have played a major part in the training of the airline industry and the military but its use in otology surgical training has not been fully elucidated. This thesis aims to investigate the role of virtual reality simulation in temporal bone surgical training by testing i) its construct validity, ii) the transferability of skills, iii) to develop an “intelligent” tutor in the virtual reality simulation and iv) to compare self-directed virtual reality simulation training to traditional teaching methods on the performance of cadaver temporal bone dissection. Results: It was found that the University of Melbourne virtual reality temporal bone simulator had construct validity and was able to differentiate not only between experts and novices participants but also intermediate residents. Using it as a teaching tool by a senior otologist it was demonstrated that participants perform better in cadaver temporal bone dissection compared with traditional teaching methods in a randomized control trial. Finally, it was found that the simulator could be used as an “intelligent tutor” independent of expert supervision to teach novice trainees the fundamentals of temporal bone surgery. Once again in a randomized control trial, it was found that training on the VR simulator improved cadaveric temporal bone dissection compared with traditional teaching methods. Conclusion: Virtual reality temporal bone simulators could have a significant role in the education of temporal bone dissection. It’s most significant contribution would be towards novice surgical training by allowing early education to occur on a virtual reality simulator independent of consultant supervision. This would provide a more efficient use of the precious educational resources of cadaver temporal bone as well as time needed from consultant surgeons to teach and supervise junior trainees. While there are queries regarding the fidelity of the virtual reality simulation environment, it is important to remember that appropriate fidelity for the designed task is more important than absolute comparison to reality. In this regard the current virtual reality temporal bone simulator has sufficient realism to teach novice trainees the fundamental basic of temporal bone dissection. Future research direction would focus on determining the transfer of skills and knowledge from the virtual reality simulator to operating room performance as well as broadening the use of the virtual reality simulator to other areas such as technical skills assessment and surgical rehearsal.