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Introduction The Simbionix (Tel Hashomer, Israel) GI-Mentor is an in-teractive computerized simulator, designed to provide medical experts with hands-on training for endoscopic procedures. The system uses a specially designed mannequin and a computer simulation program, utilizing a texture-mapped simulation of the endoluminal view, combined with a force-feedback mechanism and a real Pentax colonoscope to mimic the look and feel of an actual endoscopy procedure. The simulator may potentially replace the initial phase of endoscopists' training, but for this to happen, the trainees themselves must agree that the simulator session is indeed worthwhile in terms of ease of use, realism, and technical challenges. The aim of the present study was to assess user satisfaction in a realistic training setting. Materials and Methods The Simbionix simulator was made available to the participants in our annual SADE (Scandinavian Association for Digestive Endoscopy) course in advanced gastrointestinal endoscopy [1]. This course comprises a 3-day hands-on period at various Scandinavian endoscopy centers, and 2 days of summarizing lectures, video cases, and expert discussions. During this summary session, the simulator was installed just outside the lecture hall, and the course participants were repeatedly encouraged to use this opportunity to test the simulator. After a brief introduction by a Simbionix technician, each course participant completed at least one full case of colonoscopy training (Figure 1). Directly after the exercise, all users were asked to complete a simple questionnaire. The questions included direct feed-back on the simulator experience, as well as some background information on the users themselves. Altogether, 33 course participants completed the questionnaire. Most of the participants were in the initial phase of their endoscopy training, having performed fewer than 200 colonoscopies (58 %), while 18 % had done more than 500 procedures. This was emphasized by the fact that only eight (24 %) had done more than 20 endoscopic retrograde cholangiopancreatographies. Results Figure 2 summarizes the assessment of realism of the course participants. All participants concluded that the visual environment and the clinical scenarios depicted were realistic or very realistic. The mechanical simulation, primarily relating to the force-feedback implementation, was deemed not realistic by seven (21 %) and very realistic only by one of the respondents. This may be partly linked to the assessment of difficulty; 29/33 participants felt the simulator to be easier to complete than a real colonoscopy (Figure 3). Judging from the free-text comments offered on the response sheets, it appears that the lack of proper simulation of loop formation was the main issue of complaint. Still, 91 % of the participants concluded that the simulator would be very (52 %) or somewhat (33 %) useful in their training, and 61 % indicated that it would have a potential role in training and recertification of doctors. A similar response was given in relation to training of nurses: only three participants felt the simulator would have no role in this group. The impression of usefulness related to the respondent's experience in colonoscopy is shown in Figure 4. It shows, importantly, though not surprisingly, that the usefulness of the simulator was rated highest by the least experienced participants. However, users at every level of experience did report a certain degree of usefulness. |
Figure 1 One of the participants testing the simulator
for the first time.
Figure 2 Simulator realism as Figure
3 Assessment of
assessed by the participants (n=33). complexity
with regard to real- life
procedures (n=33).
Figure 4 Usefulness assessment related to participants'
level of
experience (n=33).
Discussion
Increasing demands from patients, increasing needs for trained endoscopists, and increasing requirements for objective measurements of competence all serve to define a role for endoscopic simulators for training. The patient, the physician, and the payers will benefit from a preclinical endoscopy training by computer simulation. Until recently, however, the complexity of a colonoscopy "look and feel" has been unachievable within acceptable cost, and initial attempts have been expensive and mostly useless prototypes, never seen commercially available. Various mechanical models have been suggested, including a board-mounted "vacuum-cleaner tube", but very few of the aspects of a real colonoscopy were accurately rendered with such models.
The rapid development in affordable computer power, together with advanced 3-D modeling software and surface-rendering techniques, has changed the situation substantially. Fuelled by the commercial potential in gaming software for such advances, these techniques have been applied by a number of ingenious small groups in medical training systems. Simbionix is one of several companies developing systems for gastrointestinal endoscopy, with a version already available for commercial distribution.
However, before these systems can enjoy general acceptance, solid testing in a relevant context is crucial. We applied the system to such a setting, offering it to participants in a hands-on endoscopy training course. The number of evaluable procedures is limited, but we still believe that the feedback offered gives a valid impression of the user acceptance.
The visual experience was generally regarded as good, as were the clinical scenarios depicted. The mechanical part, utilizing advanced force-feedback algorithms, still has a way to go, but the mere inclusion of a "feel" aspect of the procedure is a major step forward, together with the use of a real endoscope. Loop formation is still insufficiently modeled in the computer, and probably requires even more sophisticated algorithms than the ones presently applied. In addition, a number of the participants indicated that the introduction of the instrument was too "easy", allowing a continuous push technique not generally successful in real life. This type of feedback is obviously necessary for the continued development of the software. However, considering the rapid progress in other areas of software development, it is probably only a matter of time before these areas improve, given the excellent platform of an endo-scope, a computer with a screen, and the introduction of force-feedback support.
Simulators, by definition, cannot surpass real-life experience. That is, however, not the issue. The participants in this survey generally saw an important place for endoscopy simulators in training and recertification. We agree, and we believe that active participation on the part of endoscopists at all levels of training is vital to ensure an optimal further development of this and other similar systems.
Acknowledgments
We thank Simbionix for making the GI-Mentor system available for this survey.
References
1 Aabakken L, Osnes M, Rosseland AR, et al. Hands-on endoscopy training; an evaluation of the SADE endoscopy course. Endoscopy 1994; 27: 66 - 69
Corresponding Author
L. Aabakken, M.D., Ph.D., B.C.
Medical Dept. A
Rikshopitalet
0027 Oslo
Norway
Fax: + 47- 2307- 2008
E-mail: larsaa@klinmed.uio.no
Endoscopy 2000; 32 (11): 911-
913
© Georg Thieme Verlag Stuttgart
New York
ISSN 0013-726X
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