GI Mentor Validation Studies

The following abstract was presented at the Annual Meeting of the Digestive Disease Week (DDW) May 17 - 22, 2008. San Diego Convention Center, San Diego, CA, USA

Face and Construct Validity of a Computer-Based VirtuaL Reality Simulator for Endoscopic Retrograde Cholangiopancreatography

James G. Bittner, Obinna Ezeamuzie, Toufic Imam, Bruce V Macfadyen, Robert R. Schade, John D. Mellinger

Medical College of Georgia Augusta, Georgia, USA

Introduction: The American Society For Gastrointestinal Endoscopy encourages curriculum-based simulator use for endoscopir retrograde cholangiopancreatography (ERCP) training, though little data currently exist related to this recommendation. The study aim was to determine face and construct validity of a high-fidelity ERCP simulator and to assess its perceived utility as a training tool.
Methods: Twelve subjects were grouped into novice (n = 4 < 25 ERCPs), intermediate (n = 4; 100-200 ERCPs), and expert (n = 4; >200 ERCPs) skill levels. After 30 minutes of monitored practice to ensure simulator familiarity, subjects completed two cases. Case 1 requires stent placement with optional sphincterotomy for cystic duct leak. Case 2 involves common bile duct brushing and balloon dilation for stricture plus sphincterotomy and stent placement for duct decompression. Performance measures include times to complete procedure, reach papilla, and apply flouroscopy; number of attempts to cannulate the papilla, pancreatic duct, and common bile duct; number of contrast injections; use of endoscopic tools, and complications. By online survey, subjects assessed the graphics, procedural accuracy, difficulty, and haptics, plus overall realism and training potential of the simulator using Likert-type scales. Data are given as medians and analyzed using proper nonparametric tests.
Results: Age, postgraduate year, and prior endoscopy and ERCP experience positively correlate with skill level (all p < 0.001). There was no difference between groups with regard to gender, handedness, or interest in ERCP. For all cases combined, total procedure time differed across novices (607 sec), intermediates, and experts (332 sec; P = 0.009). For the same measure, Case I differentiated all skill levels (p = 0.024) while Case 2 distinguished only novice from expert (487 sec. 273 sec; p = 0.043). Across all skill levels and regardless of interest in ERCP opinions were similar regarding graphics (moderately realistic), accuracy (similar to real procedure), difficulty (somewhat less difficult), overall realism (moderately realistic), and haptics. As skill level decreased, subjects felt the haptics were comparable to real ERCP (p < 0.001). Subjects (67%) believe the simulator has definite training potential.
Conclusions: The two simulated cases on the Gl Mentor II differentiate novice, intermediate, and expert skill levels (construct validity) for FRCP based on total procedure time. The majority of subjects felt the simulated graphics, procedural accuracy and overall realism exhibit face validity, though haptics seemed most appreciated by novices. In addition, subjects believe it is- useful training tool.

The following abstract was presented at the Annual Meeting of the Digestive Disease Week (DDW) May 17 - 22, 2008. San Diego Convention Center, San Diego, CA, USA

Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for GI Fellow Trainees in Colonoscopy.

JR Lightdale, ME Fredette, PA Rufo, VL Fox, JR Saltzman, JM Poneros

Division of Gastroenterology, Children's Hospital Boston, Boston, Massachusetts, USA.

The Simbionix GI Mentor II Endoscopy Simulator is designed to provide detailed feedback, including time to anatomic landmarks, intraprocedural patient discomfort, and visualization of the mucosa. While construct validation studies have shown that the GI Mentor II can distinguish beginners from experts, its capacity to discriminate between
fellows in a 3-year training program is unknown.
AIM: To determine whether feedback measures provided by the GI Mentor II differ between 1st and 3rd year fellows.
METHODS: Fellows in their 1st and 3rd years of training at Children's Hospital Boston and the Brigham and Women's Hospital were invited to record colonoscopies (6/06 - ll/07) on a GI Mentor II. Fellows were instructed to reach the cecum as quickly as possible, while visualizing the entire mucosa and avoiding colonoscopic looping. Patient discomfort was defined as the # and % duration of procedure time excessive loops were
formed causing local pressure. Other simulator parameters included % time spent with clear view of the lumen, and # of times view of the lumen was lost.
RESULTS: 16 GI Trainees (10 1st Yrs, 6 3rd Yrs; 9 male; median age 32 yrs (IQR 29, 35)) recorded a total of 63 simulated colonoscopies. No differences were found between groups in # pediatric fellows (80% vs. 50%, p= .225), nor median # of simulations (1st Yr: 3 (IQR (2,7) 3rd Yr: 3 (3, 5). P=0.865). 1st year fellows did not spend more total time per simulated procedure than 3rd year fellows (13 min (9, l9) vs. 9 (8, l5). P=0.084), but did take longer to reach the cecum (7 min (4, 11) vs. 3 (2, 6), p=0.002). Few fellows formed excessive loops (1st Yrs: 0 (0, l); 3rd Yrs: 0 (0, l), p=0.383), and there was no difference in "virtual" patient discomfort (1st Yr: 1% procedural time in pain (0, 5); 3rd Yr: 0% (0,2), P= .108). 1st and 3rd year fellows did not differ in terms of their propensity to lose view of the lumen (1 time (0,2) vs. 0 (0,1), p=0.102), but 1st Yrs spent less time visualizing the entire mucosa (1st Yr: 84% (77,88) vs. 3rd Yr: 89% (8I,91), p= .011) and were less efficient in screening as calculated by the simulator (64% (39, 81) vs. 84o/o (64,89), p= .006).
CONCLUSIONS: Test parameters concerning time to anatomic landmarks and visualization of the mucosa generated by the GI Mentor II Endoscopy Simulator can discriminate between 1st and 3rd year GI fellows. Although the simulator did not detect differences in patient comfort, our findings suggests progression in endoscopy skills over a 3 year fellowship training period. Further study is needed to understand how performance enhancement on simulator measures translates into improved endoscopy in live patients.

The following abstract was presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) April 9- 12, 2008, Pennsylvania Convention Center, Philadelphia, PA, US

The Influence of Simulator Feedback on the Colonoscopy Performance Curve

S.N. Buzink H.G. Baan1, J.D. Degenaar1, K.A.Y. van Mourik1, J.J. Jakimowicz

Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands.
Catharina Hospital, Eindhoven, The Netherlands.

BACKGROUND: Pre-clinical training of fundamental colonoscopy skills is important to safeguard patient safety. The objective was to investigate the influence of simulator feedback on the colonoscopy performance curve on the Simbionix GI Mentor II VR simulator.
METHODS: Thirty medical trainees (no flexible endoscopy experience) performed four preset training sessions within one week. Each session comprised one EndoBubble L1 task and multiple VR colonoscopies (two in first session, three in subsequent sessions), with the assignment to accomplish the task as quick as possible, while causing as little patient discomfort as possible. VR colonoscopy I-3 was repeatedly performed as last VR colonoscopy in each session. Group F (N=15) performed the VR colonoscopies in ‘Full Screen Mode’ and group T (N=15) in ‘Training Mode’, which provides additional visual information on the level of patient discomfort and on-screen tips and warnings.
RESULTS: Both groups improved their performances significantly, particularly for the time to accomplish the tasks (Friedman’s ANOVA, p≤.001). Between the groups, the performances differed considerably on several aspects, particularly in the first session (Mann-Whitney U, p≤.05). And overall, Group F performed the tasks with considerable better scores on the parameters ‘percentage of time the patient was in pain’ and the ‘percentage of time with clear view’.
CONCLUSIONS: In Training Mode, trainees appear to be inclined to take slightly more risks and operate closer to the verge of patient discomfort than in Full Screen Mode. The added value of the supplementary feedback could be superseded by the dispersion of attention.

Expert and construct validity of the Simbionix GI Mentor II endoscopy simulator for colonoscopy.

Koch AD, Buzink SN, Heemskerk J, Botden SM, Veenendaal R, Jakimowicz JJ, Schoon EJ.
Department of Gastroenterology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.

Surg Endosc. 2008 Jan;22(1):158-62.

OBJECTIVES: The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.
METHODS: Four groups were selected to perform one hand-eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200-1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.
RESULTS: Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).
CONCLUSION: In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.

Acquiring basic endoscopy skills by training on the GI Mentor II

Buzink SN, Koch AD, Heemskerk J, Botden SM, Goossens RH, de Ridder H, Schoon EJ, Jakimowicz JJ.
Faculty of Industrial Design Engineering, Delft University of Technology,
Landbergstraat 15, 2628 CE, Delft, The Netherlands.

Surg Endosc. 2007 Nov;21(11):1996-2003.

BACKGROUND: Achieving proficiency in flexible endoscopy requires a great amount of practice. Virtual reality (VR) simulators could provide an effective alternative for clinical training. This study aimed to gain insight into the proficiency curve for basic endoscope navigation skills with training on the GI Mentor II.
METHODS: For this study, 30 novice endoscopists performed four preset training sessions. In each session, they performed one EndoBubble task and managed multiple VR colonoscopy cases (two in first session and three in subsequent sessions). Virtual reality colonoscopy I-3 was repeatedly performed as the last VR colonoscopy in each session. The assignment for the VR colonoscopies was to visualize the cecum as quickly as possible without causing patient discomfort. Five expert endoscopists also performed the training sessions. Additionally, the performance of the novices was compared with the performance of 20 experienced and 40 expert endoscopists.
RESULTS: The novices progressed significantly, particularly in the time required to accomplish the tasks (p < 0.05, Friedman's analysis of variance [ANOVA], p < 0.05, Wilcoxon signed ranks). The experts did not improve significantly, except in the percentage of time the patient was in excessive pain. For all the runs, the performance of the novices differed significantly from that of both the experienced and the expert endoscopists (p < 0.05, Mann-Whitney U). The performance of the novices in the latter runs differed less from those of both the experienced and the expert endoscopists. CONCLUSIONS: The study findings demonstrate that training in both VR colonoscopy and EndoBubble tasks on the GI Mentor II improves the basic endoscope navigation skills of novice endoscopists significantly.

Expert and construct validity of the Simbionix GI Mentor II endoscopy simulator for colonoscopy.

Koch AD, Buzink SN, Heemskerk J, Botden SM, Veenendaal R, Jakimowicz JJ, Schoon EJ.

Department of Gastroenterology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands

Surg Endosc. 2007 May 22;

OBJECTIVES: The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.
METHODS: Four groups were selected to perform one hand-eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200-1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.
RESULTS: Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).
CONCLUSION: In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.

Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy

Cohen J, Cohen SA, Vora KC, Xue X, Burdick JS, Bank S, Bini EJ, Bodenheimer H, Cerulli M, Gerdes H, Greenwald D, Gress F, Grosman I, Hawes R, Mullen G, Schnoll-Sussman F, Starpoli A, Stevens P, Tenner S, Villanueva G.

Gastrointest Endosc. 2006 Sep;64(3):361-368

Current affiliations: NYU School of Medicine, New York, NY (Drs J Cohen and Vora); Beth Israel Medical Center, New York, NY (Drs SA Cohen and Bodenheimer); Albert Einstein College of Medicine, Bronx, NY (Dr Xue); University of Texas Southwestern, Dallas, Tex (Dr Burdick); Long Island Jewish Hospital, New Hyde Park, NY (Dr Bank); NYU Medical Center, New York, NY (Drs Bini and Villanueva); Brooklyn Hospital, Brooklyn, NY (Dr Cerulli); Memorial Sloan Kettering, New York, NY (Dr Gerdes); Montefiore Hospital, Bronx, NY (Dr Greenwald); Winthrop Hospital, Mineola, NY (Dr Gress); Long Island City Hospital, Long Island City, NY (Dr Grosman); Medical University of South Carolina, Charleston, SC (Dr Hawes), North Shore Hospital, Manhasset, NY (Dr Mullen); Cornell University Hospital, New York, NY (Dr Schnoll-Sussman); St. Vincent's Hospital, New York, NY (Dr Starpoli); Columbia University, New York, NY (Dr Stevens); and Maimonides Hospital, Brooklyn, NY (Dr Tenner).
BACKGROUND: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience. OBJECTIVE: To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy.
DESIGN: Randomized, controlled, blinded, multicenter trial. SETTING: Academic medical centers with accredited gastroenterology training programs. PATIENTS: First-year GI fellows. INTERVENTIONS: Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure. MAIN OUTCOME MEASUREMENTS: A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time.
RESULTS: Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar.
CONCLUSIONS: Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.

Simbionix simulator.

Bar-Meir S.

Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.

Gastrointest Endosc Clin N Am. 2006 Jul;16(3):471-8

The GI Mentor (Simbionix, Lod, Israel) is a computer-based simulator used for training in endoscopy. It contains modules for training in hand-eye coordination, upper and lower gastrointestinal endoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. It provides experience in the steering and torque of the endoscope, suction, and inflation, a realistic view through the monitor, and a realistic force feedback when performing the procedure. Its advantages include its availability for training with no need for previous preparation and the constant interaction with the trainee. It is costly, however, and presently is suitable only for the initial steps of training.

Perceptual, visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator.

Ritter EM, McClusky DA 3rd, Gallagher AG, Enochsson L, Smith CD.

E*STAR Laboratory, Emory Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA, and Center for Advanced Medical Simulation, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.

Am J Surg. 2006 Sep;192(3):379-84

BACKGROUND: Trainees acquire endoscopic skills at different rates. Fundamental abilities testing could predict the amount of training required to reach a performance goal on a virtual-reality simulator. METHODS: Eleven medical students were tested for fundamental abilities. Baseline endoscopic proficiency was evaluated with the GI Mentor II VR simulator (Simbionix, USA, Cleveland, OH). Subjects trained on the simulator with a defined performance goal. Subjects who achieved the goal were then reassessed. RESULTS: All subjects completed at least 10 trials or reached the performance goal. The <10 trial group (n=6) tested better for all fundamental abilities and baseline endoscopic performance than the >10 trial group (n=5). The number of trials required to reach the performance goal correlated significantly with both perceptual (r=.92, P=0.001) and visuospatial ability (r=.76, P=.03). Multiple regression showed strong correlation of all three abilities with duration of training (r=.95, P=.015). CONCLUSIONS: Most of the variability in acquisition of endoscopic skills can be accounted for by differences in fundamental abilities of trainees. Testing of fundamental abilities could help identify trainees who will require additional training to achieve desired performance objectives.

Objective assessment of visuospatial and psychomotor ability and flow of residents and senior endoscopists in simulated gastroscopy.
Enochsson L, Westman B, Ritter EM, Hedman L, Kjellin A, Wredmark T, Fellander-Tsai L.
Surg Endosc:  2006 May 12
Department of Clinical Science Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet and Center for Advanced Medical Simulation at Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden, Lars.Enochsson@karolinska.se.

BACKGROUND: Advanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training. METHODS: Eighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests. RESULTS: Total gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 +/- 0.8 vs 5.5 +/- 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy. CONCLUSIONS: A virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.

Visuospatial abilities correlate with performance of senior endoscopy specialist in simulated colonoscopy.
Westman B, Ritter EM, Kjellin A, Torkvist L, Wredmark T, Fellander-Tsai L, Enochsson L.
Center for Advanced Medical Simulation, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
J Gastrointest Surg. 2006 Apr;10(4):593-9

Visuospatial abilities have been demonstrated to predict the performance of medical students in simulated endoscopy. However, little has been reported whether differences in visuospatial abilities influence the performance of senior endoscopists or whether their vast endoscopy experience reduces the importance of these abilities. Eleven senior endoscopists were included in our study. Before the simulated endoscopies in GI Mentor II (gastroscopy: case 3, module 1 and colonoscopy: case 3, module 1), the endoscopists performed three visuospatial tests: (1) pictorial surface orientation (PicSOr), (2) card rotation, and (3) cube comparison tests that monitor the ability of the tested person to re-create a three-dimensional image from a two-dimensional presentation as well as mentally manipulate that re-created image. The results of the visuospatial tests were correlated to the performance parameters of the virtual-reality endoscopy simulator. The percent of time spent with clear view in the simulated colonoscopy correlated well with the performance in the visuospatial PicSOr (r = -0.75, P = 0.01), card rotation (r = 0.75, P = 0.01), and cube comparison (r = 0.79, P = 0.004) tests. The endoscopists who performed better in the visuospatial tests also were better at maintaining visualization of the colon lumen. Those who performed better in the PicSOr test formed fewer loops during colonoscopy (r = 0.60, P = 0.05). In the technically less demanding simulated gastroscopy, there were no such correlations. The visuospatial tests performed better in endoscopists not playing computer games. Good visuospatial ability correlates significantly with the performance of experienced endoscopists in a technically demanding simulated colonoscopy, but not in the less demanding simulated gastroscopy.

Objective assessment of gastrointestinal endoscopy skills using a virtual reality simulator.
Grantcharov TP, Carstensen L, Schulze S.
Department of Surgical Gastroenterology D, Copenhagen University, Glostrup Hospital, Glostrup, Denmark.
JSLS. 2005 Apr-Jun;9(2):130-3.

BACKGROUND: This study was carried out to validate the role of virtual reality computer simulation as a method of assessment of psychomotor skills in gastrointestinal endoscopy. We aimed to investigate whether the GI Mentor II computer system (Simbionix Ltd.) was able to differentiate between subjects with different experience with GI endoscopy. METHODS: Twenty-eight subjects were included in the study. They were divided into 3 groups according to their experience with GI endoscopy: experienced [group 1, performed > 200 endoscopic procedures, (n = 8)] residents [group 2, performed < 50 endoscopic procedures, (n = 10)] and medical students [group 3, never performed GI endoscopy, (n = 10)]. All participants received identical pretest instruction on the simulator. Assessment of endoscopic skills was performed during a simulated colonoscopy and was based on parameters measured by the computer system: time, percentage of mucosa surface examined, efficiency of screening, time with a clear view, excessive local pressure, pain, time with pain, loop formation, and total time with a loop. RESULTS: Significant differences in performance existed between surgeons in the 3 groups. Experienced surgeons demonstrated best performance parameters, followed by the residents and the medical students. Significant differences in time (Kruskal-Wallis test, P < 0.001), percentage of mucosa surface examined (P = 0.001), efficiency of screening (P = 0.001), time with a clear view (P = 0.001), pain experienced (P = 0.004), time with pain (P = 0.012), loop formation (P < 0.001), time with a loop (P < 0.001), and excessive local pressure (P = 0.001) were demonstrated. Significant differences existed between group 1 and 2 and 1 and 3 (Mann-Whitney test, P < 0.05). Differences between groups 2 and 3 did not reach statistical significance (P > 0.05). CONCLUSIONS: The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates that the GI Mentor measures skills relevant for gastrointestinal endoscopy and can be used in training programs as an assessment tool.

Validation of a flexible endoscopy simulator.
Felsher JJ, Olesevich M, Farres H, Rosen M, Fanning A, Dunkin BJ, Marks JM.
Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, OH, USA.
Am J Surg. 2005 Apr;189(4):497-500.

BACKGROUND: Virtual reality (VR) simulation is a rapidly proliferating adjunct of surgical training. Numerous devices have evolved as educational tools in a variety of fields. Whether these tools can be used for validation of physicians' skills has yet to be determined. The objective of this study was to determine whether the GI Mentor (Simbionix, Lod, Israel) flexible endoscopy simulator construct could distinguish experienced endoscopists from beginners. METHODS: Seventy-five surgical attendings, fellows, and residents were recruited for participation in the study. Two cohorts were used and these groups were selected from 2 separate scientific sessions. Participants completed a standardized questionnaire documenting their endoscopic training and experience. Physicians subsequently were designated as experienced or beginner after their endoscopic training and experience were evaluated. All participants completed 1 of 2 colonoscopic simulations. The GI Mentor objectively evaluated performance on the basis of programmed data points, including the time to reach the cecum, the percentage of mucosa visualized, the completed polypectomy rate, the percentage of time spent in clear view through the lumen, the percentage of time that the patient was in pain, and overall efficiency. RESULTS: In both simulations, experienced endoscopists were more efficient than beginners (.32%/s vs. .26%/s, P=.02; and .53%/s vs. .37%/s, P=.03) and achieved a greater polypectomy rate (78% vs. 43%, P=.03; and 87% vs. 48%, P=.01). Furthermore, experienced endoscopists visualized more of the colonic surface (86% vs. 82%, P=.02) and spent a greater proportion of the time in clear view of the lumen (55% vs. 47%, P=.05) than beginners completing the first simulation. In the second simulation, experienced participants reached the cecum more rapidly than beginners (175 vs. 262 s, P=.01). CONCLUSIONS: The G1 Mentor VR colonoscopy construct appears valid. Significant performance differences were shown between the experienced and beginner cohorts. The beginner participants in this study were all physicians with some degree of endoscopic experience. Therefore, the G1 Mentor distinguished endoscopists of varying experience and exposure. Further validation studies are needed to evaluate the breadth of programs inherent to this simulator and to determine whether it may be used in the future for qualification and certification purposes.

Initial experience using an endoscopic simulator to train surgical residents in flexible endoscopy in a community medical center residency program.
Clark JA, Volchok JA, Hazey JW, Sadighi PJ, Fanelli RD.
Department of Surgery, Berkshire Medical Center, Pittsfield, Massachusetts, USA.
Curr Surg. 2005 Jan-Feb;62(1):59-63

INTRODUCTION: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins. METHODS: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed. RESULTS: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%. CONCLUSIONS: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

Teaching and Testing Surgical Skills On a VR Endoscopy Simulator- Learning Curves and Impact of Psychomotor Training on Performance in Simulated Colonoscopy
Teodor P Grantcharov MD, Andreas Eversbusch MD, Peter Funch-JensenMD Department of Surgical Gastroenterology, Copenhagen University, Glostrup Hospital & Department of Surgery L, Aarhus University Hospital

The abstract was published and presented as part of the poster session at the 2004 SAGES meeting, March 31 - April 3 2004 in Denver , Colorado. Education/Outcomes, Poster P179
This study demonstrates that different learning curves exist for surgeons with different endoscopic background. The familiarization rate on the simulator was proportional to the endoscopic experience of the surgeons. It also demonstrates that a significant effect of psychomotor training on performance in simulated colonoscopy.

Validity and Reliability of a Virtual Reality Upper Gastrointestinal Simulator and Cross Validation Using Structured Assessment of Individual Performance with Video Playback.
Moorthy K, Munz Y, Jiwanji M, Bann S, Chang A, Darzi A.
Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, 10th Floor, QEQM Building, St. Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom.
Surg Endosc. 2004 Feb;18(2):328-33.

BACKGROUND: This study aims to evaluate the ability of an upper gastrointestinal virtual reality simulator to assess skills in endoscopy, and to validate its metrics using a video-endoscopic (VES) technique. METHODS: The 32 participants in this study were requested to undertake two cases on the simulator ( Simbionix , Israel ). Each module was repeated twice. The simulator's metrics of performance were used for analysis. two blinded observers rated performance watching the simulator's playback feature. RESULTS: There were 11 novices (group 1), 11 trainees with intermediate experience (10-50 procedures, group 2), and 10 experienced endoscopists (>200 procedures, group 3). There was a significant difference in the total time required to perform the procedure (p < 0.001), percentage of mucosa visualized (p < 0.001), percentage of pathologies visualized (p < 0.001), and number of inappropriate retroflexions (p = 0.015) across the three groups. The reliability of assessment on the simulator was greater than 0.80 for all parameters. The VES assessment also was able to discriminate performance across the groups (p < 0.001). There was a significant correlation between the VES score and the percentage of mucosa visualized (rho = 0.60; p < 0.001). CONCLUSIONS: The upper gastrointestinal simulator may be a useful tool for determining whether a trainee has achieved a desired level of competence in endoscopy. The next step will be to validate the VES score in real procedures.

Objective Psychomotor Skills Assessment of Experienced and Novice Flexible Endoscopists with a Virtual Reality Simulator.
Ritter EM, McClusky DA 3rd, Lederman AB, Gallagher AG, Smith CD.
Emory Endosurgery Unit, Emory University School of Medicine, Atlanta, Georgia 30322, USA .
J Gastrointest Surg. 2003 Nov;7(7):871-7; discussion 877-8.

The objective of this study was to determine whether the GI Mentor II virtual reality simulator can distinguish the psychomotor skills of intermediately experienced endoscopists from those of novices, and do so with a high level of consistency and reliability. A total of five intermediate and nine novice endoscopists were evaluated using the EndoBubble abstract psychomotor task. Each subject performed three repetitions of the task. Performance and error data were recorded for each trial. The intermediate group performed better than the novice group in each trial. The differences were significant in trial 1 for balloons popped (P=.001), completion time (P=.04), and errors (P=.03). Trial 2 showed significance only for balloons popped (P=.002). Trial 3 showed significance for balloons popped (P=.004) and errors (P=.008). The novice group showed significant improvement between trials 1 and 3 (P<0.05). No improvement was noted in the intermediate group. Measures of consistency and reliability were greater than 0.8 in both groups with the exception of novice completion time where test-retest reliability was 0.74. The GI Mentor II simulator can distinguish between novice and intermediate endoscopists. The simulator assesses skills with levels of consistency and reliability required for high-stakes assessment.

Flexible Endoscopy Simulator
Dunkin BJ.
Department of Surgery, University of Miami School of Medicine, Miami , Florida 33136 , USA.
Semin Laparosc Surg. 2003 Mar;10(1):29-35

Training in flexible endoscopy is becoming increasingly complex. In an effort to improve the efficiency of endoscopic education, physicians are turning to simulation technology to provide a platform for training away from the endoscopy suite. The concept of medical simulation is not new, but the recent addition of powerful computer-generated virtual reality simulation has revolutionized the field. These compact computers are now able to generate a simulated environment that not only mimics the movement of the endoscope, but also recreates the sounds of the endoscopy suite, the feel of the movement of the scope, the reaction of intestinal tissue, and the response of a patient experiencing discomfort. Within this life-like simulated environment, a wide variety of diagnostic and therapeutic endoscopic procedures can be performed. This article reviews the history of flexible endoscopy simulators and details the most advanced models currently available. The literature supporting the use of these simulators is also presented, and issues involving the incorporation of simulation technology into endoscopic education and credentialing are discussed.

Evaluation of a Virtual Endoscopy Simulator for Training in Gastrointestinal Endoscopy
Ferlitsch A, Glauninger P, Gupper A, Schillinger M, Haefner M, Gangl A Schoefl R
Endoscopy 2002; 34: 698–702

This virtual endoscopy simulator is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. A 3-week training improves the performance of beginners significantly
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The following abstracts on topics involving the GI Mentor™ simulator were published and presented as part of the poster session at the 2003 SAGES meeting, March 12 - 15, 2003 in Los Angeles, CA.

Poster of Distinction–P014

Establishing the Reliability and Validity of a Virtual Reality Upper Gastrointestinal Simulator Using a Novel Video-Endoscopic Assessment Technique. Krishna Moorthy MBBS, Yaron Munz MD, Avril Chang MBBS, Mustafa Jiwanji, Ara Darzi MD, Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, St. Mary’s Hospital, London, UK

This study has established the construct validity of the GI Mentor as a simulator for upper GI procedures which can strongly discriminate between groups with different levels of experience.
A video-endoscopic method developed by the investigators validated the simulator’s assessment parameters.   
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Education/Outcomes–P155

Assessment of GI Endoscopic Skills on a VR Simulator - Validation of
GI MENTOR. Teodor Grantcharov, M.D., Sven Adamsen, M.D., Jacob Rosenberg, M.D., Peter Funch-Jensen, M.D., Departments of Surgical gastroenterology: 1) Aarhus University, Kommunehospitalet 2) University of Copenhagen, Glostrup Hospital 3) University of Copenhagen, Gentofte Hospital 4) University of Copenhagen, Herlev Hospital. Denmark

In this study it was found that the VR simulator Cyberscopy Module was able to differentiate between subjects with different endoscopic experience. This indicates that GI Mentor measures skills relevant for GI endoscopy and can be used in training programs as an assessment tool. Read More >>

Education/Outcomes–P156

Are Technical Skills in Minimally Invasive Surgery and GI Endoscopy Identical? Teodor P. Grantcharov, M.D., Sven Adamsen, M.D., Peter Funch-Jensen, M.D., Jacob Rosenberg, M.D., Departments of surgical gastroenterology: 1) Aarhus University, Kommunehospitalet 2) University of Copenhagen, Glostrup Hospital 3) University of Copenhagen, Gentofte Hospital 4) University of Copenhagen, Herlev Hospital. Denmark

The study provides objective and quantitative evidence of strong correlation between performance scores demonstrated during simulated laparoscopy and GI endoscopy. This indicates that psychomotor skills necessary for the performance of these procedures are identical.   
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Flexible Diagnostic & Therapeutic Endoscopy–P233

Initial Experience Using an Endoscopic Simulator to Train Residents in Flexible Endoscopy in a Community Medical Center Based Residency Program. Robert D. Fanelli, MD, FACS; Mark T. Mainella, DO; Justin R. Clark, DO; Keith S. Gersin, MD, FACS, Surgical Specialists of Western New England, PC, Pittsfield, MA; Berkshire Medical Center, Department of Surgery, Pittsfield, MA; University of Cincinatti, Department of Surgery, Cincinatti, OH.

The conclusions in this study are that endoscopic simulators provide surgical residents with valuable training that allows them to master basic skills quickly, and prepares them to perform GI endoscopy in less time than exposure based learning.   Read More >>

The study shows that compared to expert gastroenterologists, GI nurses with no prior hands-on endoscopy experience required more time to reach the transverse colon, caused more excessive pressure, and received more help from the virtual instructor and the 3-D map. The authors claim that such variables could be used to assess the skills of endoscopy trainees.

Evaluation of a Virtual Endoscopy Simulator for Training in Gastrointestinal Endoscopy
Published in Endoscopy 2002; 34(9): 698-702. A. Ferlitsch, P. Glauninger, A. Gupper, M. S. Schillinger, M. Haefner, A. Gangl, R. schoefl.

The article shows that the GI MENTOR™ is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. In addition, 3 week training improves the performance of beginners significantly.

Basic Endoscopy Training: Usefulness Of A Computer-Based Simulator.
Presented as a Poster at the DDW exhibition on May 22, 2001,
Atlanta, U.S.A
DIEGO FREGONESE, TINO CASETTI, RENZO CESTARI, FAUSTO CHILOVI, GIANCARLO D'AMBRA, GIANFRANCO DELLE FAVE, EMILIO DI GIULIO, GIOVANNI DI MATTEO, LEONARDO FICANO
Cooperative Group for Training in Endoscopy (Endo Teaching Group) - Rome, Italy   Read More >>

Virtual Endoscopy Simulation for Training of Gastrointestinal Endoscopy
Presented as a Poster at the DDW exhibition on May 22, 2001,
Atlanta, U.S.A
Arnulf Ferlitsch, Peter Glauninger, Astrid Gupper, Martin Schillinger, Michael Haefner, Alfred Gangl, Rainer Schoefl
Dept. of Internal Medicine IV, Div. of Gastroenterology and Hepatology,
Univ. of Vienna   Read More >>

A multi-institutional international study evaluating the use of simulation technology to train fellows in colonoscopy is in the process of being conducted by Brian J. Dunkin, M.D. from University of Miami School of Medicine, Jeffrey M. Marks, M.D. from Case Western Reserve School of Medicine and Jeffrey Ponsky, M.D. from CCF. The study which began on July 1, 2002 is planned to last for one year, and includes participation by a number of major medical centers from around the world. The study seeks to show that colonoscopy training of endoscopy fellows on the GI MENTOR simulator measurably improves their performance on real patients, increases patient safety and comfort and shortens the trainee learning curve.

GI Mentor Publications

Developing a computerized simulator for Endoscopic Ultrasound (EUS)
Dr. Stefania Petra, Alexandra Schaeffer and Albert Schaeffer,
PolyDimensions GmbH, Lundgreenstr. 37, 64404 Bickenbach, Germany
Sagi Nachum, Tal Gutterman, Alex Shaharit, Ury Zhilinsky and Mira Barki
Simbionix USA Corporation, 11000 Cedar Ave. Cleveland, Ohio 44106
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The Future of Simulators in GI Endoscopy
An article published in the April issue of Gastrointestinal Endoscopy, poses the question of the future of simulators in GI endoscopy. The article contains a review of current literature reporting studies conducted on at least 2 medical training simulators. Though the article poses a number of yet to be answered questions on how best to employ simulators, it concludes that the initial goals of medical simulation have been achieved, and their future is promising.
Gerson, Lauren B. MD, MSC and Van Dam, Jacques, Ph.D. The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality? Gastrointestinal Endoscopy 4/2002;55: 608-611

Faster and Better
Translated from an article in NYT H:S, a Copenhagen journal for the Hospitals of Copenhagen Hospital Corporation, January 2001.   
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A New Endoscopic Simulator
S. Bar-Meir, Endoscopy 2000;31 (11): 898 - 900
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Performance of a Colonoscopy Simulator: Experience from a Hands-On Endoscopy Course
L. Aabakken, S. Adamsen, A. Kruse, Endoscopy 2000; 32 (11): 911 - 913
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A Simulator for Endoscopic Examinations is now in use at the Institute of Gastroenterology
Translated from "Our Sheba" - The magazine of Sheba Employees, December 2000
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