JOURNAL OF ENDOUROLOGY Volume 19, Number 3, April 2005 Mary Ann Liebert, Inc.

Can Video Games be Used to Predict or Improve Laparoscopic Skills?

BRADLEY H. ROSENBERG, M.D.,1 DOUGLAS LANDSITTEL,2 and TIMOTHY D. AVERCH, M.D.1

ABSTRACT Background and Purpose: Performance of laparoscopic surgery requires adequate handeye coordination. Video games are an effective way to judge ones handeye coordination, and practicing these games may improve ones skills. Our goal was to see if there is a correlation between skill in video games and skill in laparoscopy. Also, we hoped to demonstrate that practicing video games can improve ones laparoscopic skills. Subjects and Methods: Eleven medical students (nine male, two female) volunteered to participate. On day 1, each student played three commercially available video games (Top Spin, XSN Sports; Project Gotham Racing 2, Bizarre Creations; and Amped 2, XSN Sports) for 30 minutes on an X-box (Microsoft, Seattle, WA) and was judged both objectively and subjectively. Next, the students performed four laparoscopic tasks (object transfer, tracing a figure-of-eight, suture placement, and knot-tying) in a swine model and were assessed for time to complete the task, number of errors committed, and handeye coordination. The students were then randomized to control (group A) or training (i.e., video game practicing; group B) arms. Two weeks later, all students repeated the laparoscopic skills laboratory and were reassessed. Results: Spearman correlation coefficients demonstrated a significant relation between many of the parameters, particularly time to complete each task and handeye coordination at the different games. There was a weaker association between video game performance and both laparoscopic errors committed and handeye coordination. Group B subjects did not improve significantly over those in group A in any measure (P 0.05 for all). Conclusion: Video game aptitude appears to predict the level of laparoscopic skill in the novice surgeon. In this study, practicing video games did not improve ones laparoscopic skill significantly, but a larger study with more practice time could prove games to be helpful.

INTRODUCTION

OINCIDING WITH THE INTRODUCTION and expansion of laparoscopy in the past 20 years has been a surge in the interest in, and the complexity of, commercially available video games. Many of todays surgeons (especially younger surgeons) grew up playing video games as a hobby. Casual banter among surgeons has suggested a link between video game playing and surgical skills, as most believe video games can sharpen ones handeye coordination. Intuitively, therefore, it seems that practicing video games could improve ones surgical acumen. Much of todays surgery has become minimally invasive, either endoscopic or laparoscopic, and
1Departments

both types of procedures seem to mimic video games in many ways. With the recent introduction of laparoscopy to most surgical residencies, a need for skill training has developed. Obviously, programs would prefer their residents to begin their laparoscopic experience with less-challenging cases, but urology has been hampered in laparoscopic skills acquisition by the lack of a common beginner operation like cholecystectomy in general surgery. Therefore, programs seek out different models on which their residents may acquire basic laparoscopic skills. Inanimate trainers have been shown by other authors to improve handeye coordination, which could translate into greater laparoscopic skills.1 Different types of trainers are available, from

of 1Urology and 2Biostatistics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

372

VIDEO GAMES AND LAPAROSCOPY cadaver models to elaborate virtual reality (VR) simulators. These models aid the novice laparoscopist in acquiring the skills he or she may find awkward compared with open surgery25 such as compensating for the diminished tactile feedback, operating on a fulcrum, handling laparoscopic instruments ergonomically, and working in three dimensions while looking at a two-dimensional image. It has recently been shown that video-game playing can improve visual skills, but to our knowledge, no one has looked at video games specifically and how they correlate with laparoscopic surgical experience.6 The goal of our study was to take students with no surgical experience and see if video-game acumen correlated with performance in laparoscopic surgery. Moreover, we sought to discover if practicing video games could positively impact ones laparoscopic skill. If game playing does translate into laparoscopic success, it could be an important resource for training programs. Not only could they best choose surgical candidates on the basis of video game-playing history, but also the games could serve as an excellent inexpensive, readily available skill exercise.

373 and knot-tying. They then performed a series of laparoscopic tasks on one of two anesthetized pigs, as approved by the IACUC. The four tasks (object transfer, tracing a figure-ofeight, suture placement, and knot-tying) are described in detail in the Appendix. For each task, the students were evaluated for the time it took to complete the task, the number of errors made, and handeye coordination (1 worst; 5 best) by either an attending urologist or a urology resident.

Day 2
The students were randomized into control (Group A: N 6) and training (Group B; N 5) arms. Students in group B were asked to practice playing any type of video game over the 2-week hiatus between study dates; the amount of time they spent was recorded. These students returned on day 2, and each played 2 hours worth of the same X-box video games they played on day 1. Group A students were asked to refrain from playing any video games over the 2-week period. All 11 students returned to the laparoscopic skills laboratory (session 2), repeated the same four tasks, and were graded.

Statistical analysis SUBJECTS AND METHODS Subjects

Eleven students (nine male, two female) with an average age of 25.7 years (range 2132 years) were recruited from the University of Pittsburgh School of Medicine to take part in this Institutional Review Board-approved study. They completed a questionnaire inquiring about their handedness, career aspirations (i.e., medical or surgical), experience with video games, and experience with laparoscopy. All but one was right-handed. Six aspired to surgical careers; the remainder were not sure. All students had completed large-animal training as required by the Institutional Animal Care and Use Committee (IACUC). The study took place on 2 days 2 weeks apart, each day consisting of two sessions, one video game and one laparoscopic. None of the students had significant laparoscopy experience, and none had played the games used in this study. To determine if a relation exists between video-game aptitude and baseline laparoscopic skills, the Spearman correlation coefficient was utilized. For the video games, the analysis was based on the assessment of handeye coordination in Top Spin, Amped 2, and the Cone Challenge in PGR2 and place finished in Street Race. We calculated correlations between each of these summary measures and each quantitative variable from the four laparoscopic tasks. To look for a training effect on skill level between groups A and B, P values were calculated using the Wilcoxon rank-sum test. Significance for all variables was determined by a P value of 0.05.

RESULTS
Video game experience was minimal, moderate, and extensive in 3, 5, and 3 students, respectively. Spearman coefficients demonstrated a statistically significant correlation between video game experience and video-game performance in two of the four exercises (Cone Challenge and Amped 2).

Day 1: Video game session

After an introductory session to master the joystick and receive instruction on the basics of each game, the students spent approximately 30 minutes playing three commercially available video games (Top Spin, XSN Sports; Project Gotham Racing 2 (PGR2), Bizarre Creations; Amped 2, XSN Sports) on an X-box (Microsoft, Seattle, WA). Game settings were standardized to beginner levels. Each student played one set of tennis in Top Spin, one Street Race and one Cone Challenge on PGR2, and one trip downhill on Amped 2. Their performances were evaluated both objectively by the computer (i.e., wins, crashes, time, points, etc.) and subjectively by an observer (either an attending urologist or a urology resident), who graded the student 1 through 5 on overall handeye coordination (1 worst, 5 best).

Association between video-game performance and laparoscopic skills

Table 1 summarizes the correlations between video game and laparoscopy performance at baseline. The denoted Spearman correlations (*) were statistically significant at P 0.05 or marginally significant at P 0.10 (). The laparoscopic task measurement that best correlated with video game performance was time to complete the objective. Five significant correlations were identified between video games and time, along with two more that were marginally significant. This difference was more pronounced in the simpler tasks (object transfer and figure-ofeight). The more-complex tasks (suturing and knot-tying) showed little difference (only one significant parameter). In terms of number of errors and handeye coordination, for all tasks and all games, there were only two correlations that were marginally significant.

Day 1: Laparoscopic skills lab (session 1)

Next, the students proceeded to the animal laboratory and were familiarized with laparoscopic instrumentation, suturing,

374 TABLE 1. SPEARMAN CORRELATIONS

BETWEEN

ROSENBERG VIDEO GAME

AND

LAPAROSCOPY PERFORMANCE

Video game Laparoscopy operation Object transfer Time needed No. errors Handeye* Figure-of-eight Time needed No. errors Handeye* Suture Time needed No. errors Handeye* Knot tying Time needed No. errors Handeye*
aSkill bSkill

Top Spina 0.73* 0.005 0.11 0.64* 0.0 0.27 0.27 0.40 0.32 0.40 0.10 0.25

Street Raceb 0.58 0.13 0.09 0.47 0.32 0.16 0.23 0.47 0.45 0.26 0.27 0.45

Cone Challengea 0.53 0.12 0.23 0.50 0.16 0.51 0.13 0.38 0.42 0.37 0.0 0.04

Amped 2a 0.68* 0.39 0.38 0.60* 0.0 0.64 0.36 0.49 0.54 0.63* 0.20 0.13

*p p

assessed via handeye coordination rating: 1 (worst) to 5 (best). assessed via place finished: 1 (best) to 6 (worst). 0.05. 0.10.

Effect of video-game training on changes in laparoscopic skills

The baseline characteristics of groups A and B showed no significance in video-game performance or laparoscopic skill (Table 2; P values all 0.20). Students in group B spent an average of 6.2 hours training (i.e., practicing video games) over the 2-week period (range 2.59 hours). No student in group A played any video games during that time. Table 2 lists the results of the laparoscopic skills laboratory broken down by group and session. In the group as a whole, the time taken to complete each task improved on average from session 1 to session 2, but this change was significant only for object transfer and knot-tying. The number of errors committed and the handeye coordination rating for the whole group did not change significantly between the two sessions. The mean change for each skill was calculated by subtracting the baseline measure from the follow-up measure. A positive number thus represents an increase in the measure from baseline to follow-up; a negative number represents a decrease from baseline to follow-up. Group B improved no more than group A (P 0.25) in any measure. Only one measure showed significance, where the control group actually showed an improvement over the training group in knot-tying errors committed.

DISCUSSION
With the current widespread use of laparoscopic and endoscopic surgery, attention throughout the surgical literature has turned to methods of training surgeons in these techniques. Certainly, laparoendoscopic surgery does require a skill set much different than that of open surgery, and many surgeons may not

feel innately comfortable with these. Subramonian and associates7 showed that laparoscopic-skill acquisition is in fact more difficult than that for open surgery, further validating the need for training. Laparoscopic surgery requires a surgeon to think in three dimensions while looking at a two-dimensional image. Additionally, he or she is operating on a fulcrum with limited tactile feedback. Because these skills are so foreign to many, trainers have been employed in an attempt to reduce the risk associated with initial laparoendoscopic surgical experience. Trainers not only help with skills acquisition in current surgical trainees but also may aid programs in selecting resident candidates. On that topic, Gettman and colleagues8 found that basic human performance resources could be used to predict laparoscopic performance. In other words, a surgeons innate laparoscopic ability could be predicted by measuring objectives such as visual information-processing speed, upper-extremity steadiness, and isometric strength. Many laparoendoscopic trainers are now available, including everything from cadavers to both low- and high-fidelity bench models and VR simulators. A ureteroscopy simulator (URO Mentor; Simbionix Ltd, Lob, Israel) has been found to result in rapid skills acquisition for novice trainees.2 A VR simulator (Minimally Invasive Surgical Trainer in Virtual Reality [MIST-VR]) has proven capable of distinguishing between experienced surgeons and novices.3 It likewise provides for rapid acquisition of skills in many beginners. Matsumoto and coworkers4 determined that any hands-on training, whether it was on a low- or a high-fidelity model, improved performance more than a simple didactic session. So it does appear conclusive that students quickly improve their skills when operating on models. But does that necessarily translate into an actual operative procedure? Few studies have looked at trainers and how they impact eventual live surgery, and so far, the results have been

VIDEO GAMES AND LAPAROSCOPY TABLE 2. LAPAROSCOPIC SKILL RESULTS BROKEN DOWN
BY

375 GROUP
AND

SESSION

Mean times Skill Object transfer Time (secs)a Errors Handeye Figure-of-eight Time Errors Handeye Suturing Time Errors Handeye Knot-Tying Timea Errors Handeye
aSignificant

Group Control Training Control Training Control Training Control Training Control Training Control Training Control Training Control Training Control Training Control Training Control Training Control Training

Session 1 (t1) 61 47 0.7 1.4 3.5 3.8 67 40 0.2 0 3.5 3.8 181 108 1.7 1.6 2.8 3.6 139 116 1.3 0.6 3.7 4.2

Session 2 (t2) 30 27 0.3 0.8 3.5 3.8 37 20 0.5 0.6 2.7 3.2 179 96 2.8 2.4 2.3 3.0 75 68 1.0 1.8 3.3 3.2

Change (t2 t1) 31 20 0.4 0.6 0 0 30 20 0.3 0.6 0.8 0.6 2 12 1.1 0.8 0.5 0.6 64 48 0.3 1.2 0.4 1

Range 78, 7 44, 7 1, 1 4, 1 1, 2 2, 3 199, 38, 1, 0.0, 3, 3, 305, 106, 0, 2, 1, 2, 135, 140, 2, 0, 1, 2, 13 2 2 2.0 1 1 283 155 2 7 0 1 48 60 0 2 1 1

improvement (P 0.05) by the Wilcoxon signed-rank test for the whole group in the given skill from session 1 to session 2. No measure of any task showed significant improvement for the training group over the control group.

mixed. Traxter et al9 concluded that in vivo training is what matters most. They found that students who practiced on an inanimate box trainer performed porcine laparoscopic nephrectomy no better than those without the extra training. On the other hand, Grantcharov and associates5 had better results using the MIST-VR. They convincingly showed that surgical residents trained on a VR simulator performed live laparoscopic cholecystectomy better than a control group.5 Likewise, Whitted and coworkers10 found that formal laparoscopic training of gynecologic residents led to better patient outcomes. The perceptual learning that takes place with these models tends to be specific to the task.6 The more realistic the model, supposedly, the more useful it is. That may also explain why a VR simulator would prove more important than an inanimate box trainer. This result would imply, for instance, that playing a car-racing video game would not necessarily improve ones laparoscopic suturing ability. Therefore, most of the models are designed to replicate laparoendoscopic surgery as closely as possible. Commercial video games, on the other hand, would provide perceptual learning, namely, improvement in handeye coordination, rather than discrete task training like that provided by VR simulators. Despite their attractiveness as a model, in view of their widespread availability and low cost, video games

cannot train a surgeon as well as VR can. A VR simulation, however, is not without its own inherent weaknesses, namely the current smoothness of the image, the lack of haptic feedback, and certainly cost.11 Video games improve ones visual skills. Green and Bavelier6 showed that habitual video-game players possess enhanced attentional capacity. Moreover, those investigators showed that nonplayers improved their visual attention after video-game training. This would suggest that game playing may improve surgical skills, but to our knowledge, no one had yet applied this idea to laparoscopy specifically. We sought to discover if video-game aptitude predicted performance in a live laparoscopic model and whether the perceptual learning one gains from playing video games can translate into improvement in laparoscopic skills. Our study did demonstrate some evidence of moderate to strong correlations between video-game performance and skill in laparoscopy, which goes along with our prediction. This was most evident in the simpler laparoscopic drills (object transfer and figure of eight). The more complex tasks proved daunting to all the students, not just the weak video gamesters. Time to complete the task correlated best with video-game skill, more so than the number of errors committed or handeye coordina-

376 tion. Lack of significant p values in many cases appears to be a consequence of the small sample size. Our data show that practicing video games does not seem to improve ones laparoscopic skills significantly. Overall, there was improvement in session 2 compared with session 1, most notably in terms of time, but no parameter showed significant improvement for group B over group A. It was our hypothesis that extensive video gaming would lead to significant improvements in laparoscopy; however, both groups improved equally in session 2, at least in terms of procedure time. Admittedly, the sample size here is small, and the training period was short. Perhaps a larger study with more intense training would demonstrate a significant difference between the two arms. It appears more likely that actual laparoscopic experience or highly realistic simulation of laparoscopy is the only way to gain laparoscopic aptitude. This is consistent with the conclusions drawn by previous investigators.5,9 Certain limitations of this study should be discussed. The small sample size limits statistical significance in many cases. Our goal was 24 subjects, which was determined to provide adequate power for the analysis, but we could recruit no more than 11. Also, longer training is liable to create a greater training effect. Naturally, it is difficult for busy students to spend much time playing video games during the academic year. Also, the laparoscopic observers were not blinded to the training status of the subject. This could have affected the handeye coordination assessment, but it should not affect either time required or errors committed. In order to simplify comparisons between video game performance and laparoscopic skill, only one variable from each video game was utilized (handeye coordination in three of four). Incorporating more measures from the video games would likely be more thorough, but we opted to use the one best summary measure for each.

ROSENBERG turing techniques, a suture needle is picked up off the bowel, adjusted appropriately within the needle driver, driven through a segment of small bowel, and pulled out the other side. Task 4: Knot tying. Using the suture just placed through the bowel, a single knot is tied by the instrument-tie technique.

ACKNOWLEDGMENTS
We are grateful to the following individuals for their help and participation in this study: Hugh Perkin, Benjamin Davies, Robert Stein, Zachary Zuniga, Danielle Sweeney, and Glenn Cannon.

REFERENCES
1. Tsai CL, Heinrichs WL. Acquisition of eyehand coordination skills for videoendoscopic surgery. J Am Assoc Gynecol Laparosc 1994;1(4 part 2):S37. 2. Watterson JD, Beiko DT, Kuan JK, et al. A randomized, prospective blinded study validating the acquisition of ureteroscopy skills using a computer based virtual reality endourological simulator. J Urol 2002;168:1928. 3. Gallagher AG, Lederman AB, McGlade K, et al. Discriminative validity of the Minimally Invasive Surgical Trainer in Virtual Reality (MIST-VR) using criteria levels based on expert performance. Surg Endosc 2004; 2004;18(4):660665. 4. Matsumoto ED, Hamstra SJ, Radomski SB, et al. The effect of bench model fidelity on endourological skills: A randomized controlled study. J Urol 2002;167:1243. 5. Grantcharov TP, Kristiansen VB, Bendix J, et al. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91:146. 6. Green CS, Bavelier D. Action video game modifies visual selective attention. Nature 2003;423:534. 7. Subramonian K, DeSylva S, Bishai P, et al. Acquiring surgical skills: A comparative study of oepn versus laparoscopic surgery. Eur Urol 2004;45:346. 8. Gettman MT, Kondraske GV, Traxer O, et al. Assessment of basic human performance resources predicts operative performance of laparoscopic surgery. J Am Coll Surg 2003;197:489. 9. Traxter O, Gettman MT, Napper CA, et al. The impact of intense laparoscopic skills training on the operative performance of urology residents. J Urol 2001;166:1658. 10. Whitted RW, Pietro PA, Martin G, et al. A retrospective study evaluating the impact of formal laparoscopic training on patient outcomes in a residency program. J Am Assoc Gynecol Laparosc 2003;10:484. 11. Kuo RL, Delvecchio FC, Preminger GM. Virtual reality: Current urologic applications and future developments. J Endourol 2001; 15:117.

CONCLUSIONS
Video games do improve ones handeye coordination, and they appear to predict inherent laparoscopic skill. Practicing, however, does not seem to offer a way to improve these skills. At this point, the best way to improve as a laparoscopist appears to be by practicing laparoscopy itself or working on a realistic simulator. A larger-scale study is indicated to understand conclusively what if any role video games may play in laparoscopic surgery.

APPENDIX
Task 1: Object transfer. An 11-mm round rubber washer is picked up off the sigmoid colon with one grasping instrument, transferred into the grasper in the surgeons other hand, and placed on the liver on a spot cauterized with an X. Task 2: Cauterize a figure-of-eight. With the surgeons dominant hand, a figure-of-eight is cauterized on the pigs abdominal sidewall. Task 3: Suturing of bowel. Using free-hand laparoscopic su-

Address reprint requests to: Timothy Averch, M.D. Dept. of Urology University of Pittsburgh 3471 Fifth Ave., Suite 700 Pittsburgh, PA 15213 E-mail: averchtd@upmc.edu