Access to a simulator is not enough: the benefits of virtual reality training based on peer-group-derived benchmarks--a randomized controlled trial.

BACKGROUND: Virtual reality (VR) simulators are widely used to familiarize surgical novices with laparoscopy, but VR training methods differ in efficacy. In the present trial, self-controlled basic VR training (SC-training) was tested against training based on peer-group-derived benchmarks (PGD-training). METHODS: First, novice laparoscopic residents were randomized into a SC group (n = 34), and a group using PGD-benchmarks (n = 34) for basic laparoscopic training. After completing basic training, both groups performed 60 VR laparoscopic cholecystectomies for performance analysis. Primary endpoints were simulator metrics; secondary endpoints were program adherence, trainee motivation, and training efficacy. RESULTS: Altogether, 66 residents completed basic training, and 3,837 of 3,960 (96.8 %) cholecystectomies were available for analysis. Course adherence was good, with only two dropouts, both in the SC-group. The PGD-group spent more time and repetitions in basic training until the benchmarks were reached and subsequently showed better performance in the readout cholecystectomies: Median time (gallbladder extraction) showed significant differences of 520 s (IQR 354-738 s) in SC-training versus 390 s (IQR 278-536 s) in the PGD-group (p < 0.001) and 215 s (IQR 175-276 s) in experts, respectively. Path length of the right instrument also showed significant differences, again with the PGD-training group being more efficient. CONCLUSIONS: Basic VR laparoscopic training based on PGD benchmarks with external assessment is superior to SC training, resulting in higher trainee motivation and better performance in simulated laparoscopic cholecystectomies. We recommend such a basic course based on PGD benchmarks before advancing to more elaborate VR training.

The future of patient safety: Surgical trainees accept virtual reality as a new training tool.

BACKGROUND: The use of virtual reality (VR) has gained increasing interest to acquire laparoscopic skills outside the operating theatre and thus increasing patients' safety. The aim of this study was to evaluate trainees' acceptance of VR for assessment and training during a skills course and at their institution. METHODS: All 735 surgical trainees of the International Gastrointestinal Surgery Workshop 2006-2008, held in Davos, Switzerland, were given a minimum of 45 minutes for VR training during the course. Participants' opinion on VR was analyzed with a standardized questionnaire. RESULTS: Fivehundred-twenty-seven participants (72%) from 28 countries attended the VR sessions and answered the questionnaires. The possibility of using VR at the course was estimated as excellent or good in 68%, useful in 21%, reasonable in 9% and unsuitable or useless in 2%. If such VR simulators were available at their institution, most course participants would train at least one hour per week (46%), two or more hours (42%) and only 12% wouldn't use VR. Similarly, 63% of the participants would accept to operate on patients only after VR training and 55% to have VR as part of their assessment. CONCLUSION: Residents accept and appreciate VR simulation for surgical assessment and training. The majority of the trainees are motivated to regularly spend time for VR training if accessible.

Correlations between Vocal Input and Visual Response Apparently Enhance Presence in a Virtual Environment

This work investigates novel alternative means of interaction in a virtual environment (VE).We analyze whether humans can remap established body functions to learn to interact with digital information in an environment that is cross-sensory by nature and uses vocal utterances in order to influence (abstract) virtual objects. We thus establish a correlation among learning, control of the interface, and the perceived sense of presence in the VE. The application enables intuitive interaction by mapping actions (the prosodic aspects of the human voice) to a certain response (i.e., visualization). A series of single-user and multiuser studies shows that users can gain control of the intuitive interface and learn to adapt to new and previously unseen tasks in VEs. Despite the abstract nature of the presented environment, presence scores were generally very high.

Is my hand connected to my body? The impact of body continuity and arm alignment on the virtual hand illusion

When a rubber hand is placed on a table top in a plausible position as if part of a person"s body, and is stroked synchronously with the person"s corresponding hidden real hand, an illusion of ownership over the rubber hand can occur (Botvinick and Cohen 1998). A similar result has been found with respect to a virtual hand portrayed in a virtual environment, a virtual hand illusion (Slater et al. 2008). The conditions under which these illusions occur have been the subject of considerable study. Here we exploited the flexibility of virtual reality to examine four contributory factors: visuo-tactile synchrony while stroking the virtual and the real arms, body continuity, alignment between the real and virtual arms, and the distance between them. We carried out three experiments on a total of 32 participants where these factors were varied. The results show that the subjective illusion of ownership over the virtual arm and the time to evoke this illusion are highly dependent on synchronous visuo-tactile stimulation and on connectivity of the virtual arm with the rest of the virtual body. The alignment between the real and virtual arms and the distance between these were less important. It was found that proprioceptive drift was not a sensitive measure of the illusion, but was only related to the distance between the real and virtual arms.

Correlations between vocal input and visual response apparently enhance presence in a virtual environment

This work investigates novel alternative means of interaction in a virtual environment (VE).We analyze whether humans can remap established body functions to learn to interact with digital information in an environment that is cross-sensory by nature and uses vocal utterances in order to influence (abstract) virtual objects. We thus establish a correlation among learning, control of the interface, and the perceived sense of presence in the VE. The application enables intuitive interaction by mapping actions (the prosodic aspects of the human voice) to a certain response (i.e., visualization). A series of single-user and multiuser studies shows that users can gain control of the intuitive interface and learn to adapt to new and previously unseen tasks in VEs. Despite the abstract nature of the presented environment, presence scores were generally very high.

Measuring the effects through time of the influence of visuomotor and visuotactile synchronous stimulation on a virtual body ownership illusion

Previous studies have examined the experience of owning a virtual surrogate body or body part through specific combinations of cross-modal multisensory stimulation. Both visuomotor (VM) and visuotactile (VT) synchronous stimulation have been shown to be important for inducing a body ownership illusion, each tested separately or both in combination. In this study we compared the relative importance of these two cross-modal correlations, when both are provided in the same immersive virtual reality setup and the same experiment. We systematically manipulated VT and VM contingencies in order to assess their relative role and mutual interaction. Moreover, we present a new method for measuring the induced body ownership illusion through time, by recording reports of breaks in the illusion of ownership ("breaks") throughout the experimental phase. The balance of the evidence, from both questionnaires and analysis of the breaks, suggests that while VM synchronous stimulation contributes the greatest to the attainment of the illusion, a disruption of either (through asynchronous stimulation) contributes equally to the probability of a break in the illusion.

Virtual hand illusion induced by visuomotor correlations

Our body schema gives the subjective impression of being highly stable. However, a number of easily-evoked illusions illustrate its remarkable malleability. In the rubber-hand illusion, illusory ownership of a rubber-hand is evoked by synchronous visual and tactile stimulation on a visible rubber arm and on the hidden real arm. Ownership is concurrent with a proprioceptive illusion of displacement of the arm position towards the fake arm. We have previously shown that this illusion of ownership plus the proprioceptive displacement also occurs towards a virtual 3D projection of an arm when the appropriate synchronous visuotactile stimulation is provided. Our objective here was to explore whether these illusions (ownership and proprioceptive displacement) can be induced by only synchronous visuomotor stimulation, in the absence of tactile stimulation.

Drumming in immersive virtual reality: the body shapes the way we play

It has been shown that it is possible to generate perceptual illusions of ownership in immersive virtual reality (IVR) over a virtual body seen from first person perspective, in other words over a body that visually substitutes the person's real body. This can occur even when the virtual body is quite different in appearance from the person's real body. However, investigation of the psychological, behavioral and attitudinal consequences of such body transformations remains an interesting problem with much to be discovered. Thirty six Caucasian people participated in a between-groups experiment where they played a West-African Djembe hand drum while immersed in IVR and with a virtual body that substituted their own. The virtual hand drum was registered with a physical drum. They were alongside a virtual character that played a drum in a supporting, accompanying role. In a baseline condition participants were represented only by plainly shaded white hands, so that they were able merely to play. In the experimental condition they were represented either by a casually dressed dark-skinned virtual body (Casual Dark-Skinned - CD) or by a formal suited light-skinned body (Formal Light-Skinned - FL). Although participants of both groups experienced a strong body ownership illusion towards the virtual body, only those with the CD representation showed significant increases in their movement patterns for drumming compared to the baseline condition and compared with those embodied in the FL body. Moreover, the stronger the illusion of body ownership in the CD condition, the greater this behavioral change. A path analysis showed that the observed behavioral changes were a function of the strength of the illusion of body ownership towards the virtual body and its perceived appropriateness for the drumming task. These results demonstrate that full body ownership illusions can lead to substantial behavioral and possibly cognitive changes depending on the appearance of the virtual body. This could be important for many applications such as learning, education, training, psychotherapy and rehabilitation using IVR.

The Use of virtual reality in the study of people's responses to violent incidents

This paper reviews experimental methods for the study of the responses of people to violence in digital media, and in particular considers the issues of internal validity and ecological validity or generalisability of results to events in the real world. Experimental methods typically involve a significant level of abstraction from reality, with participants required to carry out tasks that are far removed from violence in real life, and hence their ecological validity is questionable. On the other hand studies based on fi eld data, while having ecological validity, cannot control multiple confounding variables that may have an impact on observed results, so that their internal validity is questionable. It is argued that immersive virtual reality may provide a unifi cation of these two approaches. Since people tend to respond realistically to situations and events that occur in virtual reality, and since virtual reality simulations can be completely controlled for experimental purposes, studies of responses to violence within virtual reality are likely to have both ecological and internal validity. This depends on a property that we call"plausibility"- including the fi delity of the depicted situation with prior knowledge and expectations. We illustrate this with data from a previously published experiment, a virtual reprise of Stanley Milgram"s 1960s obedience experiment, and also with pilot data from a new study being developed that looks at bystander responses to violent incidents.

Effects of P300-based BCI use on reported presence in a virtual environment

Brain-computer interfaces (BCIs) are becoming more and more popular as an input device for virtual worlds and computer games. Depending on their function, a major drawback is the mental workload associated with their use and there is significant effort and training required to effectively control them. In this paper, we present two studies assessing how mental workload of a P300-based BCI affects participants" reported sense of presence in a virtual environment (VE). In the first study, we employ a BCI exploiting the P300 event-related potential (ERP) that allows control of over 200 items in a virtual apartment. In the second study, the BCI is replaced by a gaze-based selection method coupled with wand navigation. In both studies, overall performance is measured and individual presence scores are assessed by means of a short questionnaire. The results suggest that there is no immediate benefit for visualizing events in the VE triggered by the BCI and that no learning about the layout of the virtual space takes place. In order to alleviate this, we propose that future P300-based BCIs in VR are set up so as require users to make some inference about the virtual space so that they become aware of it,which is likely to lead to higher reported presence.

The Sense of embodiment in virtual reality

What does it feel like to own, to control, and to be inside a body? The multidimensional nature of this experience together with the continuous presence of one's biological body, render both theoretical and experimental approaches problematic. Nevertheless, exploitation of immersive virtual reality has allowed a reframing of this question to whether it is possible to experience the same sensations towards a virtual body inside an immersive virtual environment as toward the biological body, and if so, to what extent. The current paper addresses these issues by referring to the Sense of Embodiment (SoE). Due to the conceptual confusion around this sense, we provide a working definition which states that SoE consists of three subcomponents: the sense of self-location, the sense of agency, and the sense of body ownership. Under this proposed structure, measures and experimental manipulations reported in the literature are reviewed and related challenges are outlined. Finally, future experimental studies are proposed to overcome those challenges, toward deepening the concept of SoE and enhancing it in virtual applications.

Impact of examinees' stereopsis and near visual acuity on laparoscopic virtual reality performance.

PURPOSE: Laparoscopic surgery represents specific challenges, such as the reduction of a three-dimensional anatomic environment to two dimensions. The aim of this study was to investigate the impact of the loss of the third dimension on laparoscopic virtual reality (VR) performance. METHODS: We compared a group of examinees with impaired stereopsis (group 1, n = 28) to a group with accurate stereopsis (group 2, n = 29). The primary outcome was the difference between the mean total score (MTS) of all tasks taken together and the performance in task 3 (eye-hand coordination), which was a priori considered to be the most dependent on intact stereopsis. RESULTS: The MTS and performance in task 3 tended to be slightly, but not significantly, better in group 2 than in group 1 [MTS: -0.12 (95 % CI -0.32, 0.08; p = 0.234); task 3: -0.09 (95 % CI -0.29, 0.11; p = 0.385)]. The difference of MTS between simulated impaired stereopsis between group 2 (by attaching an eye patch on the adominant eye in the 2nd run) and the first run of group 1 was not significant (MTS: p = 0.981; task 3: p = 0.527). CONCLUSION: We were unable to demonstrate an impact of impaired examinees' stereopsis on laparoscopic VR performance. Individuals with accurate stereopsis seem to be able to compensate for the loss of the third dimension in laparoscopic VR simulations.

The effect on lower spine muscle activation of walking on a narrow beam in virtual reality

To what extent do people behave in immersive virtual environments as they would in similar situations in a physical environment? There are many ways to address this question, ranging from questionnaires, behavioral studies, and the use of physiological measures. Here, we compare the onsets of muscle activity using surface electromyography (EMG) while participants were walking under three different conditions: on a normal floor surface, on a narrow ribbon along the floor, and on a narrow platform raised off the floor. The same situation was rendered in an immersive virtual environment (IVE) Cave-like system, and 12 participants did the three types of walking in a counter-balanced within-groups design. The mean number of EMG activity onsets per unit time followed the same pattern in the virtual environment as in the physical environment-significantly higher for walking on the platform compared to walking on the floor. Even though participants knew that they were in fact really walking at floor level in the virtual environment condition, the visual illusion of walking on a raised platform was sufficient to influence their behavior in a measurable way. This opens up the door for this technique to be used in gait and posture related scenarios including rehabilitation.

Body Image in Eating Disorders: The Influence of Exposure to Virtual-Reality Environments.

The aim of this article was to study the effect of virtual-reality exposure to situations that are emotionally significant for patients with eating disorders (ED) on the stability of body-image distortion and body-image dissatisfaction. A total of 85 ED patients and 108 non-ED students were randomly exposed to four experimental virtual environments: a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with low-calorie food, and a restaurant with high-calorie food. In the interval between the presentation of each situation, body-image distortion and body-image dissatisfaction were assessed. Several 2 x 2 x 2 repeated measures analyses of variance (high-calorie vs. low-calorie food x presence vs. absence of people x ED group vs. control group) showed that ED participants had significantly higher levels of body-image distortion and body dissatisfaction after eating high-calorie food than after eating low-calorie food, while control participants reported a similar body image in all situations. The results suggest that body-image distortion and body-image dissatisfaction show both trait and state features. On the one hand, ED patients show a general predisposition to overestimate their body size and to feel more dissatisfied with their body image than controls. On the other hand, these body-image disturbances fluctuate when participants are exposed to virtual situations that are emotionally relevant for them.

Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods. The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries). Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered