Psychomotor skills and cognitive load training on a virtual reality laparoscopic simulator for tubal surgery is effective Rasiah Bharathan a, *, Saaliha Vali a , Thomas Setchell b , Tariq Miskry b , Ara Darzi a , Rajesh Aggarwal a a Department of Surgery and Cancer, Imperial College, St. Mary’s Hospital, 10th Floor QEQM, South Wharf Road, Paddington, London W2 1NY, United Kingdom b Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, St. Mary’s Hospital, Praed Street, London W2 1NY, United Kingdom 1. Introduction An estimated 11,000 cases of ectopic pregnancy (EP) occur annually in the UK, with an incidence rate of 1% amongst all pregnancies [1]. Due to the wide availability of dedicated early pregnancy assessment units, ectopic pregnancies are now diag- nosed at an earlier stage [2]. Timely diagnosis enables less invasive therapeutic options such as conservative and medical manage- ment [3]. In a recent study analysing a five-year trend, the proportion of women undergoing medical treatment had increased from 11.1% to 35.1%, and amongst those undergoing surgical treatment an increasing proportion of women had laparoscopic surgery [4]. When surgical treatment is warranted, high quality evidence supports laparoscopic management [5]. Current guide- lines recommend salpingectomy rather than salpingotomy for tubal ectopic pregnancy, unless the contralateral tube is diseased and the patient wishes to preserve fertility [5]. Salpingotomy is rarely performed in the context of ectopic pregnancy. Comparative studies of salpingectomy and salpingot- omy in terms of psychomotor profile are scarce and the evidence from a study in an ovine model suggests salpingectomy takes longer to perform and yielded higher scores (indicating better performance) than salpingotomy using a penalty scoring system, though retrieval of ectopic gestational tissue was not assessed in European Journal of Obstetrics & Gynecology and Reproductive Biology 169 (2013) 347–352 A R T I C L E I N F O Article history: Received 12 November 2012 Received in revised form 28 February 2013 Accepted 28 March 2013 Keywords: Virtual reality Salpingectomy Salpingotomy Learning curve Cognitive load A B S T R A C T Objectives: Validation of a virtual reality (VR) simulator for the training and assessment of laparoscopic tubal surgery and mapping of cognitive load. Study design: Prospective cohort study conducted at the Imperial College Virtual Reality Surgical Skills laboratory amongst 25 trainees and nine senior gynaecologists. Participants performed two sessions of salpingectomy and salpingotomy procedures on a VR simulator to assess construct validity. Nine novices performed ten such sessions to enable assessment of the learning curve. The relationship between cognitive load and the dexterity parameters was assessed. Simulator fidelity was reported by experienced and intermediate level gynaecologists. Statistical analyses utilised non-parametric tests, Kruskall–Wallis and Mann–Whitney U tests. Learning curves were assessed using the Friedman test and Wilcoxon Signed Ranks test. Relationship between dexterity metrics and cognitive load was performed using Spearman’s rank order correlation. Results: Salpingectomy demonstrated construct validity for time taken by experienced, intermediate and novice gynaecologists (median 170 vs. 191 vs. 313 s (P = 0.003) respectively) and movements (median 200 vs. 267 vs. 376 s, P = 0.045). Salpingotomy demonstrated construct validity for time taken (median 183 vs. 191 vs. 306 s, P = <0.001) and movements (median 210 vs. 233 vs. 328 s, P = 0.005). Learning curve analysis for salpingectomy displayed a plateau for time taken after the eighth session, and the fourth session for movements. Salpingotomy displayed a plateau after the eighth session for both time taken and movements. Cognitive load correlated significantly with dexterity parameters. The fidelity scores were not significantly different between the two procedures (P = 0.619). Conclusion: The LAP Mentor VR laparoscopic simulator is a valid and effective tool for training novice surgeons in ectopic pregnancy surgery. Reduction in cognitive load significantly correlates with the learning curves. ß 2013 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Imperial College, St Mary’s Hospital, 1092, 10th Floor QEQM, South Wharf Road, Paddington, London W2 1NY, United Kingdom. Tel.: +44 0 20 3312 1012. E-mail address: r.bharathan@imperial.ac.uk (R. Bharathan). Contents lists available at SciVerse ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.03.017