CAE Healthcare NeuroVR Surgical Simulator from CAE Healthcare on Vimeo.

A study objective was to assess if surgical performance and subjective assessment of a virtual reality simulator platform were influenced by changing force feedback devices.

Participants used the NeuroVR (formerly NeuroTouch) simulator to perform 5 practice scenarios and a realistic scenario involving subpial resection of a virtual reality brain tumor with simulated bleeding. The influence of force feedback was assessed by utilizing the Omni and Entact haptic systems. Tier 1, tier 2, and tier 2 advanced metrics were used to compare results. Operator subjective assessment of the haptic systems tested utilized seven Likert criteria (score 1 to 5).

The study is carried out at the McGill Neurosurgical Simulation Research and Training Centre, Montreal Neurological Institute and Hospital, Montreal, Canada.

PARTICIPANTS: Six expert operators in the utilization of the NeuroVR simulator platform.

No significant differences in surgical performance were found between the two haptic devices. Participants significantly preferred the Entact system on all 7 Likert criteria of subjective assessment.

This results show no statistical differences in virtual reality surgical performance utilizing the two bimanual haptic devices tested. Subjective assessments demonstrated that participants preferred the Entact system. The results suggest that to maximize the realism of the training experience educators employing virtual reality simulators may find it useful to assess expert opinion before choosing a force feedback device 1).

Previous work has shown that hand ergonomics plays an important role in surgical psychomotor performance during virtual reality brain tumor resections. In a study Sawaya et al. proposed a hypothetical model that integrates the human and task factors at play during simulated brain tumor resections to better understand the hand ergonomics needed for optimal safety and efficiency. They hypothesized that 1) experts (neurosurgeons), compared to novices (residents and medical students), spend a greater proportion of their time in direct contact with critical tumor areas; 2) hand ergonomic conditions (most favorable to unfavorable) prompt participants to adapt in order to optimize tumor resection; and 3) hand ergonomic adaptation is acquired with increasing expertise.

In an earlier study, experts (neurosurgeons) and novices (residents and medical students) were instructed to resect simulated brain tumors on the NeuroVR (formerly NeuroTouch) virtual reality neurosurgical simulation platform. For the present study, the simulated tumors were divided into four quadrants (Q1 to Q4) to assess hand ergonomics at various levels of difficulty. The spatial distribution of time expended, force applied, and tumor volume removed was analyzed for each participant group (total of 22 participants).

Neurosurgeons spent a significantly greater percentage of their time in direct contact with critical tumor areas. Under the favorable hand ergonomic conditions of Q1 and Q3, neurosurgeons and senior residents spent significantly more time in Q1 than in Q3. Although forces applied in these quadrants were similar, neurosurgeons, having spent more time in Q1, removed significantly more tumor in Q1 than in Q3. In a comparison of the most favorable (Q2) to unfavorable (Q4) hand ergonomic conditions, neurosurgeons adapted the forces applied in each quadrant to resect similar tumor volumes. Differences between Q2 and Q4 were emphasized in measures of force applied per second, tumor volume removed per second, and tumor volume removed per unit of force applied. In contrast, the hand ergonomics of medical students did not vary across quadrants, indicating the existence of an “adaptive capacity” in neurosurgeons.

The study results confirm the experts’ (neurosurgeons) greater capacity to adapt their hand ergonomics during simulated neurosurgical tasks. The proposed hypothetical model integrates the study findings with various human and task factors that highlight the importance of learning in the acquisition of hand ergonomic adaptation 2).

The force pyramid is a novel visual representation allowing spatial delineation of instrument force application during surgical procedures. In this study, the force pyramid concept is employed to create and quantify dominant hand, nondominant hand, and bimanual force pyramids during resection of virtual reality brain tumors.

To address 4 questions: Do ergonomics and handedness influence force pyramid structure? What are the differences between dominant and nondominant force pyramids? What is the spatial distribution of forces applied in specific tumor quadrants? What differentiates “expert” and “novice” groups regarding their force pyramids?

Using a simulated aspirator in the dominant hand and a simulated sucker in the nondominant hand, 6 neurosurgeons and 14 residents resected 8 different tumors using the CAE NeuroVR virtual reality neurosurgical simulation platform (CAE Healthcare, Montréal, Québec and the National Research Council Canada, Boucherville, Québec). Position and force data were used to create force pyramids and quantify tumor quadrant force distribution.

Force distribution quantification demonstrates the critical role that handedness and ergonomics play on psychomotor performance during simulated brain tumor resections. Neurosurgeons concentrate their dominant hand forces in a defined crescent in the lower right tumor quadrant. Nondominant force pyramids showed a central peak force application in all groups. Bimanual force pyramids outlined the combined impact of each hand. Distinct force pyramid patterns were seen when tumor stiffness, border complexity, and color were altered.

Force pyramids allow delineation of specific tumor regions requiring greater psychomotor ability to resect. This information can focus and improve resident technical skills training 3).

Simulation technology identifies neurosurgical residency applicants with differing levels of technical ability. These results provide information for studies being developed for longitudinal studies on the acquisition, development, and maintenance of psychomotor skills. Technical abilities customized training programs that maximize individual resident bimanual psychomotor training dependant on continuously updated and validated metrics from virtual reality simulation studies should be explored 4).

“Experts” display significantly more automaticity when operating on identical simulated tumors separated by a series of different tumors using the NeuroVR platform. These results support the Fitts and Posner model of motor learning and are consistent with the concept that automaticity improves after completing residency training. The potential educational application of the findings is outlined related to neurosurgical resident training 5).

Ultrasonic aspirator force application was continually assessed during resection of simulated brain tumors by neurosurgeons, residents, and medical students. The participants performed simulated resections of 18 simulated brain tumors with different visual and haptic characteristics. The raw data, namely, coordinates of the instrument tip as well as contact force values, were collected by the simulator. To provide a visual and qualitative spatial analysis of forces, the authors created a graph, called a force pyramid, representing force sum along the z-coordinate for different xy coordinates of the tool tip.

Sixteen neurosurgeons, 15 residents, and 84 medical students participated in the study. Neurosurgeon, resident and medical student groups displayed easily distinguishable 3D “force pyramid fingerprints.” Neurosurgeons had the lowest force pyramids, indicating application of the lowest forces, followed by resident and medical student groups. Handedness, ergonomics, and visual and haptic tumor characteristics resulted in distinct well-defined 3D force pyramid patterns.

Force pyramid fingerprints provide 3D spatial assessment displays of instrument force application during simulated tumor resection. Neurosurgeon force utilization and ergonomic data form a basis for understanding and modulating resident force application and improving patient safety during tumor resection 6).



Bugdadi A, Sawaya R, Bajunaid K, Olwi D, Winkler-Schwartz A, Ledwos N, Marwa I, Alsideiri G, Sabbagh AJ, Alotaibi FE, Al-Zhrani G, Maestro RD. Is Virtual Reality Surgical Performance Influenced by Force Feedback Device Utilized? J Surg Educ. 2019 Jan – Feb;76(1):262-273. doi: 10.1016/j.jsurg.2018.06.012. Epub 2018 Jul 31. PubMed PMID: 30072262.

Sawaya R, Alsideiri G, Bugdadi A, Winkler-Schwartz A, Azarnoush H, Bajunaid K, Sabbagh AJ, Del Maestro R. Development of a performance model for virtual reality tumor resections. J Neurosurg. 2018 Jul 1:1-9. doi: 10.3171/2018.2.JNS172327. [Epub ahead of print] PubMed PMID: 30074456.

Sawaya R, Bugdadi A, Azarnoush H, Winkler-Schwartz A, Alotaibi FE, Bajunaid K, AlZhrani GA, Alsideiri G, Sabbagh AJ, Del Maestro RF. Virtual Reality Tumor Resection: The Force Pyramid Approach. Oper Neurosurg (Hagerstown). 2018 Jun 1;14(6):686-696. doi: 10.1093/ons/opx189. PubMed PMID: 28962033.

Winkler-Schwartz A, Bajunaid K, Mullah MA, Marwa I, Alotaibi FE, Fares J, Baggiani M, Azarnoush H, Zharni GA, Christie S, Sabbagh AJ, Werthner P, Del Maestro RF. Bimanual Psychomotor Performance in Neurosurgical Resident Applicants Assessed Using NeuroTouch, a Virtual Reality Simulator. J Surg Educ. 2016 Nov – Dec;73(6):942-953. doi: 10.1016/j.jsurg.2016.04.013. Epub 2016 Jul 7. PubMed PMID: 27395397.

Bugdadi A, Sawaya R, Olwi D, Al-Zhrani G, Azarnoush H, Sabbagh AJ, Alsideiri G, Bajunaid K, Alotaibi FE, Winkler-Schwartz A, Del Maestro R. Automaticity of Force Application During Simulated Brain Tumor Resection: Testing the Fitts and Posner Model. J Surg Educ. 2017 Jul 3. pii: S1931-7204(17)30114-9. doi: 10.1016/j.jsurg.2017.06.018. [Epub ahead of print] PubMed PMID: 28684100.

Azarnoush H, Siar S, Sawaya R, Zhrani GA, Winkler-Schwartz A, Alotaibi FE, Bugdadi A, Bajunaid K, Marwa I, Sabbagh AJ, Del Maestro RF. The force pyramid: a spatial analysis of force application during virtual reality brain tumor resection. J Neurosurg. 2017 Jul;127(1):171-181. doi: 10.3171/2016.7.JNS16322. Epub 2016 Sep 30. PubMed PMID: 27689458.

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