The ‘LapAR’ augmented reality training device in surgical simulation: a multi-center pilot study
Authors: Colman Samuel , El-Bahnasawi Mohammed , Abdulkader Nayaab , Aloul Zaina , Brown Jeremy , Luthra Pramod , Rawaf David 
Published: January 2025

Abstract

Introduction
In recent years, there has been a significant change in the way that post-graduate education is delivered, particularly in skills training for surgical trainees. In line with national guidance in the United Kingdom (UK), such as Segal Quince Wicksteed Partnership’s (SQW) 2020 independent evaluation ‘Improving Surgical Training’, novel surgical training devices, particularly those utilizing advancing augmented reality (AR) technologies, are beginning to be implemented. This study aimed to provide evidence towards the validation of efficacy of a novel AR laparoscopic simulator, the LapAR™ from Inovus Medical, guided by Messick’s validity framework. The primary objective was to determine the simulator's impact on enhancing the technical skills of surgical trainees during simulated laparoscopic appendectomies.

Methods
This mixed methods study combined a prospective cohort study with an extensive qualitative component, employing a semi-structured interview followed by thematic framework analysis. The trainees were orientated face to face and then given a LapAR™ simulator to take home, where they were asked to perform ten appendectomies interspersed with applicable standardized procedural tasks. Objective performance metrics in procedure completion time and the distances traveled of standard surgical instruments were collected as primary outcome measures. Further metrics assessing the smoothness and acceleration of instrument movements were also secondarily utilized to gauge technical proficiency. Outcomes were compared with the performance of consultant surgeons on the same simulator, providing a benchmark for assessing the trainees’ advancement towards expert-level competency. In addition to quantitative assessments, this study seeked to gather qualitative feedback on the LapAR™ simulator to explore its usability, acceptability, and feasibility as a training device, as well as to identify potential use cases as suggested by its users.

Results
Fifteen trainees and two consultants across five training sites were recruited to participate in the study. Findings show that by their final appendectomy procedure, the trainees’ mean performance for time for completion of the procedure was 6.53 min (95% C.I. 5.39–7.67), reaching equivalence to that of the benchmarking consultant, 6.76 min (95% C.I. 5.64–7.88). The same equivalence in performance was found in the trainees' first and final procedures for distance of surgical instruments traveled 50.52 cm (95% C.I. 29.35–71.69) and 31.51 cm (95% C.I. 20.57–42.45) respectively, compared to the benchmarking consultants 42.91 cm (95% C.I. − 18.84–104.65). Statistically significant improvements in time for procedure completion (p = 0.001) and surgical instrument distance traveled were found (p = 0.043) across the trainee’s repeated procedures. Improvements in smoothness and acceleration of instrument use were also observed, but did not reach statistical significance. During qualitative analysis of the interviews, three key themes were identified; enablers, barriers, and improved practice. It was found that this training method was ideal to coincide with the start of their surgical training and that it had particular relevance. There was agreement that the technology could be used for preparation for operating lists, including warm-up, knowledge and skills acquisition. Training at home provided the flexibility and time to practice when convenient away from the high-pressure operating room environment. Despite some isolated issues with set-up and consumable quality, it was felt that the levels of realism provided tangible educational benefits.

Conclusion
This study demonstrates the LapAR™ simulator as an exciting new innovation in surgical training, with the potential to reduce the surgical risk of operative inexperience, offering surgical trainees a new format to learn techniques, hone laparoscopic skills and prove competency. This study provides further evidence highlighting the impact that augmented reality technologies are having on transforming surgical education by providing immersive, interactive environments that enhance the learning experience beyond traditional methods. Further to this, the LapAR™ simulator also presents an opportunity for pre-operative ‘warm up’ time for experienced surgeons, seeking to improve operative outcomes and enable operative list time efficiency. There remains a need for further research focussing on construct validity, the expansion of the cohort to improve generalisability, and an assessment of external validity of whether improvements in performance on the LapAR™ simulator correlates with the existing gold standard of increasing operative experience.