# Designing Pedagogically Effective Haptic Systems for Learning: A Review
## 3 Haptics Applications for Learning
### Medicine
#### 3.2.2 Surgical Training  
Surgical procedures have been canonically practiced on cadavers or animals. While these modalities of training allow for an immersive and realistic experience, they are expensive and non-reusable. It has been stated that on average 750 operations are needed to improve surgical procedure ability and it has been found that patients who have been treated by doctors with 750-10,250 procedures worth of surgical experience tend to have fewer procedure-related complications than patients who were treated by less experienced doctors [31]. Haptic technology provides an immersive, realistic, cost-effective and reusable route to prepare medical students for surgical procedures. Haptics have shown promise for reducing cognitive load and improving accuracy during minimally invasive surgery training, and have been determined to improve training results [34]. Laparoscopic procedures are minimally invasive procedures of the abdomen that require small incisions for surgical instruments to enter through. During a laparoscopic surgery, surgeons cut small incisions in the abdominal wall through which surgical tools and the laparoscope (which is a small fiber-optic camera used to view internal organs and the procedure) can be inserted. Since laparoscopic surgical tools are long-stemmed, surgeons often receive distorted force feedback while performing the procedure [27]. A study conducted by [PERSON] et al. [27] looked at the role haptic augmentation played in a virtual reality laparoscopic surgery simulator. [PERSON] et al. investigated the efficacy of surgeons while inducing cognitive load via mental math questions in three different virtual reality surgery simulations: one without haptic feedback (the MIST-VR), one with haptic feedback (the ProMIS-AR), and one with exaggerated haptic feedback (the ProMIS-AR). The MIST-VR, developed by Wolfson Centre for Minimally Invasive Therapy (Manchester, UK) is a minimally invasive surgery trainer exclusively for virtual reality and is composed of two position-sensing gimbals that detect the hand movement of the user in order to control the position of two laparoscopic instruments on a computer screen. The ProMIS-AR (Haptica, Dublin, Ireland), a commercial laparoscopic simulation platform, is an augmented reality simulator and includes a life-size torso with a light source and laparoscopic tools. The ProMIS-AR, equipped with three cameras, can track and display on a computer screen the three-dimensional position of the laparoscopic tools inside the torso. Three performance measures were collected from each simulator: time to task completion, errors, and number of math problemsattempted. The subjects preformed the virtual procedure 21% faster when they were not cognitively loaded, which indicated that the mental math problems were competing with the laparoscopic task for cognitive resources. In general, even while cognitively loaded, the subjects preformed faster (36% with exaggerated haptics and 33% with haptics) and more accurately (97% with exaggerated haptics and 91% with haptics) with haptics than without. This data suggests that haptics has the potential to not only enhance surgical performance, but possibly mitigate the amount of cognitive load experienced [27]. These findings held true in the study regardless of the magnitude of haptic feedback, and it was determined that haptic feedback enhances performance and negates cognitive load during virtual surgical simulations compared to non-haptic simulations. Haptic augmentation has also proven beneficial during real laparoscopic surgery as well. The tools utilized during laparoscopic surgery can significantly reduce sensitivity and consequently may impede the transmission of important tactile feedback [1]. Sensory loss from long-stemmed endoscopic instruments has been found, with the main cause of this disturbance being frictional forces. It was found that when haptic feedback was absent, there was increased tissue slippage and damage that occurred during grasping actions [35].