ABSTRACT
A significant source of iatrogenic complication in laparoscopic cholecystectomy (LC) is biliary injury due
to misidentification of the cystic duct and artery. Of the ~750,000 LCs performed annually, bile duct injury
occurs in up to 0.15% of cases, with a concomitant mortality rate of 20.8%. Of these ~30% occur in procedures
performed by experienced surgeons, who have completed more than 200 LC surgeries. The Critical View of
Safety (CVS), established by a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) task
force, lays out specific procedural steps to avoid biliary injury during LC. Preliminary data on virtual reality (VR)
training of CVS in the United Kingdom and Sweden have indicated that it results in fewer surgical errors. In this
study we propose to develop and validate a VR CVS curriculum on a prototype portable camera aided
simulator (PortCAS) using a web-based interactive, virtual, smart mentored training protocol. The study will
consist of two specific aims. The first aim is to develop the PortCAS hardware, software, the virtual simulation,
and an interactive cloud-based smart mentoring training environment. The second aim is to test the efficacy of
the PortCAS training platform on virtual and real obtainment of the CVS by experienced surgeons.
PortCAS combines function and low cost by using computer vision to track the motion of laparoscopic
tools, bridging the gap between low-tech simulators (low fidelity, no feedback, low cost) and high-tech
simulators (high fidelity, some feedback with minimal analytics, high cost). The vision for PortCAS is to provide
the least expensive way to automate assessment of simulation (feedback to the trainee) for manual or motion-
based tasks. PortCAS can be extended across many other training disciplines besides laparoscopic surgery.
The small size and portability of PortCAS makes it available for mentored smart training
anywhere/anytime for busy surgeons, and for trainees at any step of the learning curve. Camera tracking is
conducted at the client side to minimize latency while the smart training algorithms will be located in the cloud.
This allows training regimens to be accessed remotely and reduces the requirements for complexity at the
client level. This strategy is innovative in that it reduces the cost, enables a lightweight portable training device
and centralizes the learning paradigms and individual performance and tailored smart mentoring in the cloud
server. The training will evaluate progress in both technical mastery and expert judgement in practicing
surgeons using intra-surgical images of the CVS. Unlike training toolboxes or video trainers, VR-based
simulators expose trainees to rare adverse events, allow customization based on individual needs, allow for
subtle measurement of the trainee's performance, and provide very detailed and objective feedback in real
time, independent of a proctor. We expect that effectively training surgeons in intra-operative attainment of
CVS, using both normal and unusual vasculobiliary anatomy simulations, will reduce the incidence and
mortality caused by iatrogenic biliary injury.
