Studies using conventional consoles have suggested a possible link between video-gaming and laparoscopic skill. The authors hypothesized that the Nintendo Wii, with its motion-sensing interface, would provide a better model for laparoscopic tasks. This study investigated the relationship between Nintendo Wii skill, prior gaming experience, and laparoscopic skill.
In this study, 20 participants who had minimal experience with either laparoscopic surgery or Nintendo Wii performed three tasks on a Webcam-based laparoscopic simulator and were assessed on three games on the Wii. The participants completed a questionnaire assessing prior gaming experience.
The score for each of the three Wii games correlated positively with the laparoscopic score (r = 0.78, 0.63, 0.77; P < 0.001), as did the combined Wii score (r = 0.82; P < 0.001). The participants in the top tertile of Wii performance scored 60.3% higher on the laparoscopic tasks than those in the bottom tertile (P < 0.01). Partial correlation analysis with control for the effect of prior gaming experience showed a significant positive correlation between the Wii score and the laparoscopic score (r = 0.713; P < 0.001). Prior gaming experience also correlated positively with the laparoscopic score (r = 0.578; P < 0.01), but no significant difference in the laparoscopic score was observed when the participants in the top tertile of experience were compared with those in the bottom tertile (P = 0.26).
The study findings suggest a skill overlap between the Nintendo Wii and basic laparoscopic tasks. Surgical candidates with advanced Nintendo Wii ability may possess higher baseline laparoscopic ability.
Changes in surgical training and reduced working hours have created an increasing demand that surgeons be trained efficiently. In addition, surgeons face a steep learning curve when they start performing laparoscopic procedures . As a result, surgical simulators are widely used to enable trainees to acquire as much technical competence as possible outside the operating room. Recent interest has focused on whether video-gaming might be a useful adjunct [2–8].
In a recent study, Rosser et al.  tested 33 surgeons on a laparoscopic skills and suturing program and on the Nintendo Gamecube (Nintendo of America Inc., Redmond, Washington), Sony Playstation 2 (Sony Computer Entertainment Ltd., London, UK), and Microsoft Xbox (Microsoft UK, Reading, Berkshire, UK). The participants in the top tertile of the video game score performed significantly better when scored for time and number of errors on the laparoscopic skill program than those in the bottom tertile. A questionnaire-based assessment of video-gaming experience showed that both current and past gamers scored better on the laparoscopic simulator. Furthermore, Grantcharov et al.  showed that computer gamers made significantly fewer errors than non–computer gamers on a minimally invasive virtual reality surgical trainer.
In contrast, another recent study found that computer-gaming experience did not predict skill on laparoscopic training devices , whereas still another study showed that video-gaming experience was inversely correlated with the ability to learn robotic suturing . Rosenberg et al.  found that training 11 medical students on the Microsoft Xbox for 2 weeks did not improve their laparoscopic skill.
As Rosser et al.  noted, the style of the video game interface is likely to influence the association between gaming and laparoscopy. The aforementioned studies involved conventional gaming consoles with button-push and joystick controllers. The relatively new Nintendo Wii console has a more advanced controller with a motion-sensing interface that allows game players to move the controller through three dimensions. We speculate that this interface will provide a better model of laparoscopic surgery.
This study aimed primarily to investigate whether ability on the Nintendo Wii predicts performance on a laparoscopic trainer. Considering the ambiguity of previous studies, we also aimed to assess whether prior video-gaming experience correlates with laparoscopic trainer performance.
Materials and methods
The study participants were 20 medical students and junior doctors. The participants completed a questionnaire detailing the total hours of gaming experience on both the Nintendo Wii and other gaming consoles. The inclusion criteria specified no participation or training in laparoscopic surgery and fewer than 5 h of previous experience on the Nintendo Wii.
A Webcam-based laparoscopic surgical trainer was constructed (Fig. 1) to the specification of Beatty . Studies have shown such trainers to be comparable with commercial trainers in current use for assessing basic surgical skills [10, 11].
Laparoscopic performance was assessed on three standard “beginner” box trainer tasks used in many laparoscopic courses to familiarize the trainee with the equipment, hand–eye coordination, and use of a laparoscopic setup. This provided a suitable objective way to assess basic laparoscopic skill in the naive study population. Before beginning, the participants were given an instruction sheet detailing the scoring system and the requirements of each task. They also were allowed to familiarize themselves with the instruments for 1 minute.
Task 1 began with 12 sugar cubes placed randomly in the working area. The participants were given 3 min to build the highest tower of sugar cubes using two grasper tools. The score was the maximum height in number of cubes achieved at any time during the task.
For task 2, two pairs of latex gloves were secured to the floor of the working area using a drawing pin. The participants were given 4 min to remove as many fingers as possible by cutting between two parallel lines marked on each finger. The lines were 1.5 cm apart, with the proximal line 1 cm from the base of the glove finger. The scissors tool was held in the dominant hand, with a grasper in the nondominant hand. The participants were scored on the number of fingers successfully removed. Fingers cut outside the lines scored zero.
For task 3, a shoelace knotted at one end and 25 Polo Nestle Co Ltd (Croydon, UK) mints were placed in the working area. The participants were given 10 min to thread as many mints as possible onto the shoelace using two grasper tools. The score was the number of mints added to the shoelace at the end of the task.
Nintendo Wii set-up and game selection
A Nintendo Wii console (Nintendo Co Ltd., Tokyo, Japan) was connected to a television screen positioned 2.5 m from the participant. Performance was assessed using Wii Play (Nintendo Co. Ltd.), a game that features mini-games in which players are awarded a score based on their handling of the remote controller during game play. This provided a simple and objective test of Nintendo Wii skill.
The participants played three of the mini-games as described in the following sections. Each mini-game was chosen based on similarity to skills required in laparoscopic tasks including fine motor control, visuospatial processing, reaction time, hand–eye coordination, attention needs, and two-dimensional depth perception. Games also were selected based on their suitability for measurement of skill with the nondominant hand. Game novelty also was a selection criterion. None of the subjects had ever played any of the three video games used for this study.
The player uses the Wii Remote to move a character to pop falling bubbles that contain a silhouette of the character at different shapes and angles. The player must rotate the cursor to the precise angle to pop the bubbles. In addition to this, as the game progresses, the poses inside the bubbles change, and the player must select the correct pose using buttons on the Remote. The subjects performed one run with their dominant hand, followed by a run with their nondominant hand.
The player goes through rounds of shooting various targets that appear at different points on the screen. Bonus points are awarded for making consecutive hits without missing. The participants performed one run with their dominant hand, followed by a run with their nondominant hand.
The player rides a cow through a race course and topples scarecrows to score points. A time bonus is added at crossing of the finish line. The cow is controlled by tilting the controller in different directions to apply a steering force. The participants performed two runs, both of which were two-handed.
The scores from the six runs then were totaled to give an overall score for each subject.
All data analysis was performed using the statistics package SPSS (SPSS 11.0.4, SPSS Inc., Chicago, Illinois). Composite scores were obtained for both laparoscopic and Wii Play performance by summing the scores on the three tasks for each. Pearson correlation coefficients were obtained for the relationship between the composite score on the laparoscopic trainer and the composite score on the Wii. In addition, the Pearson coefficients for the relationship between the score on each of the three Wii Play games separately and the composite score on the laparoscopic trainer were obtained. Partial correlation analysis was performed for the correlation between the composite score on the laparoscopic trainer and the composite score on the Wii, with control used for the effect of prior gaming experience. The Mann–Whitney U statistic was calculated for the difference in composite laparoscopic score between those in the highest and lowest tertiles of the composite Wii Play score, and between those in the highest and lowest tertiles of previous video-gaming experience.
A total of 20 participants were recruited to the study. One participant was excluded after completion of the questionnaire for failing to meet the inclusion criteria.
Nintendo Wii skill as a predictor of laparoscopic skill
The composite Wii score correlated strongly with the laparoscopic score (Fig. 2; r = 0.82; P < 0.001). This correlation remained after a partial correlation analysis was performed to control for the potential confounding factor of past experience (r = 0.713; P < 0.001). The score on each of the individual video games also correlated positively with the laparoscopic score as follows: Pose Mii (r = 0.78; P < 0.001), Shooting Range (r = 0.77; P < 0.001), and Charge! (r = 0.63; P < 0.01). The participants in the top tertile of the Wii score performed significantly better at the laparoscopic tasks than those in the bottom tertiles of the Wii score (Fig. 3; percentage mean difference, 60.3%; P = 0.008).
Total past gaming experience as a predictor of laparoscopic skill
Past non-Wii gaming experience ranged from 0 to 9,360 h (mean, 1,255 h). The total non-Wii gaming experience correlated with the laparoscopic score (r = 0.578; P = 0.01). No significant difference (P = 0.26) was observed between the laparoscopic score of participants in the top tertile of gaming experience and the score of those in the bottom tertile (Fig. 3).
The results of this study demonstrate a strong positive correlation between the Nintendo Wii score and the score on a box-design laparoscopic surgical trainer. This correlation remained after control was used for past gaming experience. These results suggest a significant skill overlap between Nintendo Wii ability and skill for basic laparoscopic tasks.
The finding of modest correlation between laparoscopic score and previous non-Wii gaming experience is in keeping with some previous studies [2, 3, 5]. These studies involved consoles with standard joystick and button-push controllers. In contrast, the Nintendo Wii requires the user to move a controller in three dimensions to affect game play on a two-dimensional image. We suggest that this provides a good model of laparoscopic surgery and may well explain the observed strong correlation between demonstrated Wii performance and laparoscopic score.
In this study, ability on the Nintendo Wii correlated with skill on the laparoscopic trainer independent of prior gaming experience in a cohort of laparoscopic surgery naïve trainees with little or no experience playing on the Wii. This may suggest that surgical candidates with higher innate ability for the Wii possess higher baseline ability for basic laparoscopic tasks. Indeed, the individuals in the top tertile of the Wii score performed significantly better in the laparoscopic tasks than the individuals in the bottom tertile. As such, advanced ability of potential surgical trainees on the Wii might be viewed positively when suitable candidates are identified for laparoscopic training. These individuals would be expected to have a higher baseline of laparoscopic skill and might even learn basic laparoscopic skills at a faster rate. This idea is in keeping with studies showing that basic measures of perceptual and visuomotor skill can predict laparoscopic surgical performance [12, 13].
Video games that incorporate mechanics similar to those used in laparoscopic tasks may have a role to play in the acquisition or supplementation of the basic visuospatial, motor, and attention skills required for laparoscopic surgery. Video games may be developed and consoles adapted to simulate laparoscopic surgery better, for example, by modifying game content, reaction times, and attention needs, and by improving motion-sensing interfaces. This may create a widely available, inexpensive, and popular means by which future trainees without access to laparoscopic trainers might develop related surgical skills.
Although this study has shown a significant correlation between gaming ability and laparoscopic skill, further work is required to investigate whether training on the Nintendo Wii leads to an improvement in laparoscopic performance and whether this translates into improved performance in the operating theatre.
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The authors thank Dr. Faisal Basheer for the use of his Nintendo Wii console in this study.
Shiraz Badurdeen, Giles Story, Omar Abdul-Samad, Clare Wilson, Sue Down and Adrian Harris have no conflicts of interest or financial ties to disclose.
S. Badurdeen, O. Abdul-Samad, G. Story, and C. Wilson have equally contributed to this work. S. Down and A. Harris supervised the project and edited the manuscript.
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Badurdeen, S., Abdul-Samad, O., Story, G. et al. Nintendo Wii video-gaming ability predicts laparoscopic skill. Surg Endosc 24, 1824–1828 (2010). https://doi.org/10.1007/s00464-009-0862-z