Obesity Surgery

, Volume 29, Issue 4, pp 1309–1316 | Cite as

Virtual Reality Single-Port Sleeve Gastrectomy Training Decreases Physical and Mental Workload in Novice Surgeons: An Exploratory Study

  • Jessy BarréEmail author
  • Daphné Michelet
  • Jennifer Truchot
  • Erwan Jolivet
  • Thomas Recanzone
  • Sabrina Stiti
  • Antoine Tesnière
  • Guillaume Pourcher
Original Contributions



Novice surgeons experience high levels of physical and mental workload during the early stages of their curriculum and clinical practice. Laparoscopic sleeve gastrectomy is the first bariatric procedure worldwide. Feasibility and safety of single-port sleeve gastrectomy (SPSG) has been demonstrated. An immersive virtual reality (VR) simulation was developed to provide a repetitive exercise to learn this novel technique. The primary objective of this study was to evaluate the impact of the VR training tool on mental and physical workload in novice surgeons. The secondary objective included an evaluation of the VR simulator.


A monocentric-controlled trial was conducted. Ten participants were divided into two groups, the VR group and the control group (without VR training). Surgery residents participated in a first real case of SPSG and a second case 1 month later. The VR group underwent a VR training between the two surgeries. Mental and physical loads were assessed with self-assessment questionnaires: NASA-TLX, Borg scale, and manikin discomfort test. The VR simulator was evaluated through presence, cybersickness, and usability questionnaires.


This study showed a decrease of the mental demand and effort dimensions of NASA-TLX between the first and the second surgery in the VR group (P < .05). During the second surgery, a marginally significant difference was shown concerning the mental demand between the two groups. Postural discomfort of the VR group decreased with practice (P < .01), mainly between the first and the second surgery (P < .05). Furthermore, participants characterized the VR simulator as realistic, usable, and very useful to learned surgery.


This exploratory study showed an improvement in mental and physical workload when novice surgeons trained with VR (repetitive practice, gesture improvement, reduction of stress, etc.). Virtual reality appears to be a promising perspective for surgical training.


Single port Sleeve Obesity Learning Simulation Virtual reality Human factors 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Statement

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Arora S, Sevdalis N, Aggarwal R, et al. Stress impairs psychomotor performance in novice laparoscopic surgeons. Surg Endosc. 2010 Oct;24(10):2588–93.CrossRefGoogle Scholar
  2. 2.
    Klein MI, Warm JS, Riley MA, et al. Mental workload and stress perceived by novice operators in the laparoscopic and robotic minimally invasive surgical interfaces. J Endourol. 2012 Aug;26(8):1089–94.CrossRefGoogle Scholar
  3. 3.
    Ma M, Jain LC, Anderson P. Virtual, augmented reality and serious games for healthcare 1. Berlin: Springer; 2014.CrossRefGoogle Scholar
  4. 4.
    Khor WS, Baker B, Amin K, et al. Augmented and virtual reality in surgery—the digital surgical environment: applications, limitations and legal pitfalls. Ann Transl Med. 2016 Dec;4(23):454.CrossRefGoogle Scholar
  5. 5.
    Gebara CM, Barros-Neto TPD, Gertsenchtein L, et al. Virtual reality exposure using three-dimensional images for the treatment of social phobia. Rev Bras Psiquiatr. 2016 Mar;38(1):24–9.CrossRefGoogle Scholar
  6. 6.
    Son JH, Lee SH, Seok JW, et al. Virtual reality therapy for the treatment of alcohol dependence: a preliminary investigation with positron emission tomography/computerized tomography. J Stud Alcohol Drugs. 2015 Jul;76(4):620–7.CrossRefGoogle Scholar
  7. 7.
    Hoffman HG. Virtual-reality therapy. Sci Am. 2004 Aug;291(2):58–65.CrossRefGoogle Scholar
  8. 8.
    García-Betances RI, Arredondo Waldmeyer MT, Fico G, et al. A succinct overview of virtual reality technology use in Alzheimer’s disease. Front Aging Neurosci. 2015 May;7(80):1–8.Google Scholar
  9. 9.
    Lin CY, Chang YM. Interactive augmented reality using Scratch 2.0 to improve physical activities for children with developmental disabilities. Res Dev Disabil. 2015 Feb;37:1–8.CrossRefGoogle Scholar
  10. 10.
    Alhabdan S, Alamri H, Aggarwal R. Opportunities for education and training in bariatric surgery: a systematic review. Surg Obes Relat Dis. 2016 Aug;12(7):S147–8.CrossRefGoogle Scholar
  11. 11.
    Pulijala Y, Ma M, Pears M, et al. Effectiveness of immersive virtual reality in surgical training—a randomized control trial. J Oral Maxillofac Surg. 2018 May;76(5):1065–72.CrossRefGoogle Scholar
  12. 12.
    Pourcher G, Ferretti S, Akakpo W, et al. Single-port sleeve gastrectomy for super-obese patients. Surg Obes Relat Dis. 2016 Mar-Apr;12(3):522–7.CrossRefGoogle Scholar
  13. 13.
    Pourcher G, Di Giuro G, Lafosse T, et al. Routine single-port sleeve gastrectomy: a study of 60 consecutive patients. Surg Obes Relat Dis. 2013 May-Jun;9(3):385–9.CrossRefGoogle Scholar
  14. 14.
    Hart SG, Staveland LE. Development of NASA-TLX (task load index): results of empirical and theoretical research. Adv Psychol. 1988;52:139–83.CrossRefGoogle Scholar
  15. 15.
    Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81.CrossRefGoogle Scholar
  16. 16.
    Corlett EN, Bishop RP. A technique for assessing postural discomfort. Ergonomics. 1976;19(2):175–82.CrossRefGoogle Scholar
  17. 17.
    Steuer J. Defining virtual reality: dimensions determining telepresence. J Commun. 1992;42(4):73–93.CrossRefGoogle Scholar
  18. 18.
    Nash EB, Edwards GW, Thompson JA, et al. A review of presence and performance in virtual environments. Int J Hum Comput Interact. 2000;12(1):1–41.CrossRefGoogle Scholar
  19. 19.
    Mantovani F, Castelnuovo G. The sense of presence in virtual training: enhancing skills acquisition and transfer of knowledge through learning experience in virtual environments. In: Riva G, Davide F, IJsselsteijn WA, editors. Being there: concepts, effects and measurement of user presence in synthetic environments. Amsterdam, Netherland: Ios Press; 2003. p. 168–81.Google Scholar
  20. 20.
    Witmer BG, Singer MJ. Measuring presence in virtual environments: a presence questionnaire. Presence. 1998;7(3):225–40.CrossRefGoogle Scholar
  21. 21.
    Hill KJ, Howarth PA. Habituation to the side effects of immersion in a virtual environment. Displays. 2000;21(1):25–30.CrossRefGoogle Scholar
  22. 22.
    Nichols S, Patel H. Health and safety implications of virtual reality: a review of empirical evidence. Appl Ergon. 2002;33(3):251–71.CrossRefGoogle Scholar
  23. 23.
    Kennedy RS, Lane NE, Berbaum KS, et al. Simulator sickness questionnaire: an enhanced method for quantifying simulator sickness. Int J Aviat Psychol. 1993;3(3):203–20.CrossRefGoogle Scholar
  24. 24.
    Brooke J. SUS-A quick and dirty usability scale. Usability evaluation in industry. 1996;189(194):4–7.Google Scholar
  25. 25.
    Azmandian M, Hancock M, Benko H, et al. Haptic retargeting: dynamic repurposing of passive haptics for enhanced virtual reality experiences. Proceedings of the CHI’16 conference on human factors in computing systems. 2016:1968–79.Google Scholar
  26. 26.
    Shewaga R, Uribe-Quevedo A, Kapralos B, et al. Comparison of seated and room-scale virtual reality in a serious game for epidural preparation. In: IEEE transactions on emerging topics in computing; 2017. p. 1–14.Google Scholar
  27. 27.
    Byers JC, Bittner AC, Hill SG. Traditional and raw task load index (TLX) correlations: are paired comparisons necessary? In: Mital A, editor. Advances in industrial ergonomics and safety. London: Taylor & Francis; 1989. p. 481–5.Google Scholar
  28. 28.
    Bouchard S, Robillard G, Renaud P, et al. Exploring new dimensions in the assessment of virtual reality induced side effects. J Comput Inf Technol. 2011;1(3):20–32.Google Scholar
  29. 29.
    Bangor A, Kortum P, Miller J. Determining what individual SUS scores mean: adding an adjective rating scale. J Usability Stud. 2009;4(3):114–23.Google Scholar
  30. 30.
    Rosen KR. The history of medical simulation. J Crit Care. 2008 Jun;23(2):157–66.CrossRefGoogle Scholar
  31. 31.
    Moorthy K, Munz Y, Forrest D, et al. Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance. Ann Surg. 2006 Jul;244(1):139–47.CrossRefGoogle Scholar
  32. 32.
    Chang TP, Gerard J, Pusic MV. Screen-based simulation, virtual reality, and haptic simulators. In: Grant VJ, Cheng A, editors. Comprehensive healthcare simulation: pediatrics: Springer; 2016. p. 105–14.Google Scholar
  33. 33.
    Yiannakopoulou E, Nikiteas N, Perrea D, et al. Virtual reality simulators and training in laparoscopic surgery. Int J Surg. 2015 Jan;13:60–4.CrossRefGoogle Scholar
  34. 34.
    Botden SM, Jakimowicz JJ. What is going on in augmented reality simulation in laparoscopic surgery? Surg Endosc. 2009 Aug;23(8):1693–700.CrossRefGoogle Scholar
  35. 35.
    Huber T, Paschold M, Hansen C, et al. New dimensions in surgical training: immersive virtual reality laparoscopic simulation exhilarates surgical staff. Surg Endosc. 2017 Nov;31(11):4472–7.CrossRefGoogle Scholar
  36. 36.
    Huber T, Wunderling T, Paschold M, et al. Highly immersive virtual reality laparoscopy simulation: development and future aspects. Int J Comput Assist Radiol Surg. 2018 Feb;13(2):281–90.CrossRefGoogle Scholar
  37. 37.
    Zheng B, Jiang X, Tien G, et al. Workload assessment of surgeons: correlation between NASA TLX and blinks. Surg Endosc. 2012 Oct;26(10):2746–50.CrossRefGoogle Scholar
  38. 38.
    Elhage O, Challacombe B, Shortland A, et al. An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison between robot-assisted, laparoscopic and open approaches. BJU Int. 2015 Feb;115(2):274–81.CrossRefGoogle Scholar
  39. 39.
    Paige JT, Yu Q, Hunt JP, et al. Thinking it through: mental rehearsal and performance on 2 types of laparoscopic cholecystectomy simulators. J Surgical Educ. 2015 Jul-Aug;72(4):740–8.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Jessy Barré
    • 1
    Email author
  • Daphné Michelet
    • 1
    • 2
  • Jennifer Truchot
    • 3
    • 4
  • Erwan Jolivet
    • 5
  • Thomas Recanzone
    • 5
  • Sabrina Stiti
    • 5
  • Antoine Tesnière
    • 1
    • 6
  • Guillaume Pourcher
    • 1
    • 5
    • 7
  1. 1.Ilumens, Université Paris DescartesParisFrance
  2. 2.Department of AnesthesiaRobert Debré HospitalParisFrance
  3. 3.Ilumens, Université Paris DiderotParisFrance
  4. 4.Emergency departmentLariboisière HospitalParisFrance
  5. 5.VirtualiSurgNeuilly-sur-SeineFrance
  6. 6.Department of Anaesthesia and Intensive CareGeorge Pompidou European HospitalParisFrance
  7. 7.Centre de prise en charge de la maladie obésité, Département digestifInstitut mutualiste MontsourisParisFrance

Personalised recommendations