350 information) as indicated by previous research.17 During this training novice surgeons were asked to self-assess their own knowledge and surgical skills to assess if novice surgeons are prone to overconfidence biases and over-assessment of skills whilst learning RAS. After participating in the training, the participants were asked if they possessed all competencies described in the BPR.11 We found novice robot surgeons were too positive in the self-assessment of their own surgical skills after a training in RAS. This is in line with previous studies describing overconfidence biases.22,23 To prevent overconfidence biases the novice surgeons should be provided with feedback to inform them about their results to enhance learning and inform them of their competence levels. One method of feedback commonly used in training surgical skills is proctoring. Proctoring is a form of training where an experienced trainer supervises the trainee during the procedure and provides real-time feedback, in order to guide and assist the trainee during the acquisition of new skills.24 Proctoring is widely used in the operating room to train novice surgeons but is scarcely implemented in simulator based training due to time consumption and related costs.17,25,26 An alternative to human proctoring is the interactive task and procedural guidance by the simulator (Simulator generated guidance (SGG)) SGG is an option available on the newest simulation systems. SGG is provided by the VR simulators to guide the trainee through the steps of a surgical procedure using visual cues.27 An advantage of SGG is the possibility to assess the effect of various training curricula on the progress of the surgeon’s surgical skills. Effective training and assessment of performance are fundamental for surgeons to reach their goals and operate safely.13,28 Chapter 3 focusses on the effects of proctoring and SGG on surgical skills acquisition and participant satisfaction during surgical skills training in novice surgeons. We show that surgical skills in RAS can be significantly increased after practicing basic and advanced simulation exercises for two hours on a VR simulator. This is consistent with the findings of Brinkman et al.29 Although the participant satisfaction seems to be higher in the “human proctoring” group. The lack of difference in acquisition of surgical skills between the intervention groups seems to indicate there is a limited impact of “human proctoring” and “simulator generated guidance” during the initial phase of surgical simulation training. The exposure of novice surgeons to the robotic surgery simulator alone could possibly be enough to achieve a significant improvement of surgical skills during the initial steps of training RAS. Although VR simulators have a substantial place in the training of RAS only limited studies have proven the transference of skills learned during VR simulator training to real life situations.30,31 This is why, even though VR simulators are an integral part of most structured curricula, other modalities of training (dry lab and wet lab training)
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