INTRODUCTION

METHODS

A prospective, longitudinal, randomized and controlled study, approved by the Research Ethics Committee was conducted. The VARK (2017) questionnaire and the multiple intelligences questionnaire proposed by Gregorc (Mind Styles) were acquired online. After printing, each participating student received one copy of each quiz.

Intern medical students from the Erasto Gaertner Hospital, aged between 18 and 25 years old, attending between the second and fourth years of medical school in the city of Curitiba, state of Paraná, Brazil, were included. All those with experience in virtual reality or video games, those with degenerative diseases or visual disorders were excluded. Students that did not complete all the planned steps were also excluded.

The students were invited to participate in the project by e-mail. Sixty-three students were selected according to the inclusion criteria and then randomized into control (C), laparoscopy (L) and robotics (R) groups. All of them signed an informed consent form. The sample number was directly related to the number of interns available to participate, as well as the availability of the simulator for the study.

Sixty-one students were included. Randomization was performed right after the students’ check-in. Subsequently, they were informed of the study schedule and objectives. A pre-test was then applied, which included ten true-or-false statements regarding the operative technique. At the end, a thirty-minute lecture was given, with surgical-clinical content. A post-test, containing the same questions as the pre-test was then applied, as well as version 7.8 of the VARK questionnaire (2017) and the Mind styles. The pre-test, post-test and questionnaires were common to all groups. At the end of the post-test, the students in the L group were referred to a surgical knot exercise in the Johnson & Johnson^® laparoscopic box for sixty minutes. The students in the R group were referred to perform the same exercise for the same period, but on the dVSS^® platform. The C group did not train. After the end of the activities, an exercise in the laparoscopy box, called ‘practical test’, was applied to all students, in which the students’ performances were evaluated. The students from the L and R groups, at the end of the sixty-minute training, and those in C group, who did not train, had the objective of performing a surgical knot in the laparoscopy box within a ten-minute period. For this purpose, a specific evaluation form was created, considering time to perform the exercise and occurrence of critical errors (falls, breaking the wire, lacerating the prototype, number of attempts). A scoring system was created to generate a final score for each student.

In the end, two students from the L group did not complete all the steps and were excluded from the study, totaling nineteen students in this group. The C and R groups remained with twenty-one students each.

RESULTS

DISCUSSION

When the idea of this research with medical students came up, the first question that was raised was the adherence. Higgins et al. found that the robotic operating room experience is demotivating for medical students. There is little opportunity for mastery, autonomy, and relationship development¹⁷. However, in our study, the vast majority showed interest and motivation to participate. Another challenge was related to the availability of the dVSS^® for training, as our robotic training center was the first in the state of Paraná and, therefore, an essential part of the implementation of other robotic services and training of surgeons in the technology.

All aspects of medical education have been severely impacted by the pandemic. There is an increased interest in simulation programs at home, which could ensure the continuity of technical skills training during the COVID-19 pandemic, particularly in highly technical and demanding surgical specialties¹⁸.

During the COVID-19 pandemic, online medical training including simulated clinical scenarios prevented training interruption and the majority of the participating students had a positive attitude regarding the perceived quality of this training modality¹⁹. In addition, the COVID pandemic limited the viability of face-to-face meetings in the previously approved model, which enabled the first adaptation - increase of preventive measures and social distancing.

The dVSS^® can be integrated with the existing da Vinci Xi or Si surgeon consoles, thus providing a practice platform to be used inside or outside the operating room, without requiring additional system components²⁰. Although there are other available platforms, this was the only one used in this study.

Each platform has the capacity to train and assess a variety of different robotic skills fundamental to the technique⁷. It can be used to assess basic robotic skills, as well as the first step in training, before moving on to more advanced tasks²¹.

A final opportunity to optimize medical student learning in robotic surgery is simulation. An additional component of robotic surgery that impacts the medical student learning environment is the influence of other students, who are also navigating through the technology’s learning curve¹⁷.

Unfortunately, most of the currently available exercises in VR simulators are generic tasks testing hand - eye coordination, tissue manipulation, dissection, suturing and knot tying. There is no evidence to suggest which exercises lead to improved real-setting performance⁷.

From the evidence available, it seems that simulation-based training does result in skills transfer to the operative setting. Simulation-based training therefore provides a safe, effective, and ethical way for trainees to acquire surgical skills before entering the operating room²².

Despite a lack of evidence for a direct relationship between VR simulation and performance on actual human cases, it has been well described that the skills gained from VR training are similar to those attained via traditional robotic dry laboratory simulation training⁶.

Laparoscopic surgery requires working in a three-dimensional environment with a two-dimensional view. Skills such as depth perception, hand-to-eye coordination and bimanual manipulation are crucial to its efficacy¹.

This makes the development of skills in standard simulators very challenging, raising the question of how much virtual reality simulators can help in the learning curve. Nonetheless, training in virtual reality simulators versus ‘standard’ laparoscopic training (the traditional apprenticeship model) did not reveal any difference in the overall operating time and complication rates (measured by number of cases converted to open surgery). Performance was assessed by parameters such as tissue handling, path length of instruments and keeping the instruments within the field of vision¹.

Training in laparoscopy, notably the Fundamentals of Laparoscopy Surgery (FLS) curriculum, is more accessible to surgery residents, but evidence is lacking as to whether these skills transfer to robot-assisted surgery²³.

Few studies have compared medical students’ exposure to virtual reality training in robotic and laparoscopy surgeons. And according to Vurgun, medical students’ initial experience with robot-assisted surgery did not differ significantly after limited laparoscopy exposure²³.

Our study did not demonstrate any statistical significance when comparing skill gains between the studied groups.

Most of the studies assess surgeons’ skills. Pimentel et al. supported the concept that the fundamental techniques of robot-assisted surgery are not influenced by the surgeon's experience in laparoscopic surgery. This may be explained by the fact that the skills required for robotic surgery are different from those acquired in laparoscopic surgery training. There are no significant differences in the performance of simulated robotic surgical tasks between surgeons with laparoscopic training and surgical residents²⁴.

Altogether, Vurgun et al., suggested that exposure to laparoscopic training, in the form of limited psychomotor skills training, does not affect initial robot-assisted surgical performance among students and supports the idea that training in robotic surgery ought to take place in a robot-assisted simulation environment²³.

In medical studies, both theoretical and practical expertise have a vital role, while repetition of hands-on practice can improve the young doctors’ professional competency. Virtual reality was found to be the best for medical students regarding both learning motivation and learning competency. Medical students and teachers may select virtual reality as a new learning methodology for curriculum learning²⁵.

Learning styles based on four sensory modalities of VARK were described by Fleming. A visual student prefers the visual mode, i.e., through seeing, whereas an aural student prefers listening techniques. Read/write students prefer reading and writing for assimilating and accommodating the information. A kinesthetic student experiences learning by performing tasks . According to Valerdi et al., multimodal-type students may be in a situation that they can shift from mode to mode, depending on the context or are satisfied only when they have had their input in all their preferred modes¹¹.

Students with an aural preference prefer to receive or give information by listening and talking. Students with a read-write preference can easily understand concepts using lists, booklets, and textbooks. Students with a kinesthetic preference favor a hands-on approach, trial and error, and real-life examples¹².

Parashar et al. compared learning styles among students using Friedman’s test. The pattern of learning styles was different, and some learning styles were more often preferred than others; this difference was statistically significant (P<0.001). In this study, aural and kinesthetic styles were preferred over other styles by the students¹¹. The same results were found in our study.

The learning style varies from one group to another based on culture, the nature of the studies and the students’ characteristics. A study carried out in Malaysia showed that the mean VARK scores of kinesthetic and read/write students were higher than those of auditory and visual students¹⁴.

Knowledge of the students’ learning styles and the characteristics that affect them is important for teachers to improve lesson plans and develop teaching methodologies to adapt them to their students’ needs. Khanal et al. showed that the majority of the medical students (53.52%) were multimodal students, with more than one VARK component. Among unimodal students, most of them were kinesthetic learners (29.6%), followed by aural, visual and read/write students¹².

Learning styles may change over a shorter time frame than over the course of a medical degree. Learning styles may indeed change based on the context, environment and topic being learned and it is likely a flexible changing trait, rather than a fixed innate trait exhibited by a student²⁶.

Another way to assess learning styles is using the GSD. The GSD focuses on the cognitive abilities of perception and ordering. Arranged via a quaternary design, the GSD sums the rank order of 10 sets of 4 words, thereby creating the Concrete Sequential (CS), Abstract Sequential (AS), Abstract Random (AR), and Concrete Random (CR) mind styles. The CS individual prefers physical, hands-on tasks that are structured (e.g., repair technician). The AS individual prefers reflective thinking tasks that provide an expression of intellect and rationality (e.g., academician). The AR individual prefers nonphysical tasks that allow emotional and interpretive expression (e.g., poetic writer). The CR individual prefers investigative tasks that incorporate risk taking or multiple options (e.g., cinematographer)¹⁶.

The undergraduate students assessed in this study showed the following distribution of styles: 89 (44.5%) were CS, 21 (10.5%) were AS, 54 (27%) were AR, and 36 (18%) were CR. These results support the findings of Gregorc, who reported the CS mind style to be the most commonly preferred, followed by the AS, AR, and CR styles, respectively¹⁶. In our study, we found similar distribution of styles.

Several studies have previously reported faster learning curves and improved retention of skills with robotic assistance as compared to laparoscopy regarding basic manipulation tasks, and improved task speeds with robotic assistance have been measured as compared to laparoscopy, but with minimal transfer effects. Other studies have stated that skills transfer effects from laparoscopy to robotic surgery may be more pronounced with difficult tasks, such as suturing. In our viewpoint, laparoscopy and robotic surgery are different domains, perhaps requiring different skills²³.

STUDY LIMITATIONS

The first limitation of this study was the number of included students. A larger number of participants would improve the results. One reason is that the medical students were from a single institution. Furthermore, with the COVID pandemic and the low availability of the robotics simulator, participation was limited, as was the possibility of extending the training time. The use of a standard assessment method could facilitate data analysis or standardize them using assessments previously described in the literature.

CONCLUSION

There was no statistically significant difference between learning styles and performance of the proposed tasks. More studies are needed to determine whether learning styles influence skill development in robotic surgery and laparoscopy.