Effect of Video Games Playing on Surgical Simulation Training: a Systematic Review

1 Department of Pathophysiology, Medical University of Plovdiv, Plovdiv, Bulgaria 2 Department of Surgical and Perioperative Sciences, Umeå University, Luleå, Sweden. 3 First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece. 4 Medical Simulation Training Center at Research Institute of Medical University of Plovdiv, Plovdiv, Bulgaria.


INTRODUCTION
Patients' safety requirements have led to train health care staff in simulated settings in order to reduce cost and patient morbidity and mortality. Technological applica-tions of virtual reality, simulation, and e-learning have resulted in improved learning metrics, and they are already integrated in laparoscopic surgical training. [1][2][3] At the same time, there is evidence that video games increase visuospatial attention and spatial resolution 4,5 , while they enhance the hand-eye coordination. 6 Several studies have assessed the impact of video games (VG) on laparoscopic skills and suggested that video games could be means for surgical training. The sought applications of VG vary considerably, hence the results are different. Still, the fact that some game manufacturers have invested in creating "serious" games -that is, games played on commercially available platforms purposefully designed to train specific skills is indicative enough. This article intends to systematically review studies that evaluate the impact of video games on laparoscopic skills.

MATERIALS AND METHODS
This systematic review was conducted by searching medical literature in MEDLINE and SCOPUS, guided by the PRISMA protocol. 7,8 The last search was conducted in April 2020. All retrieved article titles and abstracts were screened for relevant manuscripts. The next step was a full text review of the selected relevant articles in order to identify the studies suitable for inclusion in this systematic review.
Relevant full text review manuscripts or systematic review manuscripts were not included in the study; however, they were used to retrieve suitable articles from their reference list and add them to this systematic review.

Inclusion and exclusion criteria
Of the articles retrieved, using the above-described search strategy, we included in this systematic review only those articles that met the following criteria: -Studies involving surgeons and/or surgical trainees, and/or residents, and/or fellows of any surgical subspecialty. Also, we included studies that were conducted using students as subjects, while those using nurses as subjects were excluded.
-Studies focused on performance during surgical operation and/or surgical simulation setting were included. Studies on non-surgical related interventions were excluded.
The included studies investigated the effects of commercially available games (both in terms of hardware and software). Studies involving only the so called "serious games" were excluded.
The search yielded 81 articles. Two of the authors (K.G. and L.E.) independently screened the abstracts of the retrieved articles that were assessed as meeting the inclusion criteria, and any differences were resolved by discussion. Forty-six articles were found suitable for further examination. Thereafter, a full text review of those articles was carried out. Finally, a total of 26 articles fulfilling all of the above criteria, were included in the review (Fig. 1).
Regarding the main purpose of the studies, they were divided into three different groups -prospective (9 studies), retrospective (5 studies) and interventional (12 studies).

RESULTS
The included studies could be divided in several different groups: Prospective studies (Table 1) These studies aimed at predicting future potential of developing laparoscopic skills by experience and/or current proficiency in video gaming.
In one of the early studies, Shane et al. 9 compared fourth-year medical students with first-year surgical residents on a virtual reality (VR) simulator and found out that "gamers" (described as having more than 3 hours per week of VG playing) acquired new skills faster than non-gamers. Interestingly, the initial apprenticeship of the gamers was lower which may be due to the overconfidence of that group dealing with something seemingly familiar, while in the other group the participants were highly concentrated from the start.
In two studies (Boyd et al. 10 , Moglia et al. 11 ), in addition to video games exposure, the ability to play a musical instrument was also assessed. The skills and dexterity needed for this artistic activity seemed to benefit laparoscopic performance.
Salkini et al. 12 also report that among medical students naive to surgery and surgical simulation, expert video game players performed different tasks on the Simbionix Lab Mentor II faster and with less overall movement as compared to their non-playing counterparts.
In another study, among 38 medical students inexperienced in surgery, Kennedy et al. 13 found that regular exposure to VG (minimum of 7 hours per week) turned out to be related to significantly better psychomotor skills, although not affecting visuospatial and perceptual capabilities -all of which were tested using a VR laparoscopic surgery simulator.
Besides medical students and residents, a couple of prospective studies were targeted at teenagers (Fanning et al. 14 ) or even at younger children (Rosenthal et al. 15 ). Both studies reported a beneficial effect of playing video games.
However, there is no uniform assumption that video gaming has a beneficial effect on potential laparoscopic skills.
Rosenberg et al. 16 tested 11 medical students by having them play 3 commercially available games. After that, all students performed four laparoscopic tasks on a porcine model. There was a weak correlation between the performance in the VGs and in the laparoscopic tasks which was not significant. Then, the students were divided into a control group and a training group which had to play video games every day for 2 weeks. On the subsequent retest there were no differences between the "training" and the control group.
Madan et al. 17 tested a group of 51 students in a box trainer or a virtual reality trainer. All participants filled in a questionnaire reporting their experience with computer games, playing musical instruments, using chopsticks and few other dexterous activities. Even though the students with pre-existing non-surgical skills performed slightly better on the surgical trainers, there was no statistical significance.
Furthermore, except for the studies which find no significant correlation between video games exposure and laparoscopic skills, the study of Harper et al. 18 found a negative effect of prior gaming.
In another study by Halvorsen et al. 19 , 48 high school students were recruited to perform two tasks on a virtual reality surgical simulator (SurgicalSim Education Platform -SEM). Their VG experience was assessed by self-reported questionnaires taking into account current and past regularity of video game playing. No association was found between VG exposure and baseline surgical simulator scores, suggesting that gaming per se could not be a reliable predictor for surgical skills. Similar results were obtained by Moglia et al. 20 with 121 medical students who were tested on a Da Vinci Skill Simulator as exposure to video games did not seem to affect the performance on the surgical simulator.

Retrospective studies (Table 2)
In these studies, the subjects were surgeons with some prior experience in surgery and their VG exposure in the past was taken into account when assessing their current skills. Some of the studies focus not only on already acquired skill level but also on the speed and ease of learning.
One of the first studies assessing this issue was performed by Grantcharov et al. 21    with little experience. They were subjected to different tasks performed on a minimally invasive surgical trainer -virtual reality (MIST-VR) simulator for one month. Experience with VG was assessed through self-reported questionnaires and it turned out that people with current or previous experience of playing such games performed better than the others. Rosser et al. 22 also found a positive correlation between previous or current VG experience and laparoscopic skills, measured by the TopGun laparoscopic Skills and Suturing Program.
Lehmann et al. 23 , in a training laparoscopy course, found that previous computer game experience strongly influenced manual skills -particularly lifting and grasping. In their study, 80% of the participants (84 out of 105) had general experience with computers but only 16% (17 subjects) were gamers and initially performed significantly better.
High-school students and non-medical college students were compared to resident surgeons using several laparoscopic training platforms in a study by Borahay et al. 24 The authors showed that on simple tasks, the performance between the two groups was very similar, while, expectedly on the more complex tasks the surgeons outperformed the students. The students had a significantly higher VG experience, and it was speculated that if the resident surgeons had the same experience, they could probably be even better at the simple tasks. A question is also raised -does that mean that current generation students with VG experience would be better learners when it comes to minimally invasive or robotic-assisted surgery?
In a specially organized laparoscopic course for medical  25 found out that the intrinsic skills of males and of those who were VG users were better than the rest. The assessment after the course showed that females and non-gamers were able to "catch-up" with the others, so the advantage of gaming did not persist after a specialized training had been performed.
Interventional studies (Table 3) In these studies, the utility of video games as a training tool or a warm-up procedure was assessed. The potential of this idea is appealing because gaming is not comparable to surgical simulators in terms of accessibility, price, availability and mobility and thus could serve as a great alternative to the sophisticated surgical simulators and training devices. Schlickum et al. 26 , in one of the first studies to assess the utility of VG as a training tool, allocated 22 surgical novices into three different groups -a control group and two training groups: one playing a 3-D first person shooter (FPS) game and the other playing a 2-D game. The subjects were tested in the MIST-VR and on the GI-Mentor surgical simulators before and after training. The results showed that there is a significant transfer effect of the skills acquired practicing a 3-D video game into manipulating the simulators. It is worth mentioning that people with previous FPS experience have better initial results as well.
In a test group of similar size (21 residents), Bokhari et al. 27 tested the applicability of Nintendo Wii as a take-home practicing tool for surgical skills. Fourteen subjects played a commercially available game -Marble Mania using a specific physical controller. The other 7 subjects did not play and served as controls. When compared for their electrocautery tasks performance, it turned out that the training group made fewer mistakes, had better ambidexterity and faster time for completion.
Boyle et al. 28 tried to answer a similar question but among students -they recruited 22 people without previous VG experience and allocated them to two groups -control group and training with Nintendo Wii group. Playing the Nintendo game at home for a week did lead to better results in the simulated laparoscopic tasks but the difference was not significant.
Nintendo Wii was used also by Gianotti et al. 29 as a training tool for 42 first-and second-year residents in different surgical departments -general, vascular and endoscopic. The intervention group were given 4 weeks of systematic training (1 hour a day, 5 days a week) and then reassessed at the same simulator tasks on Lap Mentor by Simbionix and the control group just did the two tests. Out of 16 measurable variables concerning the performance of the subjects, 13 improved significantly in the gaming group. There was improvement in the control group as well, but it was not significant and the control subjects were outperformed by their peers who had trained on Nintendo Wii.
Adams et al. 30 went even further and compared the effectiveness of training with two different gaming consoles (Xbox 360 and Nintendo DS) versus a traditional laparo-scopic simulator among residents in surgery. Both gaming devices led to greater improvement of surgical motor skills compared to non-gamers. Moreover, the subjects in the gaming arms of the study shared that playing VG was fun and helped them lower their stress levels. Cooperative play on the other hand, contributed to building relationships among colleagues.
Ju et al. 31 also compared two different gaming consoles (Nintendo Wii and PlayStation 2) but this time rather as a warm-up tool than a training tool (gaming sessions were just 30 minutes) among physicians and students. The results were somewhat better after a gaming warm-up session, but were not statistically significant.
The utility of VG as a training tool among students with no surgical experience was tested by Middleton et al. 32 in a single-blinded randomized prospective study. Nintendo Wii was the console used in this trial and 23 students were divided into three groups and assessed on a Simbionix Lap-Mentor VR laparoscopic simulator at baseline and after two weeks. Those who had played the Nintendo significantly outperformed their peers.
Since the availability and affordability of the Nintendo Wii console is not comparable to the sophisticated surgical simulators, this led to development of special games that aim at training certain skills. Araujo et al. 33 and Rosser et al. 34 compared the effectiveness of "serious games" with commercially available ones (with primary objective -entertainment) in terms of surgical skills development. Both teams concluded that both types of games have their role and they should be used in combination rather than alone.

DISCUSSION
Although plenty of studies have been conducted in the field of VG-acquired skills and their applicability in surgical stimulators, no firm conclusions have been drawn so far and there are several reasons for this. First, the questions initially asked are different and could be roughly categorized as observational studies -both prospective and retrospective and interventional ones trying to assess the utility of VG-related skills as a training or warm-up tool. Furthermore, different teams used many different methodologies and therefore the end results spurred in different directions. The subjects on which different papers focus range from school children to surgical residents with various levels of experience. The platforms being used (Nintendo, Xbox, PlayStation, etc.) also vary, as well as the gamesincluding different genres (action, shooting, sports, adventure, strategy, etc.). Some of the researchers assess the impact of other widespread activities that are directly related to manual dexterity as playing a musical instrument, for example. Even among a group of studies trying to answer the same question, there is great incomparability in regard to the testing timeframes -ranging from several hours to several weeks and of varied intensity. Folia Medica I 2021 I Vol. 63 I No. 5 Another hindrance is the relatively difficult access to facilities like surgical simulators -given their price, availability and occupancy by surgeons and trainees. That being said, almost all published papers share the limitation of a very small sample size, usually ranging from 10-12 to 20-25 subjects in total which cannot provide statistical significance, not to mention the studies with several different groups. Of course, there is also the question of how accurately the different surgical stimulators reflect the actual operating environment which requires a completely different approach. Therefore, this review does not claim to answer that question at all.
The prospective studies are the most abundant in our review, and they are also the only ones that include negative conclusions. On the other hand, retrospective studies do show some statistically significant advantage among gamers as compared to their peers, so a plausible explanation of this discrepancy is that gaming really does lead to a small advantage while acquiring surgical skills, but the effect is too slim to tip the scales of statistical significance and a lot of other factors (training, experience, dexterity, etc.) also play a role in forming a skilled surgeon.
A combination of a retrospective and an interventional approach would be necessary to assess whether the advantage that might come with VG experience refers to current skill level or rather the ability to learn more quickly or probably -to both. The review by Green CS 35 emphasizes the learning effectiveness.
Given the variety of studies and their results, it is expected to have reviews which come to different conclusions -both positive (Jalink) 36 and negative (Glassman) 37 . Those results just underline the need of a more systematic approach to the problem which would hopefully bring more sound results.
Video games do not tend to decrease their presence in our lives, especially the lives of the younger generations, in fact, we could expect that this field would develop further and become even more popular, and at the same time, more affordable. Similar things could be said about robotic surgery, endoscopic procedures, and the different simulators designed to prepare better physicians. Utilizing a method that could train dexterity, hand-eye coordination and visual-spatial orientation that could be both fun and cheap is an extremely tempting goal. However, for this to be properly backed up by scientific evidence, further efforts are needed.
The view of the authors of this review is that adequate study designs should be carefully devised and ideally applied in multicentric studies in order to obtain larger data volumes. The questions being asked should be accurate and precise and the methodologies -standardized. Thus, the potential benefits (and flaws) of gaming in acquiring surgical skills could be outlined and the items that prove to be helpful might be included in official curricula in surgeryrelated training centres. At the same time, of course, the research on how close virtual stimulators are to real life operations should definitely continue. 38

CONCLUSIONS
Video games -a source of entertainment in general -are extremely widespread nowadays and are being enjoyed by millions regardless of age and sex. It has been postulated that video game experience could give some advantages in laparoscopy. However, any previous video games experience as a catalyst of acquiring new skills in surgery has not produced any strong evidence so far. This review revealed that this might be due to the various aims, approaches and results of the different studies. However, although video games could be used as a daily warm-up or as a tool to speed up mastering new skills, their exact value remains to be elucidated in further, more focused studies.