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The Role of Simulators in Safe Adoption of Endoscopic Mitral Valve Surgery 279
Fig. 1 Final version of the simulator. A and B,Viewofthe
assembled simulator. C and D, Feedback system. E and F,
Magnetic,papillary muscles mounted in the 3-dimensional–
printed ventricle. Reprinted from The Journal of Thoracic
efficient learning without feedback [16]. To create a learning platform for mitral valve surgery,
one should receive objective and reproducible
feedback to gain proficiency and become
acquainted with the procedural steps. Moreover,
procedures as MIMVS are composed of many
layers of complexity. Four cameras around the
and Cardiovascular Surgery, Volume 157, Nia, P. S.,
Daemen, J. H., & Maessen, J. G, Development of a highfidelity minimally invasive mitral valve surgery simulator,
1567–1574, 2019, with permission from Elsevier [18]
silicone valve and an edge detectable algorithm
to calculate the suture width and depth were
installed [18]. This way, the simulator provides a
metric-based performance feedback about suturing depth and length. The idea behind having
feedback about suturing is not to mimic the exact
suture depth or width of an actual operation. The
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objective is to provide a platform on which a
surgeon could develop full control over the longshafted instruments in way that any pre-setted
suturing could be realized. Additional to this, the
metric-based feedback gives objective scori ng
for assessments of trainees.
Especially in the beginning, expert feedback
is necessary for the most effective use of the
simulator. The combination of formative and
objective feedback is the basis for long- term
knowledge retention.
3 Patient Specific 3D Mitral Valve
Modelling for Training Purpose
In the simulation-based training, we use 3Dmodelling and printing of the mitral valve to
interact with different anatomy and pathology.
We developed a dedicated process to replicate
any mitral valve pathology in 3D-printed silicone
replica from TEE. This process can roughly be
divided into six major steps, namely data acquisition, data conversion, mesh refinement, rapid
prototyping, negative mould fabrication and
casting (Fig. 2).
Mandatory components in 3D-modeling are
clinical imaging modal ities. Imaging data is
obtained by 3D transoesophageal echocardiography (TOE). These high-quality volumetric 3D
images are convert ed into Cartesian Digital
Imaging Communications in Medicine (DICOM)
format. The mitral valve annulus and the leaflets
are reconstructed. Because of technical difficulties it is not yet possible to reconstruct the subvalvular apparatus. The mitral valve is
reconstructed in the mid-systolic phase to
reproduce the coaptation defect. The data is
exported to a Surface Tessellation Language
(STL) file, the standard format for 3D printing.
In the third step, mesh refinements are conducted in MeshLab (Istituto di Scienza e Tecnologie dell’ informazione, Pisa, Italy) and
subsequently manufactured into a model on 1:1
scale. Printing is accomplished by selective laser
stereolithography, which is the golden standard
in 3D bio model production. The model is casted
in a deformable silicone to mimic true-to-nature
suture experience by negative mould fabrication
and silicone-casting [19].
4 Clinical Applications
In generic terms, simulation-based training refers
to an artificial representation of a realistic process
to achieve educational goals throughout experiential learning. The acquisition of many technical
and nontechnical skills is moving outside the
operative theatre, using simulation-based training. Achieving surgical competence in complex
surgery, such as MIMVS, requires surgical
volume.
The use of high-fidelity simulators in MIMVS
can serve different purposes. It can be used for
training surgeons, for preprocedural planning and
Fig. 2 Step by step process for solid and silicone 3D print fabrication. Reprinted with permission from The Journal of
Visualized Surgery, https://doi.org/10.21037/jovs.2019.05.01 [25]
The Role of Simulators in Safe Adoption of Endoscopic Mitral Valve Surgery 281
for assessment and certification of skills. Furthermore, the simulator can also be used for
product development, testing new instruments,
refining, and developing new surgical techniques.
For example, by using the simulator, a suturing map was designed after identifying the most
effective suturing sequences and techniques with
minimal tissue manipulation and maximal visual
experience (Fig. 3). Additionally, it was evaluated successfully in the operating room and used
in course to evaluate its teachiblity [24].
Furthermore, we conducted a study to develop
a process for modelling and 3D- printing for
preoperative planning and procedural simulation
by analyzing 10 prospective patients with different mitral valve pathologies. This study
demonstrated the additional benefit of the
designed and printed models, which can be
implanted in the simulator to improve preoperative planning and simulation of complex surgeries for training purposes. The case below is to
illustrate the process [19].
Mitral valve repair for posterior leaflet prolapse
and annular dilatation
A 63-year-old man presented on the outpatient
clinic with severe mitral valve regurgitation
based on posterior leaflet prolapse and annular
dilatation. The patient was discussed in our
multidisciplinary consultation and was found
eligible for mitral valve surgery. A normal right
and left ventricular function with an end diastolic
dimeter of 58 mm was seen on transthoracic
echocardiography. Transoesophageal echocardiography showed severe mitral valve regurgitation with an eccentric jet due to P2 prolapse
with chordal rupture. Additionally, there was a
mild P1 prolapse, a minimal trace of tricuspid
valve insufficiency and no signs of aortic insufficiency. Computed tomography showed no
contraindications for peripheral cannulation and
the patient was accepted for MIMVS. A silicone
mitral valve was created by 3D modelling and
printing, and eventually mounted in the simulator
for in vitro preoperative planning (Fig. 4).
Fig. 3 Suturing map. A: Reversed forehand position, B:
Backhand position, C: Reversed backhand position, D:
Forehand position. Images provided courtesy of The
Multimedia Manual of Cardio-Thoracic Surgery https://
mmcts.org/tutorial/1041 [24].
282 L. Aerts and P. Sardari Nia
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Fig. 4 Silicone model showing posterior leaflet pSilicone model showing rolapse and annular dilatation. Reprinted
with permission from The Journal of Visualized Surgery, https://doi.org/10.21037/jovs.2019.05.01 [25]
During the simulation 2 neochordae were
placed in the P2 segment. 1 neochord was placed
in the P1 segment and another one was placed in
the P3 segment. To stabilize the mitral valve
annulus and the repair, a semi-rigid annuloplasty
ring (size 34) was fitted into place (See Video 1).
The patient was than operated the next day
simulating the operation done in the simulator
with successful result [25].
Structural training
Simulation based training may help residents to
achieve proficiency in basic and more complex
surgical skills, while practicing surgeons can
develop new strategies or learn new techniques
more swiftly. This type of education is already
implemented in laparoscopic surgery and has
simulators but how we should implement simulation-based training.
First, we shoul d acknowledge that simulationbased training is no substitute for traditional
apprenticeship training. We showed that the highfidelity minimally invasive mitral valve surgery
simulator is a valuable tool for the development
and assessment of endoscopic mitral repair skills.
Subsequently we designed an air-pilot training
concept, through European Association for Cardiothoracic Surgery (EACTS), Endoscopic Mitral
Valve Repair Course. This 2-day course design
was based on the following basic learning
objectives (Fig. 5).
1. Awareness
2. Acquiring theoretical knowledge
3. Acquiring endoscopic skills.
been proven to be effective by reducing the
learning curve in vivo procedures [8]. The
question is no longer if we should practice on
Firstly, it is important for the participants to
get introduced to the mitral valve simulator and
The Role of Simulators in Safe Adoption of Endoscopic Mitral Valve Surgery 283
Video 1 Mitral valve repair for posterior leaflet prolapse and annular dilatation. Available online:
http://www.asvide.com/article/view/32377. Reprinted with permission from The Journal of Visualized Surgery,
https://doi.org/10.21037/jovs.2018.09.07 [26](▶ https://doi.org/10.1007/000-a8g)
Fig. 5 Overview of the philosophy of simulation based
training and its inclusion in the endoscopic mitral valve
course in our centre. 3D: three-dimensional. Reprinted
from Interactive CardioVascular and Thoracic Surgery,
Volume 30, Issue 5, Peyman Sardari Nia, Samuel Heuts,
Jean H T Daemen, Jules R Olsthoorn, W Randolph
Chitwood, Jr, Jos G Maessen, The EACTS simulationbased training course for endoscopic mitral valve repair:
an air-pilot training concept in action, 691–698, 2020,
with permission from Elsevier [26].
284 L. Aerts and P. Sardari Nia
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Fig. 6 Simulation based training for endoscopic mitral
valve repair: an air-pilot training concept in action.
Reprinted from Interactive CardioVascular and Thoracic
Surgery, Volume 30, Issue 5, Peyman Sardari Nia,
Samuel Heuts, Jean H T Daemen, Jules R Olsthoorn, W
create awareness for the demanding skills,
knowledge, organization and teamwork before
starting the endoscopic mitral valve programme.
Additional to this, one should focus on acquiring
the complemental theoretical knowledge and
technical skills (for example the use of longshafted instruments and the use of video assistance) for simulation-based training on MIMVS.
One hundred two participants completed the
full endoscopic mitral valve programme between
February 2016 and September 2018. 83 (83.3%)
participants were staff/attending surgeons, 12
(11.8%) participants had finished residency and 5
(4.9%) participants were residents.
The course started with theoretical and technical skills pre-assessment on the simulators.
During the course formative feedback was provided by an expert on MIMVS and metric-based
feedback was provided by the simulator. At the
end of the course there was a theoretical and
technical skills post-assessment and a course
evaluation with follow up.
The study showed significantly higher theoretical knowledge of endoscopic mitral valve
surgery after completion of the mitral valve
programme compared to before the training
Randolph Chitwood, Jr, Jos G Maessen, The EACTS
simulation-based training course for endoscopic mitral
valve repair: an air-pilot training concept in action, 691–
698, 2020, with permission from Elsevier [26]
(median score 58% vs. 67%, P < 0.001). Furthermore, participants significantly improved
their technical skills on the simulator in terms of
accuracy (suture accuracy 43% vs. 99%,
P < 0.001) and speed (87 vs. 42 s., P < 0.001) in
the pre—and post-assessment of technical skills
on the simulator, regardless of the expertise level
or trainee’s position (Fig. 6). We showed that by
practising on the simulator one significantly
improves the accuracy and speed of endoscopic
suturing on the simulator, independent from the
expertise level [26].
5 Future Perspectives
For future, we envision a training trajectory
rather than a single course. Successful adaption
of a new procedure requires structural and
repetitive training. To develop and optimize a
MIMVS curricula that incorporates simulation,
one should have an air-pilot training concept
course and accessibility of simulation models at
the institution or at home to continue practicing. During the training one should receive
The Role of Simulators in Safe Adoption of Endoscopic Mitral Valve Surgery 285
Fig. 7 Timeline of the air-pilot concept programme with
inclusion of the training at our course, simulation and
proctoringat the participants’ home centre and actual start of
a self-managed programme. Reprinted from Interactive
CardioVascular and Thoracic Surgery, Volume 30, Issue 5,
mentorship and proctorship to gain formative
and metric based feedback. Finally, a clinical
objective certification may be commissioned
(Fig. 7)[24].
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Trial of Current 3D Imaging Systems
Ludwig Müller
Abstract
The use of an endoscope in surgery is now
commonplace in many specialities. Unfortunately for patients its use in cardiac surgery
has had a slow uptake. Gradually more
surgeons are starting to trial it out and are
getting encouraging results. The introduction
of 3D endoscopes was originally only as a part
of a robotic system but over the past few years
more industry partners have started to supply
endoscopes capable of three dimensional
visualisation. This chapter goes through the
advantages and disadvantages of all the systems currently available on the market and
also covers reasons to consider the use of
these advanced imaging options in cardiac
surgery. The final decision will need to be
made by the surgeon and his team regarding
this technology but we hope this chapter acts
as a good introduction for those starting to
look at this technology.
Keywords
3D videoendoscopyEndoscopic cardiac
surgery
Human visionConvergence
1 Introduction
Endoscopic 3D imaging systems have heavily
influenced the practice of minimally invasive
mitral valve surgery, isolated as well as in combination with tricuspid, atrial fibrillation ablation
and atrial septal surgery including benign atrial
tumours [1]. To a lesser extent but very important
also endoscopic aortic valve replacement has
been made feasible [2]. 3D video endoscopy had
originally been limited to robotic systems [3–5]
but was made available separately in 2014, i.e.
without the extensive high tech and costly features of a surgical robotic system. Interestingly,
one of the first 3D video systems using rod lenses
and introduced successfully for minimally invasive cardiac surgery was and is still made by the
same manufacturer (Schölly Fiberoptic GmbH,
79211 Denzlingen, Germany) as the 3D endoscope of the “Da Vinci SI” Surgical System”
(Sunnyvale, CA USA).
In 2021 various 3D video endoscopic systems
are on the market and merit an in-de pth analysis
of function and use in daily practice as well as
teaching.
Before the most up to date technology is
analyzed it is reasonable to spend a few thoughts
on human vison and 3D perception.
L. Müller (&)
Department of Cardiac Surgery, Medical University
Innsbruck, Innsbruck, Austria
e-mail: ludwig.mueller@tirol-kliniken.at
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_20
First, we have to realize that 3-dimensional
vision and binocular or stereoscopic vision is not
necessarily the same. Therefore also the term
“3D imaging” might be misleading.
287
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As we know from daily experience also single
eyed, i.e. monocular vision works well for a 3dimensional perception of our environment.
Single eyed people are perfectly capable of car
driving for example. And lots of pseudo 3D
images are cheating us, e.g. in street art [6]. This
is due to so called “monocular cues” of 3D
vision. More on that later.
Second: In addition to monocular cues depth
perception is highly facilitated by so-called
binocular cues, i.e. stereoscopic vision or stereopsis. Different binocular cues contribute to a 3D
image. Here 3D imaging systems come into
place. Most interesting and striking news for
those not specialized on this topic may be that we
can perceive depth even if there is no 3dimensional structure at all. This was studied
intensively by Bela Julesz by construction of socalled random dot stereograms [7]. More on that
also below.
Briefly, depth perception can be accomplished
by monocular and binocular cues and does not
necessarily require a real 3-dimensional
structure.
Third: We must apprehend that our eyes are not
video cameras which record images or movies,
but vision takes place exclusively in the brain.
We discern between sensation and perception.
Sensation is the process located in the eyes when
photons activate receptors in the retina which
send electrical signals to the brain. Now the
highly complex process of perception, i.e. vision
takes place. It involves a number of different
brain areas located not just in the visual cortex
but distributed widely over the brain. At the end
our inner image appears in the frontal cortex
including the perception of depth, i.e. 3D vision.
And this process is not just complex with many
different circuits involved, it is also not unidirectional, that means our final vision is also
determined by earlier experience and not limited
to the visual sense but strongly determined also
by multiple other e.g. tact ile inputs. Multiple
signals travel from the frontal cortex back to the
thalamus and optical cortex thereby influencing
the signals from the visual cortex which are sent
to the frontal cortex. This complex process is
understood today only in part. Seeing without
experience of the other sensory organs is not very
helpful in daily life. It is demonstrated impressively by the history of Mike May [8] who lost
his eye sight by a chemical explosion at the age
of three. Although normal eye function was
widely restored at the age of 46 by successful
surgery, he did not regain normal vision, being
unable to grasp three-dimensional vision and to
recognize members of his family by their faces
alone, as he says. This is of importance also for
the understanding of our requirements on a surgical endoscopic video system.
The following is a short overview of the basics
of 3D vision which may be important for the
surgeon using a 3D imaging system. It is not a
summary of actual knowledge on vision in
neurophysiology and neuropsychology
Monocular cues for depth perception [9, 10]:
Relative size: familiar objects appear smaller in
distance.
Texture gradient: on closer objects more
details of surface structure can be seen.
Height in field of view: distant objects tend to
appear higher in our field of view than closer
ones.
Linear perspective: parallel lines e.g. railway
rails appear to converge in the distance.
Aerial (atmospheric) perspective: effect of the
atmosphere on the appearance of objects in the
distance. They appear bluer.
Light and shadow: are strong indicators as
they appear only in three dimensional structures.
Interposition (overlap, occlusion): an object
which obstructs the view of something else is
closer.
Defocus blur: because the depth of focus of
the human eye is limited distant objects appear
blurred.
Motion parallax (while the observer moves
objects of different distance appear to move at
different speed).
Depth from motion is calculated by use of the
changing size of an object moving towards or off
the observer.
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