The effect of fidelity: how expert behavior changes in a virtual reality environment.

Objectives/Hypothesis We compare the behavior of expert surgeons operating on the “gold standard” of simulation—the cadaveric temporal bone—against a high-fidelity virtual reality (VR) simulation. We aim to determine whether expert behavior changes within the virtual environment and to understand how the fidelity of simulation affects users' behavior. Study Design and Methods Five expert otologists performed cortical mastoidectomy and cochleostomy on a human cadaveric temporal bone and a VR temporal bone simulator. Hand movement and video recordings were used to derive a range of measures, to facilitate an analysis of surgical technique, and to compare expert behavior between the cadaveric and simulator environments. Results Drilling time was similar across the two environments. Some measures such as total time and burr change count differed predictably due to the ease of switching burrs within the simulator. Surgical strokes were generally longer in distance and duration in VR, but these measures changed proportionally to cadaveric measures across the stages of the procedure. Stroke shape metrics differed, which was attributed to the modeling of burr behavior within the simulator. This will be corrected in future versions. Conclusion Slight differences in drill interaction between a virtual environment and the real world can have measurable effects on surgical technique, particularly in terms of stroke length, duration, and curvature. It is important to understand these effects when designing and implementing surgical training programs based on VR simulation—and when improving the fidelity of VR simulators to facilitate use of a similar technique in both real and simulated situations. Level of Evidence N/A. Laryngoscope, 124:2144–2150, 2014