# A Serious Game to Study Reduced Field of View in Keyhole Surgery: Development and Experimental Study

## TL;DR

A serious game was developed to study how limited visibility affects performance in keyhole surgery, showing that reduced field of view significantly increases task time.

## Contribution

The paper introduces an open-source serious game to study the effects of limited field of view in keyhole surgery and gathers quantitative performance data.

## Key findings

- Reducing the field of view increased task performance time significantly (P<.001).
- Participants found the game engaging and reported better understanding of keyhole surgery challenges.
- The game enables future studies on limited visibility effects in surgical tasks.

## Abstract

During keyhole surgery, the surgeon is required to perform highly demanding tasks while only being able to see part of the patient’s anatomy. This limited field of view is widely cited as a key limitation of the procedure, and many computational methods have been proposed to overcome it. However, the precise effects of a limited field of view on task performance remain unknown due to the lack of tools to study these effects effectively.

This paper describes our work on developing a serious game with 2 objectives: (1) to create an engaging game that communicates some of the challenges of keyhole surgery, and (2) to test the effect of a limited field of view on task performance. The development of a serious game that can be played by a wide range of participants will enable us to gather quantitative data on the effects of the reduced field of view on task performance. These data can inform the future development of technologies to help surgeons reduce the impact of a limited field of view on clinical outcomes for patients. The game is open source and may be adapted and used by other researchers to study related problems.

We implemented an open-source serious game in JavaScript, inspired by the surgical task of selectively cauterizing blood vessels during twin-to-twin transfusion surgery. During the game, the player is required to identify and cut the correct blood vessel under different fields of view and varying levels of vascular complexity. We conducted a quantitative analysis of task performance time under different conditions and a formative analysis of the game using participant questionnaires.

We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking significantly longer (P<.001) to perform otherwise identical tasks (mean 6.4 seconds, 95% CI 5.0-7.8 seconds vs mean 13.6 seconds, 95% CI 10.3-16.9 seconds). Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery.

We recruited 25 players to test the game and recorded their task performance time, accuracy, and qualitative metrics. Reducing the field of view resulted in participants taking statistically significantly longer (16.4 vs 9.8 seconds; P=.05) to perform otherwise identical tasks. Participants found the game engaging and agreed that it enhanced their understanding of the limited field of view during keyhole surgery.