Underground

Saving robots using the Nintendo Wii nunchuks as laparoscopic controllers might not seem like the obvious way to train laparoscopic skills, but it works.

Henk ten Cate Hoedemaker, now retired surgeon in gastroenterology and gastrointestinal surgery, ran a fantastic laparoscopic skills training centre at Universitair Medisch Centrum Groningen (UMCG) full of the very best surgical simulators. However, his trainees were anywhere but in the training centre. He did notice they were playing a lot of games on their smartphones. Henk realised the games had something different to simulators that motivated trainees to play and build real game skills. The mobile game Angry Birds was a hit at the time, and he could see game-skill growth.
Around the same time, evidence emerged computer gameplay was beneficial in acquiring skills needed for minimally invasive surgery (MIS) – game play in 2D representations of 3D environments benefitted MIS skills.  Henk’s passion is training surgeons and he hypothesises that a game made specifically to train laparoscopic skills might be better at skills transfer than a random game and might be more intrinsically motivating than a simulator. This core idea kicked off the development of our game Underground.

The story of Underground.

Underground is a challenging and seriously fun game we created especially for the Nintendo Wii U. At the same time, it’s a validated training tool for laparoscopic motor skills. This award-winning game features a heartwarming storyline about a little girl named Sari and Sw4nk, her butler robot friend.

When Sw4nk does an unsatisfying job, Sari’s father sends him away to work in the mines. Sari goes against her father’s will and tries to break him out. While traveling through the underground caverns, Sari and the robots get themselves into a world of trouble and it’s up to you to help them out of their predicament.

During their quest for safety, you’re presented with challenging situations in four unique worlds; each with their own threats and opportunities. Discover all the different building blocks and build your way up to the surface in this charming game about friendship, robots and a little girl who loves to dance.

The laparoscopic controllers.

The game comes with it’s very own laparoscopic controllers. These laparoscopic controllers house a Wii Remote and a Wii Nunchuk. Each handset has a lance that is anchored to the playing field through a hinge joint. The playing field registers motion and rotation from each of the handsets using infrared light. This enables the player to control the game using motions identical to those performed during laparoscopic surgery. The Underground hardware has been scientifically validated through its stages of development. Not only does it possess solid face validity, but it also posesses a very strong construct and concurrent validity. A basic level of the game was able to distinguish various levels of laparoscopic expertise and showed a high and significant correlation (r = 0.812, P < 0.001) to the FLS Peg Transfer task, a gold standard for measuring a wide array of laparoscopic skills.

Underground is one of a kind. It’s a real video game, with an interesting narrative and goals to achieve, that is controlled entirely using controllers that behave like real laparoscopic instruments. It builds real laparoscopic skills, from interpretation of 3D space from 2D cues to hand-eye coordination and cognitive decision making, with a lot of situational awareness thrown in. The game is designed to be fun, to encourage lots of repetition and deliberate practice; the kind of things needed for skills acquisition.

Underground was throughly evaluated by Henk’s team and others and multiple papers have been published on its effectiveness. You can download a digital thesis on the validity and effects of the game here.