RESUMEN
PURPOSE: Simulation-based training allows surgical skills to be learned safely. Most virtual reality-based surgical simulators address technical skills without considering non-technical skills, such as gaze use. In this study, we investigated surgeons' visual behavior during virtual reality-based surgical training where visual guidance is provided. Our hypothesis was that the gaze distribution in the environment is correlated with the simulator's technical skills assessment. METHODS: We recorded 25 surgical training sessions on an arthroscopic simulator. Trainees were equipped with a head-mounted eye-tracking device. A U-net was trained on two sessions to segment three simulator-specific areas of interest (AoI) and the background, to quantify gaze distribution. We tested whether the percentage of gazes in those areas was correlated with the simulator's scores. RESULTS: The neural network was able to segment all AoI with a mean Intersection over Union superior to 94% for each area. The gaze percentage in the AoI differed among trainees. Despite several sources of data loss, we found significant correlations between gaze position and the simulator scores. For instance, trainees obtained better procedural scores when their gaze focused on the virtual assistance (Spearman correlation test, N = 7, r = 0.800, p = 0.031). CONCLUSION: Our findings suggest that visual behavior should be quantified for assessing surgical expertise in simulation-based training environments, especially when visual guidance is provided. Ultimately visual behavior could be used to quantitatively assess surgeons' learning curve and expertise while training on VR simulators, in a way that complements existing metrics.