Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

Simulation-based training in robotic surgery education: bibliometric analysis and visualization

Simulation-based robotic surgery training may help surgeons gain operative skills and experience in the simulation environment. This bibliometric analysis examined the development of simulation-based training for robotic surgical education. Articles pertaining to robotic surgical simulation training that were included in the Web of Science Core Collection up to April 25, 2024, were included. The temporal patterns in published paper numbers were evaluated using Microsoft Excel software, and the data regarding co-authorship and keyword co-occurrence were analyzed and visualized using the VOSviewer and SCImago Graphica tools. A total of 594 papers on simulation-based training for robotic surgical education were evaluated in this study. The United States and United Kingdom were the leading contributors in this field. The most published authors were Professor Ahmed Kamran (23 publications) and Prokar Dasgupta (22 publications). The highest number of papers was published in the journal titled "Surgical Endoscopy and Other Interventional Techniques." The most common keywords were "virtual reality," "curriculum," "robotic surgery simulator," "assessment," and "learning curve." Our study offers a detailed overview of international research on simulation-based training for robotic surgical education, including the publishing countries, institutions, authors, journals, and research hotspots. It also methodically summarizes the state of knowledge in the area, and provides definite directions and concepts for further in-depth analysis.

Assessment of the evolution of psychomotor skills in the robotic surgery simulation process

Robotic surgery is a rapidly expanding field, given the wide variety of new robotic platforms emerging. Looking at the training of surgeons in robotic surgery is of extreme necessity and urgency, considering the ongoing technological advancements. In this research, the performance during the virtual reality simulation phase of training for robotic surgery was analyzed. It was observed that, in addition to the lack of consensus among societies regarding the required simulation hours, there is no guidance on the best curriculum to be adopted. From the data in this study, it can be inferred that the more advanced skills have fewer proficient individuals, meaning that fewer surgeons in training have reached proficiency in all skill exercises. Even with differences in the number of exercises performed proficiently between groups that underwent varying amounts of simulation time, there is no statistically significant difference in the proportion between them.

Smart Operating Room in Digestive Surgery: A Narrative Review

The introduction of new technologies in current digestive surgical practice is progressively reshaping the operating room, defining the fourth surgical revolution. The implementation of black boxes and control towers aims at streamlining workflow and reducing surgical error by early identification and analysis, while augmented reality and artificial intelligence augment surgeons' perceptual and technical skills by superimposing three-dimensional models to real-time surgical images. Moreover, the operating room architecture is transitioning toward an integrated digital environment to improve efficiency and, ultimately, patients' outcomes. This narrative review describes the most recent evidence regarding the role of these technologies in transforming the current digestive surgical practice, underlining their potential benefits and drawbacks in terms of efficiency and patients' outcomes, as an attempt to foresee the digestive surgical practice of tomorrow.

Early adoption of robotic lung resection in an established video assisted thoracic surgery practice

Background

Reported advantages to robotic thoracic surgery include shorter length of stay (LOS), improved lymphadenectomy, and decreased complications. It is uncertain if these benefits occur when introducing robotics into a well-established video-assisted thoracoscopy (VATS) practice. We compared the two approaches to investigate these advantages.

Materials and methods

IRB approval was obtained for this project. Patients who underwent segmentectomy or lobectomy from May 2016-December 2018 were propensity-matched 2: 1 (VATS: robotic) and compared using weighted logistic regression with age, gender, Charlson Comorbidity Index, surgery type, stage, Exparel, and epidural as covariates. Complication rates, operation times, number of sampled lymph nodes, pain level, disposition, and LOS were compared using Wilcoxon rank-sum and with Rao-Scott Chi-squared tests.

Results

213 patients (142 VATS and 71 robot) were matched. Duration of robotic cases was longer than VATS (median 186 min (IQR 78) vs. 164 min (IQR 78.75); p < 0.001). Significantly more lymph nodes (median 11 (IQR 7.50) vs. 8 (IQR 7.00); p = 0.004) and stations were sampled (median 4 (IQR 2.00) vs. 3 (IQR 1.00); p < 0.001) with the robot. Interestingly, robotic resections had higher 72-hour pain scores (median 3 (IQR 3.25) vs. 2 (IQR 3.50); p = 0.04) and 48-hour opioid usage (median 37.50 morphine milligram equivalents (MME) (IQR 45.50) vs. 22.50 MME (IQR 37.50); p = 0.01). Morbidity, LOS, and disposition were similar (all p > 0.05).

Conclusions

The robotic approach facilitates better lymph node sampling, even in an established VATS practice.

Robotic hepaticojejunostomy training in novices using robotic simulation and dry-lab suturing (ROSIM): randomized controlled crossover trial

BACKGROUND

Robotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking.

METHODS

This was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences.

RESULTS

Overall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2-8.0] vs 3.8 [2.3-12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training.

CONCLUSION

Surgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

Training in robotic-assisted surgery: a systematic review of training modalities and objective and subjective assessment methods

INTRODUCTION

The variety of robotic surgery systems, training modalities, and assessment tools within robotic surgery training is extensive. This systematic review aimed to comprehensively overview different training modalities and assessment methods for teaching and assessing surgical skills in robotic surgery, with a specific focus on comparing objective and subjective assessment methods.

METHODS

A systematic review was conducted following the PRISMA guidelines. The electronic databases Pubmed, EMBASE, and Cochrane were searched from inception until February 1, 2022. Included studies consisted of robotic-assisted surgery training (e.g., box training, virtual reality training, cadaver training and animal tissue training) with an assessment method (objective or subjective), such as assessment forms, virtual reality scores, peer-to-peer feedback or time recording.

RESULTS

The search identified 1591 studies. After abstract screening and full-texts examination, 209 studies were identified that focused on robotic surgery training and included an assessment tool. The majority of the studies utilized the da Vinci Surgical System, with dry lab training being the most common approach, followed by the da Vinci Surgical Skills Simulator. The most frequently used assessment methods included simulator scoring system (e.g., dVSS score), and assessment forms (e.g., GEARS and OSATS).

CONCLUSION

This systematic review provides an overview of training modalities and assessment methods in robotic-assisted surgery. Dry lab training on the da Vinci Surgical System and training on the da Vinci Skills Simulator are the predominant approaches. However, focused training on tissue handling, manipulation, and force interaction is lacking, despite the absence of haptic feedback. Future research should focus on developing universal objective assessment and feedback methods to address these limitations as the field continues to evolve.

Telesurgery and telementoring

Telemedicine has revolutionized the field of surgery, with telemonitoring and telesurgery being 2 of its most promising applications. Telesurgery and telemonitoring are revolutionary applications that have the potential to change the way surgical operations are performed. These applications can allow surgeons to perform operations, enable surgeons to perform operations by assisting or supervising others through mentoring from a different location (telementoring). Despite the potential benefits of telemedicine and telementoring, there are still challenges that must be overcome before they can be widely used in clinical practice. For example, latency in data transmission can be a problem in telemedicine, as even a small delay in data transmission can affect the accuracy of the operation. Additionally, a sophisticated and expensive technological infrastructure is required, which can limit their use in some clinical settings. Although we need to work on its development technologically, ethically and legally, it is a promising tool.

Soft Tissue Robotic Assisted Orbital Surgery Using da Vinci SP: A Cadaveric Experience

PURPOSE

Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP.

METHODS

A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility.

RESULTS

Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex.

CONCLUSIONS

This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

Prediction of Robotic Anastomosis Competency Evaluation (RACE) metrics during vesico-urethral anastomosis using electroencephalography, eye-tracking, and machine learning

Residents learn the vesico-urethral anastomosis (VUA), a key step in robot-assisted radical prostatectomy (RARP), early in their training. VUA assessment and training significantly impact patient outcomes and have high educational value. This study aimed to develop objective prediction models for the Robotic Anastomosis Competency Evaluation (RACE) metrics using electroencephalogram (EEG) and eye-tracking data. Data were recorded from 23 participants performing robot-assisted VUA (henceforth 'anastomosis') on plastic models and animal tissue using the da Vinci surgical robot. EEG and eye-tracking features were extracted, and participants' anastomosis subtask performance was assessed by three raters using the RACE tool and operative videos. Random forest regression (RFR) and gradient boosting regression (GBR) models were developed to predict RACE scores using extracted features, while linear mixed models (LMM) identified associations between features and RACE scores. Overall performance scores significantly differed among inexperienced, competent, and experienced skill levels (P value < 0.0001). For plastic anastomoses, R2 values for predicting unseen test scores were: needle positioning (0.79), needle entry (0.74), needle driving and tissue trauma (0.80), suture placement (0.75), and tissue approximation (0.70). For tissue anastomoses, the values were 0.62, 0.76, 0.65, 0.68, and 0.62, respectively. The models could enhance RARP anastomosis training by offering objective performance feedback to trainees.

Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States

INTRODUCTION

Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs.

METHODS

All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy.

RESULTS

Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations.

CONCLUSION

In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.

The Role of Robotics in Meeting Institutional Goals: A Unified Strategy to Facilitate Program Excellence

PURPOSE

The rapid expansion of robotic surgical equipment necessitates a review of the needs and challenges faced by hospitals introducing robots for the first time to compete with experienced institutions. The aim of this study was to analyze the impact of robotic surgery on our hospital compared to open and laparoscopic surgery, examine internal transformations, and assess regional, domestic, and international implications.

METHODS

A retrospective review was conducted of electronic medical records (EMRs) from 2019 to 2022 at Inha University Hospital, including patients who underwent common robotic procedures and equivalent open and laparoscopic operations. The study investigated clinical and operational performance changes in the hospital after the introduction of robotic technology. It also evaluated the operational effectiveness of robot implementation in local, national, and international contexts. To facilitate comparison with other hospitals, the data were transmitted to Intuitive Surgical, Inc. for analysis. The study was conducted in compliance with domestic personal information regulations and received approval from our Institutional Review Board.

RESULTS

We analyzed EMR data from 3,147 patients who underwent surgical treatment. Over a period of 3.5 years, the adoption of robotic technology in a hospital setting significantly enhanced the technical skills of all professors involved. The introduction of robotic systems led to increased patient utilization of conventional surgical techniques, as well as a rise in the number of patients choosing robotic surgery. This collective trend contributed to an overall increase in patient numbers. This favorable evaluation of the operational effectiveness of our hospital's robot implementation in the context of local, national, and global factors is expected to positively influence policy changes.

CONCLUSION

Stakeholders should embrace data science and evidence-based techniques to generate valuable insights from objective data, assess the health of robot-assisted surgery programs, and identify opportunities for improvement and excellence.

Cognitive effort detection for tele-robotic surgery via personalized pupil response modeling

PURPOSE

Gaze tracking and pupillometry are established proxies for cognitive load, giving insights into a user's mental effort. In tele-robotic surgery, knowing a user's cognitive load can inspire novel human-machine interaction designs, fostering contextual surgical assistance systems and personalized training programs. While pupillometry-based methods for estimating cognitive effort have been proposed, their application in surgery is limited by the pupil's sensitivity to brightness changes, which can mask pupil's response to cognitive load. Thus, methods considering pupil and brightness conditions are essential for detecting cognitive effort in unconstrained scenarios.

METHODS

To contend with this challenge, we introduce a personalized pupil response model integrating pupil and brightness-based features. Discrepancies between predicted and measured pupil diameter indicate dilations due to non-brightness-related sources, i.e., cognitive effort. Combined with gaze entropy, it can detect cognitive load using a random forest classifier. To test our model, we perform a user study with the da Vinci Research Kit, where 17 users perform pick-and-place tasks in addition to auditory tasks known to generate cognitive effort responses.

RESULTS

We compare our method to two baselines (BCPD and CPD), demonstrating favorable performance in varying brightness conditions. Our method achieves an average true positive rate of 0.78, outperforming the baselines (0.57 and 0.64).

CONCLUSION

We present a personalized brightness-aware model for cognitive effort detection able to operate under unconstrained brightness conditions, comparing favorably to competing approaches, contributing to the advancement of cognitive effort detection in tele-robotic surgery. Future work will consider alternative learning strategies, handling the difficult positive-unlabeled scenario in user studies, where only some positive and no negative events are reliably known.

Robotic versus laparoscopic surgery for colorectal disease: a systematic review, meta-analysis and meta-regression of randomised controlled trials

INTRODUCTION

Robotic surgery (RS) is gaining prominence in colorectal procedures owing to advantages like three-dimensional vision and enhanced dexterity, particularly in rectal surgery. Although recent reviews report similar outcomes between laparoscopic surgery (LS) and RS, this study investigates the evolving trends in outcomes over time, paralleling the increasing experience in RS.

METHODS

A systematic review, meta-analysis and meta-regression were conducted of randomised controlled trials exploring postoperative outcomes in patients undergoing RS or LS for colorectal pathology. The primary outcome measure was postoperative complications. Risk of bias was evaluated using the Cochrane Collaboration's assessment tool. Randomised controlled trials were identified from the PubMed®, Embase® and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases via the Cochrane Central Register of Controlled Trials.

RESULTS

Of 491 articles screened, 13 fulfilled the inclusion criteria. Meta-analysis of postoperative complications revealed no significant difference between RS and LS (relative risk [RR]: 0.96, 95% confidence interval [CI]: 0.79 to 1.18, p=0.72). Meta-regression analysis of postoperative complications demonstrated a significant trend favouring RS over time (yearly change in Ln(RR): -0.0620, 95% CI: -0.1057 to -0.0183, p=0.005). Secondary outcome measures included operative time, length of stay, blood loss, conversion to open surgery, positive circumferential resection margins and lymph nodes retrieved. The only significant findings were shorter operative time favouring LS (mean difference: 41.48 minutes, 95% CI: 22.15 to 60.81 minutes, p<0.001) and fewer conversions favouring RS (RR: 0.57, 95% CI: 0.37 to 0.85, p=0.007).

CONCLUSIONS

As experience in RS grows, evidence suggests an increasing safety profile for patients. Meta-regression revealed a significant temporal trend with complication rates favouring RS over LS. Heterogeneous reporting of complications hindered subgroup analysis of minor and major complications. LS remains quicker. Rising adoption of RS coupled with emerging evidence is expected to further elucidate its clinical efficacy.

The deconstructed procedural description in robotic colorectal surgery

Increasing robotic surgical utilisation in colorectal surgery internationally has strengthened the need for standardised training. Deconstructed procedural descriptions identify components of an operation that can be integrated into proficiency-based progression training. This approach allows both access to skill level appropriate training opportunities and objective and comparable assessment. Robotic colorectal surgery has graded difficulty of operative procedures lending itself ideally to component training. Developing deconstructed procedural descriptions may assist in the structure and progression components in robotic colorectal surgical training. There is no currently published guide to procedural descriptions in robotic colorectal surgical or assessment of their training utility. This scoping review was conducted in June 2022 following the PRISMA-ScR guidelines to identify which robotic colorectal surgical procedures have available component-based procedural descriptions. Secondary aims were identifying the method of development of these descriptions and how they have been adapted in a training context. 20 published procedural descriptions were identified covering 8 robotic colorectal surgical procedures with anterior resection the most frequently described procedure. Five publications included descriptions of how the procedural description has been utilised for education and training. From these publications terminology relating to using deconstructed procedural descriptions in robotic colorectal surgical training is proposed. Development of deconstructed robotic colorectal procedural descriptions (DPDs) in an international context may assist in the development of a global curriculum of component operating competencies supported by objective metrics. This will allow for standardisation of robotic colorectal surgical training and supports a proficiency-based training approach.

Exploring the Evolution of Robotic Surgery in Obstetrics and Gynecology: Past, Present, and Future Perspectives

Robotic surgery has emerged as a transformative technology in obstetrics and gynecology, offering enhanced precision and minimally invasive techniques for various procedures. This paper explores the evolution of robotic surgery in obstetrics and gynecology, examining its historical development, current applications, and prospects. Through a comprehensive review of the literature and case studies, we highlight the benefits of robotic surgery, including reduced trauma, improved patient outcomes, and increased surgeon capabilities. However, cost, training requirements, and regulatory concerns hinder widespread adoption. Continuing technological innovation is expected to enhance the efficacy and applicability of robotic-assisted procedures. Collaboration between healthcare professionals, researchers, and industry stakeholders is essential to address these challenges and ensure optimal patient care. By embracing the opportunities presented by robotic surgery while addressing associated challenges, practitioners and researchers can contribute to the continued advancement of this transformative technology in obstetrics and gynecology.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Versius robotic surgical system: case series of 18 robot-assisted radical prostatectomies

OBJECTIVE

To present the results of the first series of patients treated with robot-assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost-effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach.

PATIENTS AND METHODS

Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3-month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set-up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set-up and operating times to optimise utilisation of the Versius system.

RESULTS

The median (interquartile range [IQR]) set-up time was 8.5 (7-10) min. The median (IQR) console time was 201 (170-242) min. The median (IQR) operative time was 213 (186-266) min. The median (IQR) total surgery time was 226 (201-277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17-20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra- or postoperative complications at the 1-month follow-up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75-5) days, and the transurethral catheter was removed after a mean (range) of 8 (7-14) days. Continence at 2 months was achieved in 72.2% of the patients.

CONCLUSIONS

Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set-up enables a rapid docking approach and efficient completion of the surgery.

Development of performance and learning rate evaluation models in robot-assisted surgery using electroencephalography and eye-tracking

The existing performance evaluation methods in robot-assisted surgery (RAS) are mainly subjective, costly, and affected by shortcomings such as the inconsistency of results and dependency on the raters' opinions. The aim of this study was to develop models for an objective evaluation of performance and rate of learning RAS skills while practicing surgical simulator tasks. The electroencephalogram (EEG) and eye-tracking data were recorded from 26 subjects while performing Tubes, Suture Sponge, and Dots and Needles tasks. Performance scores were generated by the simulator program. The functional brain networks were extracted using EEG data and coherence analysis. Then these networks, along with community detection analysis, facilitated the extraction of average search information and average temporal flexibility features at 21 Brodmann areas (BA) and four band frequencies. Twelve eye-tracking features were extracted and used to develop linear random intercept models for performance evaluation and multivariate linear regression models for the evaluation of the learning rate. Results showed that subject-wise standardization of features improved the R2 of the models. Average pupil diameter and rate of saccade were associated with performance in the Tubes task (multivariate analysis; p-value = 0.01 and p-value = 0.04, respectively). Entropy of pupil diameter was associated with performance in Dots and Needles task (multivariate analysis; p-value = 0.01). Average temporal flexibility and search information in several BAs and band frequencies were associated with performance and rate of learning. The models may be used to objectify performance and learning rate evaluation in RAS once validated with a broader sample size and tasks.

Gamification in Critical Care Education and Practice

OBJECTIVES

To explore gamification as an alternative approach to healthcare education and its potential applications to critical care.

DATA SOURCES

English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023).

STUDY SELECTION

Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches.

DATA EXTRACTION

Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior.

DATA SYNTHESIS

Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized.

CONCLUSIONS

Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.

Surgical tele-mentoring using a robotic platform: initial experience in a military institution

BACKGROUND

Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team.

METHODS

An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor.

RESULTS

Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied.

CONCLUSIONS

Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks.

Use of real-time immersive digital training and educational technologies to improve patient safety during the processing of reusable medical devices: Quo Vadis?

Hospital acquired infections stemming from contaminated reusable medical devices are of increasing concern. This issue is exaggerated with the introduction of complex medical devices like endoscopes and robotic instrumentation. Although medical device manufacturers validate their cleaning instructions for use, evidence in the literature demonstrates that effective device processing is not being performed consistently within sterile processing departments in clinical settings. The result is increased risks to patient safety. As a solution to this problem, focused one-on-one training increases compliance to the medical device manufacturer's processing instruction. However, often this is not a practical solution for the volume of healthcare staff responsible for device processing activities. This constitutes the first paper to address the blended use of educational and digital technologies to address these challenges and as a result inform safety and sustainability for the medical device sector. Cognitive learning theory is an evidence-based framework for learning. It supports the use of immersive educational experiences using emerging extended reality technologies (e.g., virtual or augmented reality) to increase learning comprehension. The delivery of educational content via these technologies provides an innovative option for repeatable leaning and training outcomes. The motivation is to decrease patient risk of contaminated reusable medical devices. The proposed approach while primary motivated by safety can also enhance sustainability and efficiency enabled by artificial intelligence and robotic instrumentation.

Eye tracking technology in medical practice: a perspective on its diverse applications

Eye tracking technology has emerged as a valuable tool in the field of medicine, offering a wide range of applications across various disciplines. This perspective article aims to provide a comprehensive overview of the diverse applications of eye tracking technology in medical practice. By summarizing the latest research findings, this article explores the potential of eye tracking technology in enhancing diagnostic accuracy, assessing and improving medical performance, as well as improving rehabilitation outcomes. Additionally, it highlights the role of eye tracking in neurology, cardiology, pathology, surgery, as well as rehabilitation, offering objective measures for various medical conditions. Furthermore, the article discusses the utility of eye tracking in autism spectrum disorders, attention-deficit/hyperactivity disorder (ADHD), and human-computer interaction in medical simulations and training. Ultimately, this perspective article underscores the transformative impact of eye tracking technology on medical practice and suggests future directions for its continued development and integration.

A systematic review of video-based educational interventions in robotic surgical training

As robotic surgical procedures become more prevalent in practice, there is a demand for effective and efficient educational strategies in robotic surgery. Video has been used in open and laparoscopic surgery to instruct trainees in the acquisition of operative knowledge and surgical skill. Robotic surgery is an ideal application of video-based technology given the access of video recording directly from the console. This review will present the evidence base for video-based educational tools in robotic surgery to guide the development of future educational interventions using this technology. A systematic review of the literature was performed using the key words "video" "robotic surgery" and "education". From a total of 538 results, 15 full text articles were screened. Inclusion criteria were the presentation of an educational intervention using video and the application of this intervention to robotic surgery. The results of 10 publications are presented in this review. Analysis of the key concepts presented in these publications revealed three themes: video as technology, video as instruction, video as feedback. All studies showed a video-based learning had a positive effect on educational outcomes. There are limited published studies looking specifically at the use of video as an educational intervention in robotic surgical training. Existing studies primarily focus on the use of video as a review tool for skill development. There is scope to expand the use of robotic video as a teaching tool through adaptation of novel technology such as 3D headsets and concepts of cognitive simulation including guided mental imagery and verbalisation.

Is there a need for a technical certification system for gynecological robotic surgery? Questionnaire survey of members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy

The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) introduced a system for the certification of laparoscopic surgeons in 2002 and a system for the certification of facilities in 2014. We examined the opinions of the members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) regarding the necessity of a certification training system and a technical certification system for robotic surgery skills in Japan. Members of the JSGOE were surveyed with two questionnaires. Overall, 870 and 519 participants responded to the first and second questionnaires, respectively. Half of the respondents indicated that both systems were necessary. The breakdown by age and qualifications showed that this was especially true for the younger generation and respondents with more experience with robotic surgery. Overall, 40% of the respondents judged that a certification system for robotic surgery alone (with or without certification in laparoscopic surgery but with a requirement of experience in laparoscopic surgery) would be necessary. The opinions of the JSGOE members on making a certification system for robotic surgery were split into two clear-cut camps. Thus, we must further seek the extent of public demand for using a public survey so that a final decision can be made on whether to establish this system.

Feasibility of Laser Lithotripsy for Midsize Stones Using Robotic Retrograde Intrarenal Surgery System easyUretero in a Porcine Model

Purpose: To test the safety and feasibility of laser lithotripsy for midsize renal stones using a newly developed robotic retrograde intrarenal surgery (RIRS) system (easyUretero) in a porcine model. Materials and Methods: Three urologic surgeons representing three different RIRS experience levels (beginner, intermediate, and expert) participated. Four female pigs (aged 6 months) underwent manual or robotic RIRS. Under general anesthesia, a nephrostomy tract was created ventrally, and calcium stones (diameter, 1.0-1.5 cm) were inserted at renal calices. For manual RIRS, surgeons operated a flexible ureteroscope. For robotic RIRS, the ureteroscope was attached to the robotic slave device. The Auriga XL™ Holmium laser was used for lithotripsy. Lasering and stone retrieval time were measured. Kidneys and ureters were inspected for injury at the end of each session. Results: For the expert, both lasering and stone retrieval by manual RIRS were quicker than by robotic RIRS (22.8 ± 11.0 s/stone vs 234.5 ± 102.5 s/stone, p = 0.02; 41.5 ± 0.5 s/stone vs 79.3 ± 8.1 s/stone, p = 0.02). For the intermediate and beginner, lasering and stone retrieval times were not significantly different between manual and robotic procedures (127.8 ± 93.2 s/stone vs 284.8 ± 112.3 s/stone, p = 0.08; 86.0 ± 30.5 s/stone vs 84.1 ± 21.4 s/stone, p = 0.92). All stones were removed. Grade 1 ureteral and renal injuries occurred in both manual RIRS and robotic RIRS. Conclusions: The laser lithotripsy using the easyUretero robotic system is safe and feasible in a porcine model, even for less-experienced surgeons.

The State of Cancer Care in the United Arab Emirates in 2022

Cancer is the third-leading cause of death in the United Arab Emirates (UAE); cancer care in the UAE has evolved dramatically over the last 40 years, from a single center in Al Ain in 1981 to more than 30 cancer centers and clinics across the UAE, with at least four comprehensive cancer centers in the UAE nowadays. Despite the significant progress in medical care, cancer quality control across the UAE is still lacking, with significant variations in cancer care across the cancer centers. Access to clinical trials is still hampered by a lack of expertise and research infrastructure and a small population, which renders patient accrual for trials a major challenge. Education and training are other areas for improvement that require immediate attention, and, in this review, we try to address these critical aspects for stakeholders to consider better cancer care in the UAE. Early cancer detection and screening are still evolving in the UAE, and a national screening program is lacking. There is also a need to address barriers to screening and to consider less invasive screening methods such as approved blood-based screening, which is likely to be more acceptable to the UAE population. In this review, we also address new topics that have not been addressed previously, including oncology medical tourism, psycho-oncology, onco-fertility, precision oncology, survivorship, oncology nursing, cancer support programs, and the oncology sector's response to the COVID-19 pandemic, all in the context of the UAE cancer landscape. Finally, we provide recommendations for policymakers, regulators, payers, patient advocacy groups, and the UAE oncology community regarding the delivery and future planning of high-quality cancer care. These recommendations are aligned with the UAE government's vision to reduce cancer mortality and provide high-quality healthcare for its citizens and residents.

Virtual classroom proficiency-based progression for robotic surgery training (VROBOT): a randomised, prospective, cross-over, effectiveness study

Robotic surgery training has lacked evidence-based standardisation. We aimed to determine the effectiveness of adjunctive interactive virtual classroom training (VCT) in concordance with the self-directed Fundamentals of Robotic Surgery (FRS) curriculum. The virtual classroom is comprised of a studio with multiple audio–visual inputs to which participants can connect remotely via the BARCO weConnect platform. Eleven novice surgical trainees were randomly allocated to two training groups (A and B). In week 1, both groups completed a robotic skills induction. In week 2, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week 3, the groups received the alternate intervention. The primary outcome was measured using the validated robotic-objective structured assessment of technical skills (R-OSAT) at the end of week 2 (time-point 1) and 3 (time-point 2). All participants completed the training curriculum and were included in the final analyses. At time-point 1, Group A achieved a statistically significant greater mean proficiency score compared to Group B (44.80 vs 35.33 points, p = 0.006). At time-point 2, there was no significant difference in mean proficiency score in Group A from time-point 1. In contrast, Group B, who received further adjunctive VCT showed significant improvement in mean proficiency by 9.67 points from time-point 1 (95% CI 5.18–14.15, p = 0.003). VCT is an effective, accessible training adjunct to self-directed robotic skills training. With the steep learning curve in robotic surgery training, VCT offers interactive, expert-led learning and can increase training effectiveness and accessibility.

What are clinically relevant performance metrics in robotic surgery? A systematic review of the literature

A crucial element of any surgical training program is the ability to provide procedure-specific, objective, and reliable measures of performance. During robotic surgery, objective clinically relevant performance metrics (CRPMs) can provide tailored contextual feedback and correlate with clinical outcomes. This review aims to define CRPMs, assess their validity in robotic surgical training and compare CRPMs to existing measures of robotic performance. A systematic search of Medline and Embase databases was conducted in May 2022 following the PRISMA guidelines. The search terms included Clinically Relevant Performance Metrics (CRPMs) OR Clinically Relevant Outcome Measures (CROMs) AND robotic surgery. The study settings, speciality, operative context, study design, metric details, and validation status were extracted and analysed. The initial search yielded 116 citations, of which 6 were included. Citation searching identified 3 additional studies, resulting in 9 studies included in this review. Metrics were defined as CRPMs, CROMs, proficiency-based performance metrics and reference-procedure metrics which were developed using a modified Delphi methodology. All metrics underwent both contents and construct validation. Two studies found a strong correlation with GEARS but none correlated their metrics with patient outcome data. CRPMs are a validated and objective approach for assessing trainee proficiency. Evaluating CRPMs with other robotic-assessment tools will facilitate a multimodal metric evaluation approach to robotic surgery training. Further studies should assess the correlation with clinical outcomes. This review highlights there is significant scope for the development and validation of CRPMs to establish proficiency-based progression curricula that can be translated from a simulation setting into clinical practice.

More than surgical tools: a systematic review of robots as didactic tools for the education of professionals in health sciences

Within the field of robots in medical education, most of the work done during the last years has focused on surgeon training in robotic surgery, practicing surgery procedures through simulators. Apart from surgical education, robots have also been widely employed in assistive and rehabilitation procedures, where education has traditionally focused in the patient. Therefore, there has been extensive review bibliography in the field of medical robotics focused on surgical and rehabilitation and assistive robots, but there is a lack of survey papers that explore the potential of robotics in the education of healthcare students and professionals beyond their training in the use of the robotic system. The scope of the current review are works in which robots are used as didactic tools for the education of professionals in health sciences, investigating the enablers and barriers that affect the use of robots as learning facilitators. Systematic literature searches were conducted in WOS and Scopus, yielding a total of 3812 candidate papers. After removing duplicates, inclusion criteria were defined and applied, resulting in 171 papers. An in-depth quality assessment was then performed leading to 26 papers for qualitative synthesis. Results show that robots in health sciences education are still developed with a roboticist mindset, without clearly incorporating aspects of the teaching/learning process. However, they have proven potential to be used in health sciences as they allow to parameterize procedures, autonomously guide learners to achieve greater engagement, or enable collective learning including patients and instructors "in the loop". Although there exist documented added-value benefits, further research and efforts needs to be done to foster the inclusion of robots as didactic tools in the curricula of health sciences professionals. On the one hand, by analyzing how robotic technology should be developed to become more flexible and usable to support both teaching and learning processes in health sciences education, as final users are not necessarily well-versed in how to use it. On the other, there continues to be a need to develop effective and standard robotic enhanced learning evaluation tools, as well good quality studies that describe effective evaluation of robotic enhanced education for professionals in health sciences. As happens with other technologies when applied to the health sciences field, studies often fail to provide sufficient detail to support transferability or direct future robotic health care education programs.

A resident robotic curriculum utilizing self-selection and a web-based feedback tool

To describe an obstetrics and gynecology residency robotic curriculum, facilitated by a web-based feedback and case-tracking tool, allowing for self-selection into advanced training. Phase I (Basic) was required for all residents and included online training modules, online assessment, and robotic bedside assistant dry lab. Phase II (Advanced) was elective console training. Before live surgery, 10 simulation drills completed to proficiency were required. A web-based tool was used for surgical feedback and case-tracking. Online assessments, drill reports, objective GEARS assessments, subjective feedback, and case-logs were reviewed (7/2018-6/2019). A satisfaction survey was reviewed. Twenty four residents completed Phase I training and 10 completed Phase II. To reach simulation proficiency, residents spent a median of 4.1 h performing required simulation drills (median of 10 (3, 26) attempts per drill) before live surgery. 128 post-surgical feedback entries were completed after performance as bedside assistant (75%, n = 96) and console surgeon (5.5%, n = 7). The most common procedure was hysterectomy 111/193 (58%). Resident console surgeons performed portions of 32 cases with a mean console time of 34.6 ± 19.5 min. Mean GEARS score 20.6 ± 3.7 (n = 28). Mean non-technical feedback results: communication (4.2 ± 0.8, n = 61), workload management (3.9 ± 0.9, n = 54), team skills (4.3 ± 0.8, n = 60). Residents completing > 50% of case assessed as "apprentice" 38.5% or "competent" 23% (n = 13). After curriculum change, 100% of surveyed attendings considered residents prepared for live surgical training, vs 17% (n = 6) prior to curriculum change [survey response rate 27/44 (61%)]. Attendings and residents were satisfied with curriculum; 95% and recommended continued use 90% (n = 19).This two-phase robotic curriculum allows residents to self-select into advanced training, alleviating many challenges of graduated robotic training.

Validation of standardized training system for robot-assisted radical prostatectomy: comparison of perioperative and surgical outcomes between experienced surgeons and novice surgeons at a low-volume institute in Japan

INTRODUCTION

Although robot-assisted radical prostatectomy (RARP) has become a standard treatment modality in patients with prostate cancer (PCa), RARP is a complicated and difficult surgical procedure due to the risk of serious surgery-related complications. This study aimed to evaluate the validation of a standardized training system for RARP in patients with PCa at a single institute.

MATERIAL AND METHODS

We retrospectively reviewed the clinical and pathological records of 155 patients with PCa who underwent RARP at Gifu University between August 2018 and April 2021. We developed an institutional program for new surgeons based on the separation of the RARP procedure into six checkpoints. The primary endpoints were surgical outcomes and perioperative complications among three groups (expert, trainer, and novice surgeon groups).

RESULTS

The console time was significantly longer in the novice surgeon group than in the other groups. Regarding bladder neck dissection, ligation of lateral pedicles, and vesicourethral anastomosis, the operative time was significantly shorter in the expert group than in the other groups. Surgery-related complications occurred in 15 patients (9.7%).

CONCLUSIONS

Our training system for RARP might help reduce the influence of the learning curve on surgical outcomes and ensure that the surgeries performed at low-volume institutions are safe and effective.

A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education

We conducted a comprehensive review of surgical simulation models used in robotic surgery education. We present an assessment of the validity and cost-effectiveness of virtual and augmented reality simulation, animal, cadaver and synthetic organ models. Face, content, construct, concurrent and predictive validity criteria were applied to each simulation model. There are six major commercial simulation machines available for robot-assisted surgery. The validity of virtual reality (VR) simulation curricula for psychomotor assessment and skill acquisition for the early phase of robotic surgery training has been demonstrated. The widespread adoption of VR simulation has been limited by the high cost of these machines. Live animal and cadavers have been the accepted standard for robotic surgical simulation since it began in the early 2000s. Our review found that there is a lack of evidence in the literature to support the use of animal and cadaver for robotic surgery training. The effectiveness of these models as a training tool is limited by logistical, ethical, financial and infection control issues. The latest evolution in synthetic organ model training for robotic surgery has been driven by new 3D-printing technology. Validated and cost-effective high-fidelity procedural models exist for robotic surgery training in urology. The development of synthetic models for the other specialties is not as mature. Expansion into multiple surgical disciplines and the widespread adoption of synthetic organ models for robotic simulation training will require the ability to engineer scalability for mass production. This would enable a transition in robotic surgical education where digital and synthetic organ models could be used in place of live animals and cadaver training to achieve robotic surgery competency.