Comparison of Two Simulation Systems to Support Robotic-Assisted Surgical Training: A Pilot Study (Swine Model)

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.

Measures of performance and proficiency in robotic assisted surgery: a systematic review

Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

A Multi-institution Study on the Association of Virtual Reality Skills with Continence Recovery after Robot-assisted Radical Prostatectomy

BACKGROUND

Virtual reality (VR) simulators are increasingly being used for surgical skills training. It is unclear what skills are best improved via VR, translate to live surgical skills, and influence patient outcomes.

OBJECTIVE

To assess surgeons in VR and live surgery using a suturing assessment tool and evaluate the association between technical skills and a clinical outcome.

DESIGN, SETTING, AND PARTICIPANTS

This prospective five-center study enrolled participants who completed VR suturing exercises and provided live surgical video. Graders provided skill assessments using the validated End-To-End Assessment of Suturing Expertise (EASE) suturing evaluation tool.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A hierarchical Poisson model was used to compare skill scores among cohorts and evaluate the association of scores with clinical outcomes. Spearman's method was used to assess correlation between VR and live skills.

RESULTS AND LIMITATIONS

Ten novices, ten surgeons with intermediate expertise (median 64 cases, interquartile range [IQR] 6-80), and 26 expert surgeons (median 850 cases, IQR 375-3000) participated in this study. Intermediate and expert surgeons were significantly more likely to have ideal scores in comparison to novices for the subskills needle hold angle, wrist rotation, and wrist rotation needle withdrawal (p < 0.01). For both intermediate and expert surgeons, there was positive correlation between VR and live skills for needle hold angle (p < 0.05). For expert surgeons, there was a positive association between ideal scores for VR needle hold angle and driving smoothness subskills and 3-mo continence recovery (p < 0.05). Limitations include the size of the intermediate surgeon sample and clinical data limited to expert surgeons.

CONCLUSIONS

EASE can be used in VR to identify skills to improve for trainee surgeons. Technical skills that influence postoperative outcomes may be assessable in VR.

PATIENT SUMMARY

This study provides insights into surgical skills that translate from virtual simulation to live surgery and that have an impact on urinary continence after robot-assisted removal of the prostate. We also highlight the usefulness of virtual reality in surgical education.

Advancing Urology Resident Surgical Autonomy

PURPOSE OF REVIEW

This paper aims to survey current literature on urologic graduate medical education focusing on surgical autonomy.

RECENT FINDINGS

Affording appropriate levels of surgical autonomy has a key role in the education of urologic trainees and perceived preparedness for independent practice. Recent studies in surgical resident autonomy have demonstrated a reduction in autonomy for trainees in recent years. Efforts to advance the state of modern surgical training include creation of targeted curricula, enhanced with use of surgical simulation, and structured feedback. Decline in surgical autonomy for urology residents may influence confidence after completion of their residency. Further study is needed into the declining levels of urology resident autonomy, how it affects urologists entering independent practice, and what interventions can advance autonomy in modern urologic training.

Robotic training for medical students: feasibility of a pilot simulation curriculum

While robotic procedures are growing rapidly, medical students have a limited role in robotic surgeries. Curricula are needed to enhance engagement. We examined feasibility of augmenting Intuitive Surgical (IS) robotic training for medical students. As a pilot, 18 senior students accepted an invitation to a simulation course with a daVinci robot trainer. Course teaching objectives included introducing robotic features, functionalities, and roles. A 1-h online module from the IS learning platform and a 4-h in-person session comprised the course. The in-person session included an overview of the robot by an IS trainer (1.5 h), skills practice at console (1.5 h), and a simulation exercise focused on the bedside assist role (1 h). Feasibility included assessing implementation and acceptability using a post-session survey and focus group (FG). Survey responses were compiled. FG transcripts were analyzed using inductive thematic analysis techniques. Fourteen students participated. Implementation was successful as interested students signed up and completed each of the course components. Regarding acceptability, students reported the training valuable and recommended it as preparation for robotic cases during core clerkships and sub-internships. In addition, FGs revealed 4 themes: (1) perceived expectations of students in the OR; (2) OR vs. outside-OR learning; (3) simulation of stress; and (4) opportunities to improve the simulation component. To increase preparation for the robotic OR and shift robotic training earlier in the surgical education continuum, educators should consider hands-on simulation for medical students. We demonstrate feasibility although logistics may limit scalability for large numbers of students.

Virtual reality simulation in robot-assisted surgery: meta-analysis of skill transfer and predictability of skill

Background

The value of virtual reality (VR) simulators for robot-assisted surgery (RAS) for skill assessment and training of surgeons has not been established. This systematic review and meta-analysis aimed to identify evidence on transferability of surgical skills acquired on robotic VR simulators to the operating room and the predictive value of robotic VR simulator performance for intraoperative performance.

Methods

MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science were searched systematically. Risk of bias was assessed using the Medical Education Research Study Quality Instrument and the Newcastle–Ottawa Scale for Education. Correlation coefficients were chosen as effect measure and pooled using the inverse-variance weighting approach. A random-effects model was applied to estimate the summary effect.

Results

A total of 14 131 potential articles were identified; there were eight studies eligible for qualitative and three for quantitative analysis. Three of four studies demonstrated transfer of surgical skills from robotic VR simulators to the operating room measured by time and technical surgical performance. Two of three studies found significant positive correlations between robotic VR simulator performance and intraoperative technical surgical performance; quantitative analysis revealed a positive combined correlation (r = 0.67, 95 per cent c.i. 0.22 to 0.88).

Conclusion

Technical surgical skills acquired through robotic VR simulator training can be transferred to the operating room, and operating room performance seems to be predictable by robotic VR simulator performance. VR training can therefore be justified before operating on patients.

Role of Simulation-Based Training in Minimally Invasive and Robotic Colorectal Surgery

Properly performing minimally invasive colorectal procedures requires specific skills. With a focus on patient safety, the training of surgeons on patients is only accepted under exceptionally controlled, expensive, and challenging conditions. Moreover, many new techniques in colorectal surgery have been developed. Therefore, undertaking minimally invasive colorectal surgery in modern times requires specific psychomotor skills that trainee surgeons must gather in less time. In addition, there are not enough proctors with sufficient expertise for such an expressive number of new different techniques likes transanal and robotic procedures. Studies that have demonstrated an improvement in minimally invasive surgery skills to the actual operating room in general surgery and a stepwise approach to surgical simulation with a combination of various training methods appears to be useful in colorectal surgery training programs. However, the scientific evidence on the transfer of skills specifically for colorectal surgery is extremely scarce and very variable. Thus, the evaluation of the results remains quite difficult. In this review, we present the best available evidence on the types of training based on simulation, their characteristics, advantages and disadvantages, and finally the results available on their adoption. Nevertheless, scientific evidence about the benefit of simulation training in minimally invasive colorectal surgery is limited and there is a need to build more robust evidence.

Quantifying the "Assistant Effect" in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance

PURPOSE

Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP).

METHODS

Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors.

RESULTS

92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P = 0.011), and prior laparoscopic experience (P < 0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho = 0.248, P = 0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P = 0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing.

CONCLUSIONS

This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.

Is it possible to continue academic teaching in surgery during the COVID pandemic era?

In the era of the novel coronavirus (COVID-19) pandemic, we critically appraised the literature by means of a systematic review on surgical education and propose an educational curriculum with the aid of available technologies. We performed a literature search on 10 May 2020 of Medline/PubMed, Embase, Google Scholar and major journals with specific COVID-19 sections. Articles eligible for inclusion contained the topic of education in surgery in the context of COVID-19. Specific questions we aimed to answer were: Is there any difference in surgical education from pre-COVID-19 to now? How does technology assist us in teaching? Can we better harness technology to augment resident training? Two-hundred and twenty-six articles were identified, 21 relevant for our aim: 14 case studies, three survey analyses, three reviews and one commentary. The collapse of the traditional educational system due to social distancing caused a fragmentation of knowledge, a reduced acquisition of skills and a decreased employment of surgical trainees. These problems can be partially overcome by using new technologies and arranging 2-weeks rotation shifts, alternating clinical activities with learning. While medical care will remain largely based on the interaction with patients, students' adaptability to innovation will be a characteristic of post-COVID classes.

Training in robot-assisted surgery

PURPOSE OF REVIEW

The aim of this narrative review is to identify the currently available training programs in the field of robotic-assisted surgery.

RECENT FINDINGS

The lack of well trained robotic surgeons represents the main obstacle facing robotic surgery. This calls for development of structured robotic training programs in order to improve patient safety and outcomes. Structured curriculum should consist of theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and final evaluation. Tele-mentoring might reveal mandatory in future curricula development. To date, several training programs are currently available for robotic surgery. However, the majority lack of clinical modular training that consists of progressive, proficiency-based training through surgical steps with increasing levels of complexity. Moreover, many of these curricula lack validation.

SUMMARY

This recent literature analysis suggests that there is an urgent need to develop and validate new structured training curricula for robotic surgery. This allows to improve the skills of the surgeons and of their team and to prevent patients from being used as a training module optimizing their safety.

Are basic robotic surgical skills transferable from the simulator to the operating room? A randomized, prospective, educational study

INTRODUCTION

We aimed to assess the transferability of basic robotic skills from the simulator to the operating room (OR) while performing robotic-assisted radical prostatectomy (RARP).

METHODS

Fourteen urology residents were randomized into two groups: group A was required to practice three sessions (nine tasks each) on the simulator, whereas group B was required to practice (same nine tasks) until they reached competency. Both groups were recorded while practicing on the da Vinci Surgical Skills Simulator. Both groups were then recorded while performing bladder mobilization during RARP. Senior residents from both groups were also recorded while performing urethro-vesical anastomosis during RARP. Recordings were assessed blindly using the validated Global Evaluative Assessment of Robotic Skills (GEARS) tool by C-SATS. Spearman's correlation coefficient (rho) was used to assess correlation between GEARS scores from practice sessions on the da Vinci Simulator and the GEARS scores from bladder mobilization and urethro-vesical anastomosis during RARP.

RESULTS

There was no difference in total GEARS scores between the two groups in the OR. Total GEARS scores for "ring and rail 2" and "suture sponge" tasks correlated with the total GEARS scores during urethro-vesical anastomosis (rho=0.86, p=0.007; rho=0.90, p=0.002, respectively). GEARS' efficiency component during "energy and dissection" task on the da Vinci Simulator correlated with GEARS' efficiency component during bladder mobilization (rho=0.62, p=0.03). GEARS' force sensitivity component during "ring and rail 2" and "dots and needles" tasks on the da Vinci Simulator correlated with GEARS' force sensitivity component during bladder mobilization (rho=0.58, p=0.047; rho =0.65, p=0.02, respectively).

CONCLUSIONS

Objective assessments of urology residents on the da Vinci Surgical Skills Simulator tasks ring and rail 2 and suture sponge correlated with their objective assessments of bladder mobilization and urethro-vesical anastomosis. Therefore, basic robotic skills could be transferred from the simulator to the OR.

Current Status of Simulation Training in Urology: A Non-Systematic Review

Simulation has emerged as an effective solution to increasing modern constraints in surgical training. It is recognized that a larger proportion of surgical complications occur during the surgeon's initial learning curve. The simulation takes the learning curve out of the operating theatre and facilitates training in a safe and pressure-free environment whilst focusing on patient safety. The cost of simulation is not insignificant and requires commitment in funding, human resources and logistics. It is therefore important for trainers to have evidence when selecting various simulators or devices. Our non-systematic review aims to provide a comprehensive up-to-date picture on urology simulators and the evidence for their validity. It also discusses emerging technologies and future directions. Urologists should embed evidence-based simulation in training programs to shorten learning curves while maintaining patient safety and work should be directed toward a validated and agreed curriculum.

Simulation Training in Urology: State of the Art and Future Directions

There has been a major shift from the old paradigm of 'see one, do one, teach one' in medical training due in large part to resident work-hour restrictions and required oversight in the operating room. In response to this, advancements in technology have allowed for the introduction of more objective measures to assess the skill competency and proficiency of surgical trainees. Patient safety and trainee well-being are important drivers for this new model, and so surgical training programs are adopting simulation into their curriculum. Urology is uniquely positioned at the forefront of new emerging technologies in surgery, because of the field's commitment to safe and efficient minimally invasive surgery and endourological procedures. Due to these technically challenging procedures, urological training must incorporate these educational technologies to allow for objective skills assessment, skills transfer, and ultimately providing optimal patient care with the production of proficient and competent urological trainees.

The Validation of a Novel Robot-Assisted Radical Prostatectomy Virtual Reality Module

OBJECTIVE

To perform the first validation of a full procedural virtual reality robotic training module and analysis of novice surgeon's learning curves.

DESIGN

Participants completed the bladder neck dissection task and urethrovesical anastomosis task (UVA) as part of the prostatectomy module. Surgeons completed feedback questionnaires assessing the realism, content, acceptability and feasibility of the module. Novice surgeons completed a 5.5-hour training programme using both tasks.

SETTING

King's College London, London.

PARTICIPANTS

13 novice, 24 intermediate and 8 expert surgeons completed the validation study.

RESULTS

Realism was scored highly for BDN (mean 3.4/5) and UVA (3.74/5), as was importance of BDN (4.32/5) and UVA (4.6/5) for training. It was rated as a feasible (3.95/5) and acceptable (4/5) tool for training. Experts performed significantly better than novice group in 6 metrics in the UVA including time (p = 0.0005), distance by camera (p = 0.0010) and instrument collisions (p = 0.0033), as well as task-specific metrics such as number of unnecessary needle piercing points (p = 0.0463). In novice surgeons, a significant improvement in performance after training was seen in many metrics for both tasks. For bladder neck dissection task, this included time (p < 0.0001), instrument collisions (p = 0.0013) and total time instruments are out of view (p = 0.0251). For UVA, this included time (p = 0.0135), instrument collisions (p = 0.0066) and task-specific metrics such as injury to the urethra (p = 0.0032) and bladder (p = 0.0189).

CONCLUSIONS

Surgeons found this full procedural VR training module to be a realistic, feasible and acceptable component for a robotic surgical training programme. Construct validity was proven between expert and novice surgeons. Novice surgeons have shown a significant learning curve over 5.5 hours of training, suggesting this module could be used in a surgical curriculum for acquisition of technical skills. Further implementation of this module into the curriculum and continued analysis would be beneficial to gauge how it can be fully utilised.

Implementing assessments of robot-assisted technical skill in urological education: a systematic review and synthesis of the validity evidence

OBJECTIVES

To systematically review and synthesise the validity evidence supporting intraoperative and simulation-based assessments of technical skill in urological robot-assisted surgery (RAS), and make evidence-based recommendations for the implementation of these assessments in urological training.

MATERIALS AND METHODS

A literature search of the Medline, PsycINFO and Embase databases was performed. Articles using technical skill and simulation-based assessments in RAS were abstracted. Only studies involving urology trainees or faculty were included in the final analysis.

RESULTS

Multiple tools for the assessment of technical robotic skill have been published, with mixed sources of validity evidence to support their use. These evaluations have been used in both the ex vivo and in vivo settings. Performance evaluations range from global rating scales to psychometrics, and assessments are carried out through automation, expert analysts, and crowdsourcing.

CONCLUSION

There have been rapid expansions in approaches to RAS technical skills assessment, both in simulated and clinical settings. Alternative approaches to assessment in RAS, such as crowdsourcing and psychometrics, remain under investigation. Evidence to support the use of these metrics in high-stakes decisions is likely insufficient at present.

Robotic Surgery Simulator: Elements to Build a Training Program

OBJECTIVE

Face, content, and construct validity of robotic surgery simulators were confirmed in the literature by several studies, but elements to build a training program are still lacking. The aim of our study was to validate a progressive training program and to assess according to prior surgical experience the amount of training needed with a robotic simulator to complete the program.

DESIGN

Exercises using the Da Vinci Skill Simulator were chosen to ensure progressive learning. A new exercise could only be started if a minimal score of 80% was achieved in the prior one. The number of repetitions to achieve an exercise was not limited. We devised a "performance index" by calculating the ratio of the sum of scores for each exercise over the number of repetitions needed to complete the exercise with at least an 80% score.

SETTING

The study took place at the François Baclesse Cancer Center. Participants all work at the primary care university Hospital located next to the cancer center.

PARTICIPANTS

A total of 32 surgeons participated in the study- 2 experienced surgeons, 8 junior and 8 senior residents in surgery, 6 registrars, and 6 attending surgeons.

RESULTS

There was no difference between junior and senior residents, whereas the registrars had better results (p < 0.0001). The registrars performed less exercise repetitions compared to the junior or senior residents (p = 0.012). Attending surgeons performed significantly more repetitions than registrars (p = 0.024), but they performed fewer repetitions than junior or senior residents with no statistical difference (p = 0.09). The registrars had a performance index of 50, which is the best result among all novice groups. Attending surgeons were between senior and junior residents with an index at 33.85.

CONCLUSION

Choice of basic exercises to manipulate different elements of the robotic surgery console in a specific and progressive order enables rapid progress. The level of prior experience in laparoscopic surgery affects outcomes. More advanced laparoscopic expertise seems to slow down learning, surgeons having to "unlearn" to acquire a new technique.

Validation of a Novel Virtual Reality Training Curriculum for Robotic Cardiac Surgery a Randomized Trial

Objective

Robotic cardiac surgery training has relied entirely on classical methods of surgical teaching. We sought to evaluate the impact of a virtual reality (VR) simulation curriculum to improve skill acquisition in robotic cardiac surgery.

Methods

We randomly assigned 20 surgical trainees to undergo a 9-exercise VR curriculum on a robotic surgical simulator or a control group that received no additional training. The trainees were then evaluated in a blinded fashion by assessing their de-identified video recordings of the following: (1) standardized robotic internal thoracic artery harvest and (2) mitral valve annuloplasty performed in porcine models, using a validated time-based scoring system and an objective intraoperative scoring tool. Postintervention assessments were compared to baseline.

Results

Trainees randomized to the VR group were faster than the control group for both the internal thoracic artery harvest (957.3 ± 98.9 vs. 749.1 ± 171.9; P = 0.004) and mitral annuloplasty (580.4 ± 14.4 vs. 463.8 ± 86.4; P < 0.001) and scored significantly higher with the intraoperative scoring tool (22.8 ± 2.7 vs. 11.0 ± 4.5; P < 0.001). Additionally, the VR group achieved a proficiency level similar to our experts for both time-based scores (P = 0.624 and P = 0.967), and the intraoperative assessment (P = 0.110), whereas the control group was not able to meet this level of proficiency for any of the primary outcomes. The average duration of training to successfully complete all required tasks was 9.3 hours.

Conclusions

We have demonstrated that a VR simulation curriculum can significantly improve the efficiency and quality of learning in robotic cardiac surgery. Further evaluation of this curriculum is required for its widespread implementation in surgical training (ClinicalTrials.gov, NCT#02357056).

A Systematic Review of Virtual Reality Simulators for Robot-assisted Surgery

CONTEXT

No single large published randomized controlled trial (RCT) has confirmed the efficacy of virtual simulators in the acquisition of skills to the standard required for safe clinical robotic surgery. This remains the main obstacle for the adoption of these virtual simulators in surgical residency curricula.

OBJECTIVE

To evaluate the level of evidence in published studies on the efficacy of training on virtual simulators for robotic surgery.

EVIDENCE ACQUISITION

In April 2015 a literature search was conducted on PubMed, Web of Science, Scopus, Cochrane Library, the Clinical Trials Database (US) and the Meta Register of Controlled Trials. All publications were scrutinized for relevance to the review and for assessment of the levels of evidence provided using the classification developed by the Oxford Centre for Evidence-Based Medicine.

EVIDENCE SYNTHESIS

The publications included in the review consisted of one RCT and 28 cohort studies on validity, and seven RCTs and two cohort studies on skills transfer from virtual simulators to robot-assisted surgery. Simulators were rated good for realism (face validity) and for usefulness as a training tool (content validity). However, the studies included used various simulation training methodologies, limiting the assessment of construct validity. The review confirms the absence of any consensus on which tasks and metrics are the most effective for the da Vinci Skills Simulator and dV-Trainer, the most widely investigated systems. Although there is consensus for the RoSS simulator, this is based on only two studies on construct validity involving four exercises. One study on initial evaluation of an augmented reality module for partial nephrectomy using the dV-Trainer reported high correlation (r=0.8) between in vivo porcine nephrectomy and a virtual renorrhaphy task according to the overall Global Evaluation Assessment of Robotic Surgery (GEARS) score. In one RCT on skills transfer, the experimental group outperformed the control group, with a significant difference in overall GEARS score (p=0.012) during performance of urethrovesical anastomosis on an inanimate model. Only one study included assessment of a surgical procedure on real patients: subjects trained on a virtual simulator outperformed the control group following traditional training. However, besides the small numbers, this study was not randomized.

CONCLUSIONS

There is an urgent need for a large, well-designed, preferably multicenter RCT to study the efficacy of virtual simulation for acquisition competence in and safe execution of clinical robotic-assisted surgery.

PATIENT SUMMARY

We reviewed the literature on virtual simulators for robot-assisted surgery. Validity studies used various simulation training methodologies. It is not clear which exercises and metrics are the most effective in distinguishing different levels of experience on the da Vinci robot. There is no reported evidence of skills transfer from simulation to clinical surgery on real patients.