Robotic Surgery Simulator: Elements to Build a Training Program

Transferring laparoscopic skills to robotic-assisted surgery: a systematic review

Robotic-Assisted Surgery (RAS) is experiencing rapid expansion, prompting the integration of robotic technical skills training into surgical education programs. As access to robotic training platforms remains limited, it is important to investigate the transferability of laparoscopic skills to RAS. This could potentially support the inclusion of early years laparoscopic training to mitigate the learning curve associated with robotic surgery. This study aims to assess the transferability of laparoscopic skills to robotic surgery. A systematic search was conducted using the PRISMA checklist to identify relevant articles. PubMed, MEDLINE, Embase, and Cochrane databases were searched, and inclusion and exclusion criteria were applied to collate eligible articles. Included were original articles comparing the performance of comparable tasks on both laparoscopic and robotic platforms written in English. Non-peer reviewed papers, conference abstracts, reviews, and case series were excluded. Seventeen articles met the inclusion criteria. Among these, 10 studies (59%) demonstrated skill transferability from laparoscopic surgery (LS) to robotic surgery (RS); while one study (5.8%) showed no significant transferability. Four studies highlighted the positive impact of prior laparoscopic training on robotic skill, whereas six papers suggested no significant difference between laparoscopic novices and experienced laparoscopists when utilizing a robotic simulator. Five studies evaluated advanced surgical skills such as intracorporeal knot tying and suturing, revealing superior robotic performance among experienced laparoscopists compared to novice learners. Laparoscopic skills appear to be transferrable to robotic surgery, particularly in complex surgical techniques. Robotic simulators demonstrate a significant reduction in the learning curve for surgical novices, albeit to a lesser extent for experienced laparoscopists.

Laparoscopic but not open surgical skills can be transferred to robot-assisted surgery: A systematic review and meta-analysis

BACKGROUND

With an increase in robot-assisted surgery across all specialties, adequate training and credentialing strategies need to be identified to ensure patients safety. The meta-analysis assesses the transferability of technical surgical skills between laparoscopic surgery, open surgery, and robot-assisted surgery.

DESIGN

A systematic search was conducted in Medline, Cochrane Central Register of Controlled Trials, and Web of Science. Outcomes were categorized into time, process, product, and composite outcome measures and pooled separately using Hedges'g (standardized mean difference [SMD]). Subgroup analyses were performed to assess the effect of study design, virtual reality platforms and task difficulty.

RESULTS

Out of 14,120 screened studies, 30 were included in the qualitative synthesis and 26 in the quantitative synthesis. Technical surgical skill transfer was demonstrated from laparoscopic to robot-assisted surgery (composite: SMD 0.40, 95%-confidence interval [CI] [0.19; 0.62], time: SMD 0.62, CI [0.33; 0.91]) and vice versa (composite: SMD 0.66, CI [0.33; 0.99], time [basic skills]: SMD 0.36, CI [0.01; 0.72]). No skill transfer was seen from open to robot-assisted surgery with limited available data.

CONCLUSION

Technical surgical skills can be transferred from laparoscopic to robot-assisted surgery and vice versa. Robot-assisted and laparoscopic surgical skills training and credentialing should not be regarded separately, but a reasonable combination could shorten overall training times and increase efficiency. Previous experience in open surgery should not be considered as an imperative prerequisite for training in robot-assisted surgery. Recommendations for studies assessing skill transfer are proposed to increase comparability and significance of future studies.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018104507.

A systematic review of robotic surgery curricula using a contemporary educational framework

BACKGROUND

There has been a rising trend in robotic surgery. Thus, there is demand for a robotic surgery curriculum (RSC) for training surgical trainees and practicing surgeons. There are limited data available about current curricular designs and the extent to which they have incorporated educational frameworks. Our aim was to study the existing robotic surgery curricula using Kern's 6-step approach in curriculum development.

METHODS

A systematic review was conducted using PubMed, PubMed Central, Cochrane, Embase, and Scopus (we searched studies from 2001 to 2021). PRISMA Guidelines was used to guide the search. Curriculum designed for general surgery and its subspecialties were included. Urology and gynecology were excluded. The articles were reviewed by five reviewers.

RESULTS

Our review yielded 71 articles, including 39 curricula at 9 different settings. Using Kern's framework, we demonstrated that the majority of robotic surgery curricula contained all the elements of Kern's curricular design. However, there were significant deficiencies in important aspects of these curricula i.e., implementation, the quality of assessment tools for measurement of performance and evaluation of the educational value of these interventions. Most institutions used commercial virtual reality simulators (VRS) as the main component of their RSC and 23% of curricula only used VRS.

CONCLUSIONS

Although majority of these studies contained all the elements of Kern's framework, there are critical deficiencies in the components of existing curricula. Future curricula should be designed using established educational frameworks to improve the quality of robotic surgery training.

Transfer of open and laparoscopic skills to robotic surgery: a systematic review

Due to its advantages over open surgery and conventional laparoscopy, uptake of robot-assisted surgery has rapidly increased. It is important to know whether the existing open or laparoscopic skills of robotic novices shorten the robotic surgery learning curve, potentially reducing the amount of training required. This systematic review aims to assess psychomotor skill transfer to the robot in clinical and simulated settings. PubMed, EMBASE, Cochrane Library and Scopus databases were systematically searched in accordance with PRISMA guidelines from inception to August 2021 alongside website searching and citation chaining. Article screening, data extraction and quality assessment were undertaken by two independent reviewers. Outcomes included simulator performance metrics or in the case of clinical studies, peri- and post-operative metrics. Twenty-nine studies met the eligibility criteria. All studies were judged to be at high or moderate overall risk of bias. Results were narratively synthesised due to heterogeneity in study designs and outcome measures. Two of the three studies assessing open surgical skill transfer found evidence of successful skill transfer while nine of twenty-seven studies evaluating laparoscopic skill transfer found no evidence. Skill transfer from both modalities is most apparent when advanced robotic tasks are performed in the initial phase of the learning curve but quality and methodological limitations of the existing literature prevent definitive conclusions. The impact of incorporating laparoscopic simulation into robotic training curricula and on the cost effectiveness of training should be investigated.

INFLUENCE OF MINIMALLY INVASIVE LAPAROSCOPIC EXPERIENCE SKILLS ON ROBOTIC SURGERY DEXTERITY

Background:

It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities.

Aim:

To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background.

Methods:

Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill.

Results:

Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition.

Conclusion:

Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

Survey of trainee attitudes to skill development and simulation training in trauma and orthopaedics

Background

Simulation training in surgery is widespread and allows surgeons to practise novel operative techniques and acquaint themselves with unfamiliar surgical procedures. The use of box or virtual reality simulators in many surgical specialities is established; however, its use within trauma and orthopaedics (T&O) in the UK and the attitudes of trainee towards it are not known. The aim of this study is to explore the experiences and opinions of T&O trainees towards simulation training.

Methods

An electronic survey consisting of 11 questions on the experiences of simulation training and attitudes towards it was sent to all T&O speciality trainees in London.

Results

Fewer than 10% of the responders had used or had ready access to simulators to prepare for unfamiliar operations, with almost 90% preferring to read about them in a journal or watch them on an online video site. Over half had only seen simulators on courses or been aware of them. Over 75% of the responders believed that simulators should be available for trainees, but most did not feel that they should be used as part of formal assessments.

Conclusions

Methods for preparing for new operations have expanded over the past 20 years, yet the use of simulator machines is not widespread. Many trainees believe current machines are not widely available nor realistic enough to be useful, with most preferring online videos and operative technique books for preparing for an unfamiliar operation.

Simulation-Based Training in Robotic Surgery: Contemporary and Future Methods

While robotic surgery has grown in popularity and scope over the past decade, there is a persistent need for simulation-based training as surgeons adapt from the working at the bedside to the immersive and multisensory tasks at the console. From dry laboratory to virtual reality (VR) environments, simulation can be used to train surgeons in basic tasks, complex operative steps, and coordination of whole operations with members of the entire operating room (OR) staff. By integrating simulation into mentored training programs, surgeons can reduce the number of cases required to master a complex operation. Future VR based simulation will become essential to the adaptation of the surgical workforce to new technologies and adoption of emerging robotic platforms. Ultimately, robotic simulation will set standards for credentialing of new surgeons.

Robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the initial training for surgical novices in an ex vivo porcine model: a randomized crossover study

Background

Robotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices.

Methods

In a randomized crossover study, medical students (n = 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment.

Results

Surgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4; p = 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6; p = 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5; p = 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%), p = 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min; p = 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC.

Conclusions

Novices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model.

Registration number

researchregistry6029

Graphic abstract

A Review of Training and Guidance Systems in Medical Surgery

In this paper, a map of the state of the art of recent medical simulators that provide evaluation and guidance for surgical procedures is performed. The systems are reviewed and compared from the viewpoint of the used technology, force feedback, learning evaluation, didactic and visual aid, guidance, data collection and storage, and type of solution (commercial or non-commercial). The works’ assessment was made to identify if—(1) current applications can provide assistance and track performance in training, and (2) virtual environments are more suitable for practicing than physical applications. Automatic analysis of the papers was performed to minimize subjective bias. It was found that some works limit themselves to recording the session data to evaluate them internally, while others assess it and provide immediate user feedback. However, it was found that few works are currently implementing guidance, aid during sessions, and assessment. Current trends suggest that the evaluation process’s automation could reduce the workload of experts and let them focus on improving the curriculum covered in medical education. Lastly, this paper also draws several conclusions, observations per area, and suggestions for future work.

Surgical Cross-Training With Surgery Naive Learners: Implications for Resident Training

OBJECTIVE

While current literature has explored the transferability of laparoscopic surgical skills to robotic surgery, this study looks to investigate the transferability of surgical skills between robotic surgical simulation and simulated traditional laparoscopy.

DESIGN

Participants completed a survey regarding prior surgery exposure and other confounding factors including previous video game experience and self-assessed hand-eye coordination. Following orientation to the laparoscopic simulator (LS) and robotic surgical simulator (RoSS), participants were timed performing the Balloon Grasp and Ball Drop tasks on the RoSS and the Peg Transfer and Ball Drop tasks on the LS. Participants were then randomized to either the laparoscopic or RoSS arm and timed performing the Ball Drop task 10 times and then reassessed performing the Ball Drop using the unpracticed modality.

SETTING

Clinical Simulation Laboratory at the University of Vermont PARTICIPANTS: A total of 31 medical students with limited experience in laparoscopic and robotic surgery.

RESULTS

There were no statistically significant differences in the demographics or prior surgical and videogame experience between the participants in the laparoscopic and robotic arms of the study (X² = 0.72, p = 0.75). Timed initial assessment of the RoSS Balloon Grasp (p = 0.84) and Ball Drop (p = 0.79) tasks and the LS Peg Transfer (p = 0.14) and Ball Drop (p = 0.44) tasks were not statistically different between the 2 arms. The simulator modality which was practiced yielded the greatest improvement. The degree of improvement on the unpracticed modality was not statistically different between the groups (p = 0.57), and it was not significantly better than 2 rounds of sequential practice on the practiced modality (LS, p = 0.98 and RoSS, p = 0.55).

CONCLUSIONS

With practice, both groups increased surgical skill on the unpracticed modality. However, this degree of improvement was equal, suggesting there is no transferability of skills between laparoscopy and robotics.

Does Previous Laparoscopic Experience Influence Basic Robotic Surgical Skills?

OBJECTIVE

Studies addressing the effect of laparoscopic experience on robotic skills have produced conflicting results. This study aimed to compare simulated robotic surgical tasks using the virtual reality simulator dV-Trainer between laparoscopically experienced surgeons and first-year surgical residents.

DESIGN

A cross-sectional study. Participants completed 4 trials of the following tasks on the dV-Trainer: Peg Board 2, Ring and Rail 1, and Suture Sponge 1. Performance was recorded using a computerized built-in scoring algorithm. Scores and metrics were compared between groups 1 and 2 and between the first and subsequent trials.

SETTING

Hospital de Clínicas, Porto Alegre, Brazil, a tertiary care teaching hospital.

PARTICIPANTS

Twenty laparoscopically experienced surgeons (group 1) and 20 first-year surgical residents (group 2). All participants completed the study.

RESULTS

The overall scores for Peg Board 2 (738.04 ± 267.83 vs 730.39 ± 225.31; p  = 0.57), Ring and Rail 1 (919.03 ± 242.69 vs 965.84 ± 222.96; p  =  0.13), and Suture Sponge 1 (563.62 ± 185.50 vs 560.99 ± 152.71; p = 0.67) did not differ significantly between groups 1 and 2. Group 1 had better results for master workspace range in Peg Board 2 and Ring and Rail 1. Group 2 had higher scores for economy of motion in Peg Board 2 and Ring and Rail 1 and for excessive instrument force in Ring and Rail 1. In both groups, the overall scores in the third and fourth trials were significantly higher than those in the first trial.

CONCLUSIONS

There are no significant differences in the performance of simulated robotic surgical tasks between laparoscopically experienced surgeons and laparoscopically naïve surgical residents. Some slight differences were observed in specific metrics, but these differences were not sufficient to change the final results. We may assume that laparoscopic experience should not be an essential step in the initial learning curve of robotic surgery.

The emerging role for robotics in cholecystectomy: the dawn of a new era?

Though laparoscopic cholecystectomy (LC) was highly criticized in its early stages, it quickly grew to become a new standard of care and has revolutionized the field of general surgery. Now emerging robotic technology is making its way into the minimally invasive arena. Robotic cholecystectomy (RC) is often disparaged as a costly technology that can lead to increased operative times with outcomes that are quite similar to LC. However, this perspective is skewed as many existing studies were performed in the early phase of learning for this procedure. RC can be performed in a cost-effective manner as the volume of robotic procedures increases. In addition, improved visualization and capability to perform fluorescence cholangiography can improve the safety profile of cholecystectomy to a level that has not yet been achieved with conventional laparoscopy. Advanced simulation technology for robotic surgery, and newer single-site robotic platforms have the potential to further revolutionize this technology and lead to improved patient satisfaction. In this review, we will present current data, trends, and controversies in robotic-assisted cholecystectomy.

Highly immersive virtual reality laparoscopy simulation: development and future aspects

PURPOSE

Virtual reality (VR) applications with head-mounted displays (HMDs) have had an impact on information and multimedia technologies. The current work aimed to describe the process of developing a highly immersive VR simulation for laparoscopic surgery.

METHODS

We combined a VR laparoscopy simulator (LapSim) and a VR-HMD to create a user-friendly VR simulation scenario. Continuous clinical feedback was an essential aspect of the development process. We created an artificial VR (AVR) scenario by integrating the simulator video output with VR game components of figures and equipment in an operating room. We also created a highly immersive VR surrounding (IVR) by integrating the simulator video output with a [Formula: see text] video of a standard laparoscopy scenario in the department's operating room.

RESULTS

Clinical feedback led to optimization of the visualization, synchronization, and resolution of the virtual operating rooms (in both the IVR and the AVR). Preliminary testing results revealed that individuals experienced a high degree of exhilaration and presence, with rare events of motion sickness. The technical performance showed no significant difference compared to that achieved with the standard LapSim.

CONCLUSION

Our results provided a proof of concept for the technical feasibility of an custom highly immersive VR-HMD setup. Future technical research is needed to improve the visualization, immersion, and capability of interacting within the virtual scenario.

[Interest of surgical companionship during the training period of robot-assisted radical prostatectomy]

OBJECTIVE

Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification.

PATIENTS AND METHODS

Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group.

RESULTS

Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3.

CONCLUSION

The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair.

LEVEL OF EVIDENCE

4.