Design and Evaluation of a Performance-based Adaptive Curriculum for Robotic Surgical Training: a Pilot Study

The impact of extended reality on surgery: a scoping review

PURPOSE

Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments to enhanced real-world environments. In the past two decades, XR-assisted surgery has seen an increase in its use and also in research and development. This scoping review aims to map out the historical trends in these technologies and their future prospects, with an emphasis on the reported outcomes and ethical considerations on the use of these technologies.

METHODS

A systematic search of PubMed, Scopus, and Embase for literature related to XR-assisted surgery and telesurgery was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Primary studies, peer-reviewed articles that described procedures performed by surgeons on human subjects and cadavers, as well as studies describing general surgical education, were included. Non-surgical procedures, bedside procedures, veterinary procedures, procedures performed by medical students, and review articles were excluded. Studies were classified into the following categories: impact on surgery (pre-operative planning and intra-operative navigation/guidance), impact on the patient (pain and anxiety), and impact on the surgeon (surgical training and surgeon confidence).

RESULTS

One hundred and sixty-eight studies were included for analysis. Thirty-one studies investigated the use of XR for pre-operative planning concluded that virtual reality (VR) enhanced the surgeon's spatial awareness of important anatomical landmarks. This leads to shorter operating sessions and decreases surgical insult. Forty-nine studies explored the use of XR for intra-operative planning. They noted that augmented reality (AR) headsets highlight key landmarks, as well as important structures to avoid, which lowers the chance of accidental surgical trauma. Eleven studies investigated patients' pain and noted that VR is able to generate a meditative state. This is beneficial for patients, as it reduces the need for analgesics. Ten studies commented on patient anxiety, suggesting that VR is unsuccessful at altering patients' physiological parameters such as mean arterial blood pressure or cortisol levels. Sixty studies investigated surgical training whilst seven studies suggested that the use of XR-assisted technology increased surgeon confidence.

CONCLUSION

The growth of XR-assisted surgery is driven by advances in hardware and software. Whilst augmented virtuality and mixed reality are underexplored, the use of VR is growing especially in the fields of surgical training and pre-operative planning. Real-time intra-operative guidance is key for surgical precision, which is being supplemented with AR technology. XR-assisted surgery is likely to undertake a greater role in the near future, given the effect of COVID-19 limiting physical presence and the increasing complexity of surgical procedures.

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.

Adaptive Surgical Robotic Training Using Real-Time Stylistic Behavior Feedback Through Haptic Cues

Surgical skill directly affects surgical procedure outcomes; thus, effective training is needed to ensure satisfactory results. Many objective assessment metrics have been developed that provide the trainee with descriptive feedback about their performance however, often lack feedback on how to improve performance. The most effective training method is one that is intuitive, easy to understand, personalized to the user,and provided in a timely manner. We propose a framework to enable user-adaptive training using near real-time detection of performance, based on intuitive styles of surgical movements, and design a haptic feedback framework to assist with correcting styles of movement. We evaluate the ability of three types of force feedback (spring, damping, and spring plus damping feedback), computed based on prior user positions, to improve different stylistic behaviors of the user during kinematically constrained reaching movement tasks. The results indicate that five out of six styles studied here were improved using at least one of the three types of force feedback. Task performance metrics were compared in the presence of the three types of feedback. Task time was statistically significantly lower when applying spring feedback, compared to the other two types of feedback. Path straightness and targeting error were statistically significantly improved when using spring-damping feedback compared to the other two types of feedback. This study presents a groundwork for adaptive training in robotic surgery based on near real-time human-centric models of surgical behavior.

Integration of Robotics in Urology Residency Programs: an Unchecked Technological Revolution

PURPOSE OF REVIEW

To review the integration of robotics in urology residency programs and evaluate how it has impacted a graduates' level of surgical competence.

RECENT FINDINGS

Surgical technique training has shown a dramatic shift towards robotics with the most profound occurring in oncology. However, integration of robotics is not uniform across programs nor even among residents themselves. Robotics require graduates to garner a broader skill set within the same prescribed training time. Unfortunately, in this modern era, graduates are feeling more ill-equipped to start independent practice and show an increased need to pursue fellowship training to achieve technical proficiency. The dissemination of robotics in residency programs has gone unchecked. Modulating existing training structures through (1) development of procedure- and surgical technique-specific target metrics for graduation and (2) integration of a formalized robotic curriculum may improve the overall quality and outcome of the educational experience.

Skill-Oriented and Performance-Driven Adaptive Curricula for Training in Robot-Assisted Surgery Using Simulators: A Feasibility Study

OBJECTIVE

Virtual Reality (VR) simulators represent a remarkable educational opportunity in order to acquire and refine surgical practical skills. Nevertheless, there exists no consensus regarding a standard curriculum of simulation-based training. This study introduces an automatic, adaptive curriculum where the training session is real-time scheduled on the basis of the trainee's performances.

METHODS

An experimental study using the master console of the da Vinci Research Kit (Intuitive Surgical Inc., Sunnyvale, US) was carried out to test this approach. Tasks involving fundamental skills of robotic surgery were designed and simulated in VR. Twelve participants without medical background along with twelve medical residents were randomly and equally divided into two groups: a control group, self-managing the training session, and an experimental group, undergoing the proposed adaptive training.

RESULTS

The performances of the experimental users were significantly better with respect to the ones of the control group after training (non-medical: p < 0.01; medical: p = 0.02). This trend was analogous in the non-medical and medical populations and no significant difference was identified between these two classes (even in the baseline assessment).

CONCLUSION

The analysis of the learning of the involved surgical skills highlighted how the proposed adaptive training managed to better identify and compensate for the trainee's gaps. The absence of initial difference between the non-medical and medical users underlines that robotic surgical devices require specific training before clinical practice.

SIGNIFICANCE

This feasibility study could pave the way towards the improvement of simulation-based training curricula.