Evaluation of a 3D-Printed Transoral Robotic Surgery Simulator Utilizing Artificial Tissue

OBJECTIVES/HYPOTHESIS

Transoral robotic surgery (TORS) poses challenges for operators in training, with limited robot access on a platform requiring distinct surgical skills. Few simulators exist, and current virtual reality training modules exclude head and neck simulations. This study evaluates the construct validity for a novel low-cost TORS simulator.

STUDY DESIGN

Single institution prospective observational study.

METHODS

Using 3D-printed oral cavity structures and replaceable artificial tissue components, a modular TORS simulator was constructed for short-duration hands-on simulations with the da Vinci SI robot. Sixteen surgeons of differing robotic skill levels, no experience (novice), prior experience, and formal robot training, participated in simulated tonsil and tongue base tumor resections. Video recordings of each participant were graded by a blinded robotically trained surgeon using a 35-point Global Evaluative Assessment of Robotic Surgery (GEARS) criterion adapted for the TORS simulator.

RESULTS

Operators reporting formal robotic training or prior robot experience achieved significantly higher mean total GEARS scores compared to novice operators (32 vs. 20.5; P < .001). Overall, mean total GEARS scores correlated with reported experience level; novice operators scored 54% of total points at 19 (4.5), operators with prior experience scored 82.3% of total points at 28.8 (2.6), and robotically trained operators scored 97.1% of total points at 34 (1.7).

CONCLUSION

With a GEARS criterion, our simulator successfully differentiated novice from experienced and robotically trained operators of the da Vinci SI robot during simulated tonsillectomy and base of tongue resections. These findings support the construct validity of this prototype simulator and offer a foundation for further testing of predictive validity.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

Mapping the robotic hysterectomy learning curve and re-establishing surgical training metrics

OBJECTIVE

Common robotic training curricula in the US entail completion of an online module followed by lab training with standardized exercises, such as manipulating needles with robotic needle drivers. Assessments are generally limited to elapsed time and subjective proficiency. We sought to test the feasibility of a simulation-based robotic hysterectomy curriculum to collect objective measurements of trainee progress, map the trainee learning curve and provide a system for trainee-specific evaluation.

METHODS

An observational cohort study of a single institutions' residency members participating in a procedural hysterectomy simulation performed every 4 months. Each simulation episode had one-on-one teaching. The robotic platform was used to measure all movements within cartesian coordinates, the number of clutches, instrument collisions, time to complete the simulated hysterectomy, and unintended injuries during the procedure.

RESULTS

Voluntary participation was high. Objective metrics were successfully recorded at each session and improved nearly universally. More senior residents demonstrated superior capabilities compared to junior residents as expected. The majority of residents (29/31) were able to complete an entire simulated hysterectomy in the allotted 30-minute training session period by the end of the year.

CONCLUSIONS

This program establishes learning curves based on objective data points using a risk-free simulation platform. The curves can then be used to evaluate trainee skill level and tailor teaching to specific objective competencies. The pilot curriculum can be tailored to the unique needs of each surgical discipline's residency training.

Transoral Robotic Surgical Proficiency Via Real-Time Tactile Collision Awareness System

OBJECTIVES

In 2009, the Food and Drug Administration approved the use of the surgical robotic system for removal of benign and malignant conditions of the upper aerodigestive tract. This novel application of robotic-assisted surgery, termed transoral robotic surgery (TORS), places robotic instruments and camera system through the mouth to reach recessed areas of the pharynx and larynx. Over the successive decade, there was a rapid adoption of TORS with a surgical growth rate that continues to increase. Despite the rapid clinical acceptance, the field of TORS has not yet seen substantive changes or advances in the technical shortcomings, the lack of which has restricted objective TORS-specific surgical skills assessment as well as subsequent skills improvement efforts. One of the primary technical challenges of TORS is operating in a confined space, where the robotic system is maneuvered within the restrictive boundaries of the mouth and throat. Due to these confined boundaries of the pharynx, instruments can frequently collide with anatomic structures such as teeth and bone, producing anatomic collisions. Therefore, we hypothesized that anatomic collisions negatively impact TORS surgical performance. Secondarily, we hypothesized that avoidance of unwanted anatomic collisions could improve TORS surgical proficiency.

METHODS

Design and fidelity testing for a custom TORS training platform with an integrated anatomic collision-sensing system providing real-time tactile feedback is described. Following successful platform assembly and testing, validation study using the platform was carried through prospective surgical training with trial randomization. Twenty otolaryngology-head and neck surgery residents, each trainee performing three discrete mock surgical trials (n = 60), performed the initial system validation. Ten of the 20 residents were randomized to perform the surgical trials utilizing the real-time feedback system. The remaining 10 residents were randomized to perform the surgical trials without the feedback system, although the system still could record collision data. Surgical proficiency was measured by Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and tumor resection scores (categorical scale ranging 0-3, describing the adequacy of resection).

RESULTS

Major anatomic collisions (greater than 5N of force) negatively affected GEARS robotic skills. A mixed model analysis demonstrated that for every additional occurrence of a major collision, GEARS robotic skills assessment score would decrease by 0.29 points (P = .04). Real-time collision awareness created significantly fewer major (> 5 N) anatomic collisions with the tactile feedback system active (n = 30, mean collisions = 2.9 ± 4.2) as compared with trials without tactile feedback (n = 30, mean collisions = 12.53 ± 23.23) (P < .001). The second assessment measure of time to completion was unaffected by the presence of collisions or by the use of tactile feedback system. The third proficiency assessment was measured with tumor resection grading. Tumor resection scores was significantly (P = .02) improved with collision awareness system activated than trials without collision awareness.

CONCLUSION

In order to test our primary hypothesis, a novel TORS training platform was successfully developed that provides collision force measurements including frequency, severity, and duration of anatomic collisions. Additionally, the platform was modulated to provide real-time tactile feedback of the occurrence of out-of-field collisions. Utilizing this custom platform, our hypothesis that anatomic collisions during TORS diminishes surgical performance was supported. Additionally, our secondary hypothesis that subsequent reduction of anatomic collisions improves TORS proficiency was supported by the surgical trial. Dedicated investigation to characterize the effect size and clinical impact is required in order to translate this finding into training curriculums and into clinical utilization.

LEVEL OF EVIDENCE

II (Randomized trial) Laryngoscope, 130:S1-S17, 2020.

Creating a Validated Simulation Training Curriculum in Otolaryngology

Purpose of Review

Simulation-based training is an integral component of surgical training. It allows practice of technical skills within a safe environment without compromising patient safety. This article seeks to review current virtual and non-virtual reality simulation models within the literature and review their validation status.

Recent Findings

Many simulation models exist within otolaryngology and are currently being used for education. New models are also continuously being developed; however, validity should be proven for the models before incorporating their use for educational purposes. Validity should be determined by experts and trainees themselves.

Summary

A validated simulation curriculum should be incorporated within the otolaryngology training programme. A curriculum based on the current training programme at our institution serves as an exemplar for local adoption.

Attitudes of robotic surgery educators and learners: challenges, advantages, tips and tricks of teaching and learning robotic surgery

As the application of robotic surgical technology grows, so does the need to instruct surgical residents in robotic techniques. To better understand the challenges and benefits unique to robotic surgery education, this study explored the attitudes of teachers and learners. A 43-item questionnaire was developed with five domains: challenges and benefits of robotic education, training methodologies, trainees' readiness for learning, and education tips. This was delivered to surgeons and surgical fellows at a high-volume surgical department. 31 surgeons and 25 fellows from 7 specialties responded (response rate 70% and 43%). The teaching and learning of robotic surgery were perceived as superior to traditional minimally invasive surgery by both surgeons (in 7/9 factors studied) and fellows (7/9), but was seen as mostly disadvantageous compared to open surgery by both surgeons (in 6/9 factors studied) and fellows (8/9). Surgeons frequently stated the greatest challenge to teaching robotics was the need to relinquish total control to the trainee. Robotic surgery education is generally well received and offers several advantages. However, teaching robotic surgery presents unique challenges, especially when compared to open surgery. Understanding the benefits of, and barriers to, robotic surgery education may help develop more effective training paradigms that are responsive to educational needs while maintaining patient safety.

A Robotic Recording and Playback Platform for Training Surgeons and Learning Autonomous Behaviors Using the da Vinci Surgical System

This paper describes a recording and playback system developed using a da Vinci Standard Surgical System and research kit. The system records stereo laparoscopic videos, robot arm joint angles, and surgeon–console interactions in a synchronized manner. A user can then, on-demand and at adjustable speeds, watch stereo videos and feel recorded movements on the hand controllers of entire procedures or sub procedures. Currently, there is no reported comprehensive ability to capture expert surgeon movements and insights and reproduce them on hardware directly. This system has important applications in several areas: (1) training of surgeons, (2) collection of learning data for the development of advanced control algorithms and intelligent autonomous behaviors, and (3) use as a “black box” for retrospective error analysis. We show a prototype of such an immersive system on a clinically-relevant platform along with its recording and playback fidelity. Lastly, we convey possible research avenues to create better systems for training and assisting robotic surgeons.

Robotic Thoracic Surgery Training for Residency Programs

Objective

Robotic-assisted surgery is increasingly being used in thoracic surgery. Currently, the Integrated Thoracic Surgery Residency Program lacks a standardized curriculum or requirement for training residents in robotic-assisted thoracic surgery. In most circumstances, because of the lack of formal residency training in robotic surgery, hospitals are requiring additional training, mentorship, and formal proctoring of cases before granting credentials to perform robotic-assisted surgery. Therefore, there is necessity for residents in Integrated Thoracic Surgery Residency Program to have early exposure and formal training on the robotic platform. We propose a curriculum that can be incorporated into such programs that would satisfy both training needs and hospital credential requirements.

Methods

We surveyed all 26 Integrated Thoracic Surgery Residency Program Directors in the United States. We also performed a PubMed literature search using the key word “robotic surgery training curriculum.” We reviewed various robotic surgery training curricula and evaluation tools used by urology, obstetrics gynecology, and general surgery training programs. We then designed a proposed curriculum geared toward thoracic Integrated Thoracic Surgery Residency Program adopted from our credentialing experience, literature review, and survey consensus.

Results

Of the 26 programs surveyed, we received 17 responses. Most Integrated Thoracic Surgery Residency Program directors believe that it is important to introduce robotic surgery training during residency. Our proposed curriculum is integrated during postgraduate years 2 to 6. In the preclinical stage postgraduate years 2 to 3, residents are required to complete introductory online modules, virtual reality simulator training, and in-house workshops. During clinical stage (postgraduate years 4–6), the resident will serve as a supervised bedside assistant and progress to a console surgeon. Each case will have defined steps that the resident must demonstrate competency. Evaluation will be based on standardized guidelines.

Conclusions

Expansion and utilization of robotic assistance in thoracic surgery have increased. Our proposed curriculum aims to enable Integrated Thoracic Surgery Residency Program residents to achieve competency in robotic-assisted thoracic surgery and to facilitate the acquirement of hospital privileges when they enter practice.

Initial and Long-term Retention of Robotic Technical Skills in an Otolaryngology Residency Program

OBJECTIVES/HYPOTHESIS

To objectively assess the initial and long-term retention of robotic surgical skills of otolaryngology residents.

STUDY DESIGN

This study was performed in an academic otolaryngology residency training program. Between October 2015 and November 2016, residents were invited to complete a prospective, multiphase robotic surgical skills training course: 1) online da Vinci Surgical System Assessment and didactic, 2) faculty-supervised robotic simulator training, 3) robotic docking and draping training, 4) robotic dry-lab exercises. To optimize surgical skill retention, the training laboratory was repeated 2 weeks after the initial training session.

METHODS

Twenty otolaryngology residents were included. Primary outcome was measured as robotic skill assessment scores on three tasks: camera targeting, peg board, and needle targeting. Skill assessments were completed prior to training, between the two training sessions, and at 1 month and 6 months after training. Residents were also asked to complete a self-assessment questionnaire.

RESULTS

Camera targeting scores were improved at midtraining (P < .001) and 1-month posttraining (P = .010). Peg board scores were improved at 1 month training (P = .043). Needle targeting scores were improved at midtraining (P = .002), 1 month (P = .002), and 6 months posttraining (P < .001). Resident self-assessment scores demonstrating comfort with using the robotic console (P < .01) and docking/draping (P < .01) improved significantly following the training.

CONCLUSIONS

Following a multiphase robotic training program, otolaryngology residents demonstrated significant, objective skill acquisition and retention at 1 month and 6 months follow-up. Although the proposed training strategy may be considered an important step in otolaryngology residency training, additional innovations are being designed toward a formal robotic training curriculum.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1380-1385, 2019.

Use of Automated Performance Metrics to Measure Surgeon Performance during Robotic Vesicourethral Anastomosis and Methodical Development of a Training Tutorial

PURPOSE

We sought to develop and validate automated performance metrics to measure surgeon performance of vesicourethral anastomosis during robotic assisted radical prostatectomy. Furthermore, we sought to methodically develop a standardized training tutorial for robotic vesicourethral anastomosis.

MATERIALS AND METHODS

We captured automated performance metrics for motion tracking and system events data, and synchronized surgical video during robotic assisted radical prostatectomy. Nonautomated performance metrics were manually annotated by video review. Automated and nonautomated performance metrics were compared between experts with 100 or more console cases and novices with fewer than 100 cases. Needle driving gestures were classified and compared. We then applied task deconstruction, cognitive task analysis and Delphi methodology to develop a standardized robotic vesicourethral anastomosis tutorial.

RESULTS

We analyzed 70 vesicourethral anastomoses with a total of 1,745 stitches. For automated performance metrics experts outperformed novices in completion time (p <0.01), EndoWrist® articulation (p <0.03), instrument movement efficiency (p <0.02) and camera manipulation (p <0.01). For nonautomated performance metrics experts had more optimal needle to needle driver positioning, fewer needle driving attempts, a more optimal needle entry angle and less tissue trauma (each p <0.01). We identified 14 common robotic needle driving gestures. Random gestures were associated with lower efficiency (p <0.01), more attempts (p <0.04) and more trauma (p <0.01). The finalized tutorial contained 66 statements and figures. Consensus among 8 expert surgeons was achieved after 2 rounds, including among 58 (88%) after round 1 and 8 (12%) after round 2.

CONCLUSIONS

Automated performance metrics can distinguish surgeon expertise during vesicourethral anastomosis. The expert vesicourethral anastomosis technique was associated with more efficient movement and less tissue trauma. Standardizing robotic vesicourethral anastomosis and using a methodically developed tutorial may help improve robotic surgical training.

Residency Training in Robotic General Surgery: A Survey of Program Directors

Objective

Robotic surgery continues to expand in minimally invasive surgery; however, the literature is insufficient to understand the current training process for general surgery residents. Therefore, the objectives of this study were to identify the current approach to and perspectives on robotic surgery training.

Methods

An electronic survey was distributed to general surgery program directors identified by the Accreditation Council for Graduate Medical Education website. Multiple choice and open-ended questions regarding current practices and opinions on robotic surgery training in general surgery residency programs were used.

Results

20 program directors were surveyed, a majority being from medium-sized programs (4–7 graduating residents per year). Most respondents (73.68%) had a formal robotic surgery curriculum at their institution, with 63.16% incorporating simulation training. Approximately half of the respondents believe that more time should be dedicated to robotic surgery training (52.63%), with simulation training prior to console use (84.21%). About two-thirds of the respondents (63.16%) believe that a formal robotic surgery curriculum should be established as a part of general surgery residency, with more than half believing that exposure should occur in postgraduate year one (55%).

Conclusion

A formal robotics curriculum with simulation training and early surgical exposure for general surgery residents should be given consideration in surgical residency training.

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.

Incorporating resident/fellow training into a robotic surgery program

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.