This common question helps to illustrate where educators should seek value in a surgical simulator. While the answer is very dependent on trainee learning objectives (resident vs faculty, beginner vs skills maintenance, basic skills vs procedures, etc.), some general conclusions can be derived by reviewing Mimic’s training database of more than 200,000 simulation training sessions stored in the cloud on MScore Portal™.
If you look at the types of activities that trainees need to become proficient using a surgeon console, you can divide them into a number of different buckets.
Basic Hand Controls
These skills focus on basic hand controls of the robotic system. The first step is just getting used to handling and moving objects around in space. This can be quite an adjustment for traditional laparoscopic surgeons that are used to their tools moving about a pivot point at the trocar. Basic hand control tasks start off simple and require the trainee to use only one or two hands. Tasks become more challenging when incorporating other interface elements such as finger clutching and foot controls. Most hospitals focus primarily on basic robot controls for maintaining privileges and maintenance of skill in general.
On the da Vinci® system, the control of the camera, clutch, instrument switching, and energy are carried out using foot pedals. Exercises in this area focus on developing muscle memory so the trainee does not need to look at their feet. On the original da Vinci S® system, there were only four pedals and clutching was solely controlled by one’s feet. Transitioning to the da Vinci Si® and da Vinci Xi® required significant rehearsal as the number of pedals increased from four to seven and single instrument clutching became available at the grips. Fortunately, Intuitive Surgical is expected to keep the current foot pedals as new robots, including da Vinci SP®, are introduced. However, it should be expected that new robots from other companies will have different interfaces that will need to be learned.
Fine Hand Controls
After a user becomes comfortable with using the surgeon console, they typically advance to finer hand skills such as needle throwing, knot tying, and suturing. These skills can be advanced in both a virtual dry lab environment or in a more clinically realistic scene. The big challenge is finding a way to restrain trainees from advancing to such surgical skills before they have mastered using the surgeon console.
As the robotic systems have developed, an increased number of advance instruments and visualization tools have become available. Simulation plays a role in educating trainees how to use the new technology. Typically, this would cover such things as single site instrumentation, stapling, vessel sealing, and advanced camera manipulation. To date, exercises focused on new instrumentation have been more product demonstrations than true educational activities. However, while Mimic’s database indicates that learning new instruments has not been a priority, it is likely adoption will increase as new instrumentation becomes more mainstream.
There are also other types of simulation exercises that focus on full procedural simulation and team training. In the past, by far the biggest application of simulators was console training. However, advanced training (fine hand control, procedures) is becoming much more popular as the fidelity and accuracy of this training content has improved. Advanced training is also becoming more popular as some institutions are starting to require competency in more advanced skills prior to being privileged in more advanced robotic procedures.
The graph below shows the evolution of exercises on Mimic’s dV-Trainer® over the past 6 years, as we can see, the use of basic controls has gone from approximately 60% of all usage in 2011 to around 30% today. Foot pedal control exercises have hovered around the 20% mark with perhaps a small decrease. The fine motor control exercises have increased from around 23% to 30%.
Where we have seen the largest increase is in the Overview / Other bucket which made up 20% of the utilization in 2016. This was driven by an increase in usage of the Maestro AR® software (procedure-specific training) as well the team training modules tied to the Xperience® Team Trainer™.
Looking at the activity on the da Vinci® Skills Simulator (DVSS) we can see that the evolution has been different. The foot control exercises started at a higher level of 30% and decreased to 25% of usage. Basic hand controls stayed fairly constant at around 45% of usage and fine controls have also fluctuated between the 18% to 12% range.
The DVSS also had some basic overview of controls as well as some additional software provided by other partners in the fine hand control area and advanced instrumentation. These have also fluctuated in the 8% to 15% range. Overall, there is significantly more advanced content available on the dV-Trainer® vs the DVSS, which may be part of the reason for different utilization patterns.
Another interesting data point is looking at system utilization in training centers. The dV-Trainer® has been used extensively to support training courses at both The Nicholson Center at Florida Hospital and also at the STAN Institute in Nancy, France.
Utilization of simulators in short courses is typically different than what is seen at institutions where training takes place over a longer period. Courses usually have a tightly controlled training curriculum while many institutions don’t enforce a training curriculum at all.
Here we can see the use of foot controls has stayed pretty static at around 18%. Basic controls decreased by about 15% from 50% to 35%. Fine motor skill increased from 24% to 32%. The increase in other activity in 2017 was the addition of team training into the curriculum, where adoption is increasing rapidly. Trainees typically enter the OR as the bedside assist, which is why lap skills in a robotics team training environment are being emphasized.
In conclusion, we can see that usage has evolved over time and the mix of exercises taking place is dependent on the ease in which new exercises can be added as well as the ability to add curriculum to the mix.