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Mimic Technologies Blog

Implementing Robotic Surgical Training: Thoughts from the French Academy of Surgeons

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On November 13, 2015, a panel of experts in robotic surgery met at the Académie Nationale de Chirurgie (ANC) in Paris to discuss training in robotic surgery. The meeting was moderated by Professor Michel Huguier and the speakers included:

  • Professor Rolland Parc, Conseil de l’Ordre des Médecins
  • Professor Jacques Marescaux of IRCAD (the institute for research into cancer of the digestive system), Strasbourg
  • Professors Jacques Hubert and Laurent Bresler of the School of Surgery at Nancy
  • Professors Xavier Cathelineau and Guy Vallancien of the École Européenne de Chirurgie (European surgical training centre), Paris
  • Professor Jacques Belghiti from the HAS (the French national health authority)
  • Dr Denis de Valmont from the insurance company SHAM
  • Dr Yves Allioux of the Caisse Nationale d’Assurance Maladie (CNAM)

The full day session included discussions and presentations on the current status of robotic training in France as well as an overview of the adoption and current state of robotic surgery in a number of key specialties from Urology to Thoracic.

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Their group identified some fundamental needs:

  1. Training requirements should be based on the established protocols for training in surgical robotics (drawn up by the teams from Nancy, France)
  2. It is essential to anticipate the arrival of new robotic platform
  3. It would not be helpful to increase the number of training centers. What is required would be several centers of excellence who are well equipped in platforms and personnel, with good reporting systems or registers.

The guiding principles of modern computer-assisted surgery, and thus of robotic surgery, should be the following:

  1. It is assumed that the clinicians should know how to operate and be competent in their surgical specialty
  2. Surgeons need to become familiar with the all aspects of the computer-assisted system
  3. Success will only be achieved through partnership with the manufacturers
  4. However, maintaining professional ethics and independence and avoiding all conflicts of interest is essential
  5. Being able to justify scientifically the evolution of treatment approaches thus being able to satisfy financial policymakers, and to defend surgeons against whom the HAS starts disciplinary proceedings.

Conclusions from the discussions:

The training in robotic surgery currently provided by the manufacturers is not a legally binding qualification. Their only obligation, as with any equipment manufacturer, is to explain to the purchaser how their product works. This training, according to published literature, is generally too short, and does not include any assessment of surgeons’ ability to use these robot systems.  The responsibility of monitoring this training should, therefore, fall to the scientific societies and the universities in partnership with the manufacturers, and should include the evaluation of teams who will be tasked with these, using these new technologies. Training in robotic surgery can be provided by both public or private institutions, bearing in mind that it requires a substantial investment in equipment. It appears that university budgets alone will not be enough to meet this investment, and that public institutions could enter into partnerships with the private sector to meet the demand.

Robotic surgery is put into practice by surgeons and their teams, and their training should cover 5 areas:

1 – Surgical training is the remit of the existing schools of surgery

2 – Basic training in the use of a “robot” is common to all specialties that plan to use the system. It should be validated by a document certifying that the surgeon attended a course of basic training involving learning about the machine and the relevant techniques, with time on a simulator and on the robot in “dry lab” and “wet lab”. This stage of training should finish with an assessment

3 – In robotic surgery the surgeon is removed from the operative field, and there is, therefore, a loss of visual communication with the rest of the team. This makes training of the other members of the surgical team (team training) indispensable

4 – The clinical training specific to each specialty and procedure will be carried out in centers that have robots and having “proctors” (“Advanced Courses”)

5 – Surgical practice involves lifelong learning, which requires that the surgeon maintain his skills throughout his or her career. The question of re-certification, like that imposed on aircraft pilots following a period of inactivity or when they don’t practice their skills on a regular basis, does not currently exist in medicine. It is likely that in future the development of simulators will enable surgeons in these situations to refresh or maintain their technical skills.

 

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The Rise of Robotics

By: Jamie Loveland
Originally published in UPMC’s First Friday

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Almost a decade ago, surgeons at UPMC began looking for better ways outside of minimally invasive surgery to achieve the same results as a traditional open approach for patients. They discovered they could use robotic surgery to perform complex procedures, resulting in very good patient outcomes. Robotic surgery uses computer-assisted, state-of-the-art technology to allow surgeons to perform procedures through small incisions with unmatched precision and control.

Over the next several years, UPMC surgeons published various high-profile articles showing that the robotic surgery approach is just as safe and feasible as traditional open surgery for the liver and pancreas. Robotic techniques were quickly adopted by other clinical specialties, and today, UPMC is one of the largest centers for robotic-assisted surgery in the United States.

The implementation of new technologies has always posed a challenge for physicians in every specialty. With robotic surgery, UPMC surgeons have found that the learning curve is quite steep.

“In surgical oncology, it took us almost 80 cases until we had things completely optimized. While patient outcomes were good, taking that length of time to learn these surgical techniques was not satisfactory,” said Herbert J. Zeh III, MD, chief, Division of Gastrointestinal (GI) Surgical Oncology, UPMC Cancer Center; co-director, UPMC Pancreatic Cancer Center; and co-director, UPCI GI Oncology Program. UPMC surgeons set out to develop a program that could teach techniques using a robot in a shorter period of time to other surgeons across the country and internationally. In 2014, the UPMC Center for Advanced Robotics Training (CART) was formed to do just that.

“Surgeons learn best when they have a comprehensive program. We wanted to create a mechanism by which we could more confidently train surgeons, and in turn, give them the confidence to adopt these skills and translate them into their own clinical practices,” said Umamaheswar Duvvuri, MD, director, Hand and Neck Robotic Surgery.

Currently the CART program is available in multiple specialties including ear, nose, and throat (ENT) surgery, thoracic surgery, surgical oncology, and cardiac surgery.

Hands-On Learning

The intensive, hands-on course provides surgical teams training both on-site at UPMC facilities and virtually. From Florida to California, China to Belgium and the Netherlands, surgeons across the globe have participated in the program.

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CART provides participating surgeons and their support staff with expertise through personalized pathways, much like private lessons in robotics. The program has two components: one introduces surgeons to robotic surgery who have no prior experience, the second helps those with robotics experience refine their skills.

Using a simulator, participants learn to use the robot much like pilots learn to fly. As they practice, the simulator gathers data that helps to track progress and determine how many more cases an individual may need before moving to the next step of the training program. Surgeons also practice by sewing on artificial organs or cadavers and then progress to watching video clips compiled from various surgical cases. Lastly, the training moves to the bedside, where surgeons are proctored and mentored by UPMC experts.

“The care of the surgical patient is so important, because there is little room for error. The days have passed where physicians are learning on patients. CART is providing physicians with an opportunity to work directly with our experts to take their skills to the next level,” said Dr. Duvvuri.

Engagement between participants and program experts continues long after the program has ended. UPMC experts are readily available to address questions and review cases; trainees are also able to return to UPMC to sit in on additional surgeries at any time. In some cases, UPMC experts will travel to other institutions to proctor surgeries, conduct lectures, and provide additional training.Mimic4789-XTT-mscore-low-res

Training the Whole Team
Though CART is focused on providing surgeons necessary technical skills, the program is unique in its emphasis on training surgical assistants and operating room nurses.

“Robotic surgery is a very intricate process. Someone is managing the patient and the robot itself. Having someone who is familiar and able to navigate between the two is critical. I go over the entire robotic system with the surgical staff – from pushing the power button on the robot to docking it. I explain how all of the different pieces work together,” said Jennifer Bonfili, BSN, robotics clinician.

UPMC operating room nurses also review what to do if there is a critical emergency, and how to go from doing a surgery robotically to traditionally, should the situation arise.

CART is a classic example of improving quality of care internally, as surgeons, nurses, residents, and fellows across a number of specialties within UPMC are currently participating in the CART program to help give our own patients the best possible, cutting-edge care.

A Paradigm Shift

Technology is always changing and there will always be new surgical devices and techniques. CART is leading the way when it comes to changing how surgeons think about incorporating new technology into practice.

Experts at UPMC want CART to serve as a prototype for the way surgeons are trained. By tracking the progress of trainees, UPMC experts hope this will show the tangible impact the program has on decreasing learning curves, heightening awareness of the culture of safety, and helping reduce complication rates.

“We don’t want surgeons to go back to trying to learn this on their own in the OR. Instead, this program should serve as a laboratory for how we train surgeons, both at UPMC and around the world,” said Dr. Zeh.

 


Click here for more information on training options and how to register for a UPMC CART course.

 

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Incorporating Team Training into a Proven Training Course

A Success Story from Nancy, France

The University of Nancy and the STAN Institute in Nancy, France, has been offering a variety of courses on robotic surgery since 2008. Under the watchful eye of Prof Jacques Hubert, the center has developed into one of the leading centers of robotic training in Europe if not the world.

Their focus has always been on ensuring enough time is spent on developing adequate psychomotor skills so that once a surgeon is at the console all they need to do is to focus on the procedure. The course is now a five day course and progresses through time spent on a micro surgery workstation, to a specified curriculum using a dV-Trainer by Mimic and eventually on to dry and wet labs with da Vinci system. The recent courses in December have attracted participants from as far away as China.

Mimic’s dV-Trainer and Xperience Team Trainer incorporated into a robotic surgery skills training course at STAN Institute in Nancy, France

In robotic procedures, the console surgeon is un-scrubbed without direct access to the patient. They can only interact with the group through audio communication, whereas in conventional surgery, more than 80% of the information exchange is realized via visual contact. The success of robotic surgery thus relies on high-quality teamwork, wherein the bedside assistant plays an important role. Some surgeons are able to develop a close working relationship with the same first assistant but in many institutions the first assistant will be constantly changing with the rotation of the OR staff. This is an area that Dr Randy Fagin from the Texas Robotic institute has often talked about and how different surgical teams can have an impact on the efficiency of the OR by extending procedural times.

Towards the middle of 2014, Mimic launched its Xperience Team Trainer (XTT), a Laparoscopic trainer that can be attached to the da Vinci console emulator (dV-Trainer) and allows a console surgeon and first assistant to work together on the same simulated exercises. Not only can they work together but their performance can also be scored on an individual basis as well as a team basis.

STAN Institute

The hands-on training lab at STAN Institute

Professor Hubert, having a strong research focus, first wanted to ensure that the device had training validity. He therefore carried out face, content, and concurrent validity testing to ensure that activities performed on the team trainer were equivalent to the similar tasks encountered in the real world. His research published online in Surgical Endoscopy shows this to be the case1. Hubert believed more research was needed to prove concurrent validity and felt that some improvement could be made in exercises and through the addition of haptics to the device. Sufficient changes were made to the system through the addition of extra exercises and the activation of the built in haptics for the STAN team to feel confident in including the team trainer as part of their December series of courses in 2015.

They decided to introduce a team training component to the course where the surgeons attending the course would each spend time as a console surgeon and also as a first assist. This is a realistic scenario as surgeons can frequently find themselves in a first assist role particularly when going through their residency training.

Overall Prof. Hubert and the STAN Institute felt that the Xperience Team Trainer was a valuable addition to their December course line up and felt that it highlighted the importance of vocal communication and team work between the participants. They also noticed that in some groups the console operator would give advice on focal depth while the student driving the laparoscopic device would provide force feedback on the patient side-assist activities.

“We have been very pleased with the inclusion of the Xperience Team Trainer into our course,” says Alexandre Thouroude, General Manager of the STAN Institute,  “it has been very good at allowing users to develop an awareness of the importance of developing non–technical verbal skills and highlighting the importance of developing team and communication strategies.”



Mimic Technologies greatly values our partnerships with the STAN Institute and Prof. Hubert, as their input into Xperience Team Trainer has been of great benefit in improving the Xperience Team Trainer product further. We thank them for the continued support and partnership.

Click here for more information on training courses available at STAN Institute

 

1 Face, content, construct, and concurrent validity of a novel robotic surgery patient-side simulator: the XperienceTM Team Trainer
Song Xu, Manuela Perez, Cyril Perrenot, Nicolas Hubert, Jacques Hubert
Surg Endosc. 2015 Dec 10. [Epub ahead of print]
DOI 10.1007/s00464-015-4607-x
PMID: 26659239

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Maestro AR Inguinal Hernia Repair module debuts at CRSA and ACS in Chicago!

New Maestro AR™ 3D augmented reality brings procedure-specific content to robotic surgery simulation training for General Surgery

Mimic Technologies, Inc, announces the launch of the Maestro AR Inguinal Hernia Repair, a new augmented reality software module exclusively available on their dV-Trainer® robotic surgery simulator. Maestro AR is the first robotic surgery simulation technology that allows trainees to manipulate 3D virtual robotic instruments as a way to interact with 3D endoscopic video footage of an actual surgical case.

This full procedure simulation was developed in collaboration with Dr. Rick Low, M.D., Chairman of Surgery at John C. Lincoln Hospital, Phoenix, AZ, Chairman of the Robotic Program at John C. Lincoln Healthcare Network, and Medical Director for CAVA Robotics. Using 3D augmented video, Dr. Low guides trainees through each step of a robot assisted laparoscopic Inguinal Hernia Repair, from port placement and robot setup considerations to the final steps of the surgery. “With this Maestro AR procedure-specific training module, we present a reproducible, stepwise approach to robotic Inguinal Hernia Repair that we believe provides an excellent mechanism for the developing robotic surgeon to overcome the learning curve and mature into an expert robotic surgeon”, said Dr. Low.

At each critical juncture of the procedure, trainees experience both cognitive learning and robotic surgery skills development by identifying critical anatomical structures and surgical landmarks, simulating tissue retractions, predicting dissection planes, answering multiple choice questions, and completing virtual reality skills exercises. Embedded virtual reality tasks emphasize hand-eye motor skills critical to proficient surgical technique, including needle handling and driving, knot-tying, and closure of a peritoneal defect. For each step in the procedure, comprehensive metrics are gathered and reported, allowing trainees to objectively track their progress at learning the procedure and becoming proficient with required robotic surgery skills.

Maestro AR for Inguinal Hernia Repair divides the complete procedure into the following steps:

 1. Patient Positioning and Setup

2. Exposure of Pre-peritoneal Space

3. Reduction of Hernia Sac

4. Positioning and Suturing of the Mesh

5. Closing the Peritoneum

“By augmenting real surgical video with interactive virtual content, we are able to deliver realism on a whole new level,” said Jeff Berkley, PhD, CEO of Mimic Technologies, Inc. “Our process for generating augmented reality is also extremely efficient and we expect to generate a large volume of content over the next few years that will allow trainees to walk through a wide variety of surgical scenarios as presented by world leading educators. We feel this will expose surgeons to a tremendous variety of surgical scenarios that would not normally be encountered under a normal case load.”

Maestro AR is available exclusively on the Mimic dV-Trainer. In addition to Inguinal Hernia Repair, modules for Hysterectomy (lead by Dr. Arnold Advincula of Columbia University) and Partial Nephrectomy, (lead by Dr. Inderbir Gill of USC) are also available. Prostatectomy and Lower Colon Resection will be added to the package within the next half year.

Maestro AR for Inguinal Hernia Repair will be demonstrated at the Mimic Technologies booth at the Clinical Robotic Surgery Association (CRSA) in Chicago, IL, on October 2-3, 2015 and during the American College of Surgeons Clinical Congress (ACS), Mimic Booth #756, Chicago, IL, on October 5-7, 2015. In addition, Dr. Low will be speaking about Maestro AR at CRSA on Saturday, October 3, 2:05pm in a talk titled, “How to optimize costs and time in ventral hernia repair”.

For more information: www.MimicSimulation.com/IHR

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Back to School Fall Robotic Surgery Simulation Training Courses

Don’t wait to start thinking about Fall training courses, register today!

Mimic will be supporting the following Fall hands-on robotic surgery simulation training courses:

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Can’t make it to a conference?  You can earn CME credits through MimicMED at the Florida Hospital Nicholson Center.  Click here to learn more about full day training courses and personalized one-on-one training.

To learn more about simulation training, please contact: training@MimicSimulation.com

 

 

 

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