Simulation is increasingly recognized as being an important component when learning how to drive a surgical robot. However, very little discussion has been held about where the best place is to learn and does the location of the simulator make a difference in its utilization.
Essentially there are three places where simulation can be used for training:
• Inside the OR using the actual robot console connected to a simulator
• In a dedicated space outside the OR, such as a Sim Center, using a surgeon console emulator
• Wherever you can find an appropriate space using a portable simulator
Let’s look at these options in a little more detail:
Inside the OR
Back in 2010, Mimic helped Intuitive Surgical develop a simulation training product that uses the da Vinci® Surgeon Console. The da Vinci® Skills Simulator can be attached to a robot’s second console or the primary console.
The second console is a device where a second surgeon can sit and watch the operative field and have the same immersive feel as the primary surgeon. Although not a simulator, it can be an effective training tool. The users can swap controls of the robotic arms between the two consoles so the student can be allowed to intervene at the appropriate time while proctor can regain control as necessary. As long as space is not an issue, it is felt that the use of a second console helps with the overall efficiency of an OR hence their popularity; approximately 20% of all da Vinci® Systems are sold with a second console, although the percentage is higher on the new Xi systems and also in the US. In theory, a second console can be moved outside of the OR when not in use, which would allow for training both inside and outside the OR. Practically speaking, the second console can be cumbersome to move and is rarely moved outside of the OR. The primary console rarely leaves the OR. Even so, 50% to 60% of customers purchasing a single console robot also purchase a da Vinci® Skills Simulator with their system.
The advantage of the Skills Simulator is that it uses the real surgeon console for input, which means the hardware fidelity is 100%. The downside is that Skills Simulators are almost always in the OR and not always accessible. The more successful the robotic program, the less time there is to use the Skills Simulator in the OR because case volume dominates OR usage. Also, some institutions also do not like giving people access to the OR outside of the normal working day. A common concern is that the system may not be shut down properly, which costs OR time the next day, or worse, the console cable may be damaged as the trainee switches it between the real robot and the simulator.
Outside the OR
Many larger institutions have been fortunate enough to invest in dedicated simulation centers. These vary from small dedicated rooms to large purpose-built buildings. These have been good locations for console emulator products such as Mimic’s dV-Trainer®. The positive is that these are often in a location that is accessible 24/7 and are often supported by dedicated staff that have knowledge of the systems and can act as proctors. The downside is that some of these centers are not in a convenient location, which will act as a deterrent to utilization. Some users are also looking for higher fidelity than the 85% to 90% offered by the dV-Trainer®.
It is still too early to say where will be the best location for a portable simulator, but the picture below illustrates just how versatile the FlexVR™ simulator is. It can be set up on nearly any table, including a spare table in the hall outside of the OR! The fidelity of the FlexVR™ has not been independently measured, but without force feedback to help hold ones hands in the air, it is expected that fidelity will fall just below Mimic’s dV-Trainer®.
The real question is, does location influence usage?
One of Mimic’s high utilization customers has been using simulation for over 5 years. They have systems in the OR, in a separate room in the OR area, and in the sim center located 2 blocks away. We have been able to track the usage of all three systems. The graph below shows the number of sessions carried out on the simulator over the past 5+ years. In total, over 200 users have done 16,000 exercises spending on average around 4 hours each on the simulator.
As we can see, the most simulation was carried out when the first system was installed. After a dip in 2013, simulation has evolved into a steady average of around 2,500 sessions per year.
The graph above shows the relative usage between the different simulators. Beginning in 2007, the dV-Trainer® was the only option and all the simulation activity took place outside of the OR. In 2011, the Si Skills Simulator was made available for training with the surgeon console. This led to an initial reduction in the usage of the dV-Trainer®, though over the next 3 years the two systems were used evenly. During 2016, the da Vinci® Xi began to supplant the Si and a new Xi Skills Simulator was required. The initial usage of the DVSS for the Xi was high, however, as time has gone on, the usage has decreased and been replaced by usage of the dV-Trainer® which accommodates both Si and Xi simulation.
It is still too early to say how simulation utilization will be affected by Mimic’s release of the portable FlexVR™ simulator. However, drawing a parallel to training inside the OR versus outside the OR, it is expected that more access will lead to higher utilization. All said, simulator access is an important consideration when deciding where to locate a simulator and the beauty of the FlexVR is that location is no longer a primary concern – the price, size, and portability make it a system that can be used virtually everywhere!
Over the past few months we have talked frequently about the importance of acquiring proficiency in robotic surgery. Although this may have been evident to many, the term proficient has been based on the Dreyfus Model of Skill Acquisition. This model, developed in the 1980’s, focuses on how students acquire skills through formal instruction and practice. It was developed by the brothers, Stuart and Hubert Dreyfus, out of the University of California, Berkeley.
The diagram below is a simple representation of the Dreyfus model:
The critical factor is being able to determine where individuals sit on this progression and what are the real objective boundaries between the different skill levels.
The concept of proficiency was taken up by surgeons when beginning to learn laparoscopic surgery and incorporated into the Fundamentals of Laparoscopic Surgery (FLS) where a proficiency level of 2 consecutive and 10 non-consecutive passes have to be achieved before certification is reached.
The da Vinci® surgical system is currently the main player in the computer-assisted surgical market. Over 3M procedures have been done with the system, of which some 650,000 were in the last 12 months. What does it take to become proficient at using a da Vinci system?
First and foremost, it is important to realize that surgery is a team activity and that while the role of the surgeon is vital in the ensuring the best outcomes for the patient, the surgeon can only do so if supported by a highly skilled OR team.
The da Vinci System was designed around three key principles, 3D visualization, dexterity, and control. This essentially means that the system allows the surgeon to see and move within the operative field in a way that they were not able to beforehand while building in safe guards to ensure patients could not be inadvertently harmed.
To achieve this, the surgeon is placed on a console outside the operative field where they can control a combination of instruments using their hands and their feet. Instruments are changed by an assistant who will replace the required instrument at the correct time.
When training to use the da Vinci system, it is not only important to ensure that the surgeon is proficient at controlling the system itself but that the whole team is also comfortable with working in this new environment. What does take some time getting used to is the fact that the team leader is no longer at the bed side but is now sitting apart outside of the sterile field immersed in the console. Given the high quality of the image, they can easily become immersed in the operative field.
How do hospitals therefore ensure that their surgeons and teams are proficient and ready to perform robotic surgery? Also how do they make sure that they after their initial training they are staying up to speed with evolutions in the technology and gaining enough exposure to the system?
The table below shows a typical case distribution by surgeon over a three year period. The X axis shows the average number of cases and the Y axis represents each surgeon ranked from lowest to highest volume.
Many hospitals will typically use a minimum case volume per year to decide whether or not a surgeon should maintain privileges on a robotic system. However, looking at the distribution of cases, can the number of cases alone really be used to determine whether or not a surgeon and team are performing as advanced beginners, competent users, or are really proficient?
Thanks to its 10 years of experience in the training of surgeons and teams to run effective robotic surgical programs, Mimic has the experience to help hospitals with this issue. MimicMED’s Consultancy Services can help organizations set their thresholds to distinguish between the different skill levels, evaluate their surgical staff, and see where they currently sit on the continuum as well as develop and implement training programs to ensure overall objectives are met.
Like any new technology, a lot of focus has been placed on ensuring that new users of robotic surgery are adequately trained. Simulation has had a large part to play with this. As the technology has become more mainstream, training requirements have moved from not only training existing surgeons but to ensuring that residents and fellows develop the required skill levels to ensure that they can adapt to the new technologies used in their practice.
Earlier this year we discussed a paper published by the EAU on their curriculum aimed at ensuring that fellows followed a clear curriculum at the end of which they would be deemed to be safe and competent to operate on patients independently. As with many ways of teaching surgery, the procedure is broken into specific steps that the trainee must master before being allowed to carry the whole procedure.
A typical prostatectomy is divided into the 7 following steps: bladder takedown, endopelvic fascia, bladder neck, seminal vesicle/vas deferens, pedicle/nerve sparing, apex, and anastomosis. Typically a trainee will be given a maximum time, of say 30 minutes,to complete one of these tasks during a procedure. Once they have shown that they have mastered the tasks, they will be allowed to move onto another task and eventually to the whole procedure. This is obviously easier to accomplish on parts of the anatomy and procedures that can be standardized.
Until recently, there have not been many studies looking into this practice to see what the potential patient impact could be comparing when a surgery was performed by just the one attending surgeon to one where parts of the case had been handed over to the resident.
Dr. Thiel from the Mayo Clinic in Jacksonville, Florida, has published a paper on just this topic comparing 140 cases where just an attending was involved in the surgery to 232 cases when a resident took over part of the case.
There were no differences in some key clinical outcomes such as positive margins, length of stay, catheter days, readmissions or re-operations when comparing surgeon only to resident –involved cases. There was, however, a difference seen in mean operative time between procedures that were surgeon only cases vs. resident involved (190.4 Min vs. 206.4 Min, P= 0.003)
The researchers also noted that residents were more likely to be involved with at least 1 procedural step after the purchase of the dV-Trainer.
Mimic believes in this way of training residents which is why the Maestro AR set of procedural curricula we have developed are divided into the procedural steps that a resident will be required to learn. We have been able to marry narrated 3D video content with didactic exercises that allow for a student’s ability to be tested. At the appropriate point, the correct psychomotor skill is inserted to make sure that the student can match the skills required for the procedural step.
Mimic currently has the following available:
- Right Partial Nephrectomy, Dr. Indibir Gill, USC
- Hysterectomy, Dr. Arnold Advincula, Columbia University
- Inguinal Hernia Repair, Dr. Rick Low, John C. Lincoln Hospital
- Prostatectomy (Si), Dr. Henk van der Poel, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute in Amsterdam
- Prostatectomy (Xi), Dr. Vip Patel, Florida Hospital
- In Development for Q4 ‘16 Release:
- Lower Anterior Resection, Dr. Eduardo Parra, Florida Hospital
Founded in 2001, Mimic Technologies has been providing robotic surgery simulation training for 15 years. Over the years, Mimic has been involved with one of the most successful surgical simulation launches of all time, with over 2,000 simulators using MSim software worldwide. We estimate that over 30,000 surgeons / residents use this simulation install base each year and that since it was launched, over 6.5 million exercise sessions have been completed.
Many leading academic centers around the world have incorporated Mimic hardware and software into their training programs and there have been numerous publications that were researched and written on Mimic’s hardware and software proving validity. (A sample of these published studies can be found here.)
All of this experience has allowed Mimic to collect simulation data as well as hands-on experience in successfully implementing best practices to help fully develop new and existing robotic surgery simulation training programs. Over the years, we have found that the most common traits of a successful simulation training program include:
- Individuals (trainees) are uniquely identified and results are recorded
Data is king! It is important for simulation users to create an account and always remember to sign in so that the record of performance over time can show a progression of skill development and maintenance.
- Proficiency levels have been discussed and agreed upon
The study, Best Practices for Robotic Surgery Training and Credentialing, published in 2011 in the Journal of Urology by Jason Lee, et al., concluded that “Rather than being based on a set number of completed cases, robotic surgery credentialing should involve the demonstration of proficiency and safety in executing basic robotic skills and procedural tasks. In addition, the accreditation process should be iterative to ensure accountability to the patient.” Setting institutional standards that have been both discussed and agreed upon will ensure that all clinicians who will be training using simulation are meeting the same requirements. Objective scoring is also helpful to implement a fair and accurate training environment.
- Curricula are developed, allocated appropriately, and continuously measured
According to a 2005 study, Virtual Reality Simulation for the Operating Room: Proficiency-Based Training as a Paradigm Shift in Surgical Skills Training, by Gallagher, et al., “Virtual reality training is more likely to be successful if it is systematically integrated into a well-thought-out education and training program.” Defining specific exercises, mapping out a training path, and continuously checking progress is essential for ensuring that trainees get the most out of simulation to build their skills and move up the learning curve towards proficiency.
- Simulation training platforms are easily accessible to trainees
Also essential for simulation training is ensuring that trainees are able to access the simulator at times that are most convenient and conducive to their learning preferences.
- Simulation time is transferable to the real tool
Face validation shows that a training tool has a realistic look and feel. The 2015 study published in Surgical Endoscopy, Robotic Surgery Simulation Validity and Usability Comparative Analysis, concluded that, “Usability can affect the consistency and commitment of users of robotic surgical simulators.” Before simulation training is implemented, the training tool should be carefully assessed to ensure the skills trainees acquire transfer to the tool they will be utilizing.
- Cognitive and psychomotor skills can be validated
In addition to validating the training tool for Face and Content, the acquisition of both cognitive and psychomotor skills should be validated and proven to make outcomes better. Construct validity distinguishes experienced medical professionals from the inexperienced, Concurrent validity measures the extent to which the simulator correlates with the “Gold standard”, and Predictive validity goes so far as to predict future performance. These types of validation are important to consider when choosing a simulation training tool.
- Teams can train together
The ability to incorporate team training within a simulation training curricula ensure that the trainees will have well-rounded skills such as communication and movement coordination in addition to being proficient in operating the tool they are training for. The study, Teaching Surgical Skills – Changes in the Wind, published in the New England Journal of Medicine by Dr. Richard Reznick, et al., stated, “Virtual reality has the potential to enhance surgical-team training as well as technical skills training. In aviation, teamwork training with simulation has been instrumental in reducing errors. The importance of teamwork in preventing medical error is well recognized, and simulator-based team training has been advocated as a possible preventive approach. Early research results have been promising.”
Advances in technology and virtual reality simulation training can make medical training safer, more cost-effective, and efficient and building a successful program doesn’t have to be difficult if similar principles and benchmarks are applied.
Surgery has often been referred to as a team sport. The role of the surgeon is undoubtedly critical but so is the role of the entire team in ensuring patient safety and positive outcomes.
This is especially true in robotic surgery where the main surgeon is no longer at the patient’s side but is seated at a robotic console outside the operative field. The console-side surgeon now relies heavily on a first assistant or patient-side surgeon. The first assistant is a skilled laparoscopic surgeon whose prime objective is to work as a team with the robotic surgeon to maximize efficiency during the procedure.
A recent study titled, “Impact of Assistant Surgeon on Outcomes in Robotic Surgery,” by Dr. Rishi Nayyar, et al., published in the Indian Journal of Urology found that, “with increasing experience of patient-side surgeon and associated console surgeon, who form a consistent surgical team, the mean operative time for all robotic procedures shows a consistent trend of reduction across all surgical types.” (Click Here to Access the Full Study)
Typically, better outcomes in robotic surgery are associated with only the console-surgeon. According to Dr. Nayyar’s study, there is no existing objective evidence regarding the impact on outcomes with the experience of the assistant surgeon in robot-assisted surgery. Therefore, the goal of this recent study was to objectively verify the hypothesis that the experience of patient-side assistant in robotic surgery affects intraoperative outcomes.
During the study, a total of 100 cases of robot-assisted laparoscopic pyeloplasty were analyzed and on comparing outcomes between the 1st and 2nd halves of the assistant experience, the mean operative time reduced from 102.50 min to 82.80 min (P = 0.001) and mean blood loss reduced from 72.00 ml to 63.90 ml (P = 0.91). (See table below)
As the study suggests, a console-surgeon and first assistant to who work consistently together make a better team and positively influence the outcome of the procedure. Mimic’s Xperience Team Trainer (XTT) was developed specifically for this reason.
The XTT simulates the patient-side and connects with the dV-Trainer that simulates the console side, thereby allowing both the console and the patient-side surgeons to train in tandem with virtual reality simulators. Routine tasks are executed crisply and efficiently while also working on communication between both surgeons.
A 2015 study done by Dr. Jacques Hubert, et al., published in Surgical Endoscopy confirmed face, content, construct, and concurrent validity of the Xperience Team Trainer as an assessment tool of robotic surgery bed-assistance skills for the patient-side surgeon.
This study also emphasized the importance of teamwork between the patient-side and console-side surgeon in robotic surgery, which may change the paradigm of robotic surgery training in the near future. To read a past post about this study, click here.
Nayyar R, Yadav S, Singh P, Dogra PN. Impact of assistant surgeon on outcomes in robotic surgery. Indian J Urol 2016;32:204-9