Growing in popularity, robotic surgery is still not without challenges. Before the benefits of robotic surgery can be fully realized, the highest level of patient safety must be ensured, while remaining cost effective and at the same time allowing new surgeons the ability to be trained and access the technology without impacting safety and cost-effectiveness.
The Halstedian Method of “see one, do one, teach one” is clearly no longer sufficient for surgical training. Many comparisons between the training of pilots and the training of surgeons have been made over the years. In 2013, the FAA updated their rules to state that to be qualified as a First Officer, a pilot needed 1,500 hours total time. This includes both real and approved simulation time. Looking at a typical Resident training program, the calculations for a general residency that will last 4 years is approximately 16,600 hours. If within this a surgical trainee chose to focus on Gynecology for 20 months they would receive 6,400 specialty hours. If a surgeon focused on minimally invasive surgery, such as robotics, the Accreditation Council for Graduate Medical Education (ACGME) guidelines recommend 105 hours exposure to a variety of cases. Even tripling this minimum, a surgeon would be only at 300 hours of surgery, which is only a fraction of the 1,500 hours the FAA recommended training time for pilots.
Just as in aviation, simulation has been seen to be a solution allowing surgeons to develop their skills without impacting patient safety. Mimic’s MSim software, found on both the dV-Trainer and the da Vinci Skills Simulator, has been one of the most researched and validated simulation software in the surgical field. Table 1 below shows the range of validation studies that have been carried out on either platform as well as other simulators.
The studies, and in a particular the predictive validity study looking at simulation and operative outcomes, carried out by Dr. Culligan, have helped shape recommendations for surgical training being developed by medical societies such as those developed by the American Association of Gynecologic Laparoscopists (AAGL) in 2014.
All of these studies and simulation programs focused on the psychomotor component of learning how to “drive the robot” and not necessarily the cognitive training requirements that would help train the next generation of surgeons. Augmented reality was developed under the Maestro AR name to help solve this issue. It is best to think of Maestro AR as a curriculum incorporating both psychomotor tasks and cognitive questions supported by a moderated guide on a procedural approach and technique.
The basic premise is that a student will learn more if the psychomotor skills that they require are placed within their procedural context as opposed to in a vacuum. As students are learning how to use the robotic device they are also being tested on tissue recognition, procedural choreography, as well as learning from the narration about the decision making process behind this specific approach.
The Benign Hysterectomy Maestro AR module, for example, is divided into 9 modules starting with a Pelvic Anatomy survey and working through clear steps on how to deal with the ligaments and uterine vasculature before finishing with the Colpotomy and the Vaginal Cuff Closure.
“Maestro AR addresses the next frontier of training by developing a pathway that incorporates Didactics with Augmented Reality through virtual reality simulation,” says Mireille Truong, Virginia Commonwealth University Medical Center, “I am confident that research will show that adding didactic elements to simulation training will continue to improve surgeon performance when they enter the OR.”
As with the airline industry, simulation is becoming a vital part of the armarmentarium required for surgeons to ensure that through all stages of their career, they have the correct level of skills for the task ahead of them. Just as pilot is able to land a plane in virtually any airport around the world on their simulator, it is hoped that surgeons will also be able to develop their skills within a procedural scenario in an augmented reality environment.
by: Christopher Simmonds
Data, data, data. That is all we seem to hear about today in healthcare. One of the consequences of the Affordable Care Act has been to ensure that hospitals, physicians, surgeons and nurses are becoming obsessed with data and information to an extent like never before. Looking at information across large data pools, trends can be identified and behaviors that drive the trends can be discovered and, if needed, modified, including robotic surgery, which is one of the areas where there is a lot of analysis occurring.
Robotic surgery is truly a misnomer, as in reality it is a computer-assisted surgery where the computer has been placed between the surgeon and the patient, enhancing the surgeon’s capabilities as compared to other surgical techniques. If the robot was compared to a super hero, its role would be to turn the surgeon into Iron Man whose every day actions are enhanced by the power of computing.
The fact that there is a computer between the surgeon and the patient means that a lot of data can be captured. At their town hall meeting in July 2015, this was specifically noted by the FDA. In addition, a main focus of that meeting was training and simulation which also is computer-based and captures a lot of information, including a surgeon’s actions which can then be translated into a scoring system. So what can these scoring systems for robotic surgery training tell us?
If you study surgeons long enough you can identify that some surgeons will be very precise in their motions and other less so. When training new surgeons there are also certain good habits you would like them to develop such as keeping their instruments in view at all times and making sure they do not use too much force or drop things. For these reasons the MScore system, which underpins all the scoring on the dv-Trainer, looks at efficiency and good habit metrics when calculating overall scores.
When Mimic initially developed the MScore system it was calculated as a percentage-based scoring system. The scores were based on the weighted average of all individual metrics as compared to an expert base line. While this provided a simple and easy way to display the score it may not have been the best in helping an individual focus on specific areas of improvement. A high percentage in one area could compensate for a low percentage in another area while still producing an acceptable overall percentage. Mimic refers to this as the classic scoring system.
After being challenged by educators, Mimic decided to take inspiration from FLS and develop what it now refers to as its proficiency-based scoring system.
Like the classic scoring system the revised MScore system is based on expert user benchmarks, however, proficiency is measured as being within one standard deviation of the mean score of those experts. As an example, if five surgeons’ results have been pooled to produce the benchmark you have to perform better than at least one of these surgeons in order for you to pass. Instead of the overall result being a combination of the scores you have to become proficient at each individual metric before you can pass. The example below shows an individual who has passed on all other areas but failed in the area of blood loss. The number shown is a weighted addition of all the metrics together. The user would have likely passed in a percentage-based system as their superior scores in all the other metrics would have been compensated for their lower score in blood loss.
The other difference between the classic scoring system and the proficiency-based scoring system is that you can set proficiency thresholds. In FLS for example, for students to pass they need to complete the same exercise twice consecutively and ten times non-consecutively. The same principal has been introduced into MScore and defaults to two consecutive and five non-consecutive passes, though this can be modified by the end user.
Mimic realized early on that they did not have all the answers and therefore ensured that the scoring system was developed with an open architecture approach. Expert level benchmarks can be input from peer reviewed literature as well as from scores posted by surgeons within specific institutions. Weighting and proficiency levels can modified to meet specific needs. However curriculum and benchmarks such as the Morristown protocol are often used and have been implemented across many systems.
Overall, both the classic scoring system and the proficiency scoring system are helping surgeons improve their performance which is a good thing, noting that it will probably take someone longer to pass a proficiency-based curriculum than a percentage based one. In some instances this data is being used a part of annual certification programs but that will be the subject of another blog post, another day.
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
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:
- SLS Master Class #1 – Wednesday, September 2nd, New York, NY
- ERUS HOT Courses – Tuesday, September 15th, Bilbao, Spain
- AAGL Postgraduate Course Robo-604 – Sunday, November 15th, Las Vegas, NV
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
Mimic Technologies supports hands-on training courses at EAU 2015 in Madrid
Mimic announced recently the beginning of a new partnership with the internationally acclaimed ORSI – OLV Robotic Surgery Institute that will jointly deliver new innovative training for robotic surgeons in Europe. This year at the annual European Association of Urology in Madrid, Mimic provided dV-Trainers for the robotic surgery hands-on training courses.
EAU TV went along at EAU 2015 to check out the hands-on training courses. Watch the video below to hear how some of the trainees enjoyed the course:
“We are delighted to collaborate with Mimic to incorporate the dV-Trainer into our EAU Fellowship Program. The dV-Trainer has built-in evaluation metrics and curriculum tools that align well with our results oriented mission”, said Prof. Alexandre Mottrie, CEO of ORSI.
Todd Larson, Executive Director of MimicMED, the training subsidiary of Mimic, also feels that this will be the beginning of something very special, “We are extremely excited to partner with a progressive institution like ORSI. It is a real privilege to partner with leading educators like Dr. Mottrie and his colleagues. We believe that by joining ORSI’s expertise in education with our training technologies, curriculum expertise, and data collection platform, we will be able to take robotic training to the next level.”
ORSI stands for the OLV Robotic Surgery Institute. ORSI has an international recognition of providing top quality surgical operations within several areas of expertise for robotic surgery. The mission of ORSI is to pass on our experience and expertise in the field of robotic surgery to physicians and their teams via result oriented training.
For more information: www.orsi-online.com