Mimic Technologies Blog

Validation of a Robotic Training Curriculum and Experience from Working with the EAU

eau general

As robotic surgery has increased in popularity and adoption, so has the recognition that training for robotic surgeons is critical.  Also critical is ensuring that when these surgeons perform their first case on live patients they will have been exposed to and trained for all aspects of the system.

In Europe, ERUS (the European Robotic Urology Section of the EAU) has been designing and developing a structured training program and curriculum to help surgeons who wish to engage in performing a robot-assisted radical prostatectomy (RARP).

eau blog1The program is divided into six clear sections. Starting and finishing with evaluation protocols, participants go through online modules and observations, simulation training aligned with wet and dry labs, as well as modular console training and training on the full procedural steps.

When implemented, the program took approximately 12 weeks for participants to complete, including one week dedicated to simulation training and dry and wet lab tasks.  After the intensive week of hands-on training was completed, the fellows returned to their institutions carrying out specific parts of the procedure and mastering them before moving onto other steps and finally a complete procedure.  Their final procedure was assessed by their mentors as well video recorded for review by independent assessors.

In total, of the ten students who took part in the study 3 were residents, 5 were fellows and 2 were staff members. Based on the final assessment, two of the residents were not deemed sufficiently proficient to carry out a RARP independently but the remaining eight (80%) of the participants were deemed proficient including three (30%) who achieved being considered able to complete complex cases.

Throughout the 12-week program, the participant’s skills were measured on a regular basis and over time showed significant improvement. The graphs below illustrate how the skills improved over the duration of the fellowship in two of the more complex exercises.

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Given the importance of simulation to this curriculum, Mimic has been pleased to work with the EAU and ERUS to offer exposure to a short simulation curriculum during the  a number of EAU congress in 2014 and 2015. At seven various educational events between September 2014 and December 2015 Mimic was able to offer 11 days of robotic simulation initiation. 107 participants were able to sit down at the simulator and complete and average of 8 exercises each. The initial courses focused only on console skills, with later courses including laparoscopic skills for bed side assistants.

All exercises were completed and the average pass rate was 28%, though it ranged from 60% to 0% depending on the student.


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The Rise of Robotics

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

upmc first friday

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.

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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Why Credentialing Is Vital To Robotic Surgery And How To Make It Work

Recently, training surgeons and surgical teams has been one of the focus areas in litigation for robotic surgery. Test cases have stated that the responsibility for training, credentialing, and privileging surgeons to use new technologies belongs to physicians and the hospitals where they work. (Taylor v. Intuitive Surgical, WA State 2015).

Dr. John Lenihan,

“The key to developing proficiency is practice, practice, practice,” says Dr. John Lenihan, “you have to do each exercise until you have passed it at least five times with at least two consecutive passes.”

Dr. John Lenihan, Medical Director of Robotics & MIS, MultiCare Health Systems, Tacoma, WA, is also a trained Air Force pilot and flight surgeon.

For a long time he has seen the similarities between flying and using a robotic surgical system. Both involve using systems that can have impact on human life, both have a learning curve that varies with the user, both require that the user makes sure their skills are being maintained before they use the system, and both can be validated on an annual basis.

As a Gynecologist, Dr. Lenihan also worries that given the national trend moving away from Hysterectomies toward other treatment modalities, that surgeons may not have as many opportunities as they had previously to keep their skill levels up. (Wright JD et al. Nationwide Trends in Inpat Hysterectomy in the US. Obstet Gynecol. Aug 2013 122(2), Part 1. 233-41).

A paper by Wallenstein MR, et al., titled “On Effects of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Conditions,” highlighted this fact. It shows that the overall volume of laparoscopic hysterectomies has decreased by some 30% over the period 2000 to 2010, however, the percentage of cases being carried out by low volume surgeons (less than 6 laparoscopic hysterectomies a year) has increased.

Effects of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Conditions

Wallenstein MR et. al. Effects of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Conditions. April 2012 Obstet Gynecol.119(4); 710-16

As a member of the AAGL (formerly the American Association of Gynecologic Laparoscopists) Special Interest Group on robotics, Dr. Lenihan produced with his colleagues guidelines for privileging for robotic-assisted Gynecological Laparoscopy. These were approved by the AAGL Board as an official recommendation by the Society in February of 2014. (J Minim Invasiv Gynecol, 21(2), Mar-Apr 2014).

It follows the same model and parameters you would expect of a pilot and is divided into three groups:

  • Initial Credentialing:
    • Establish standards to comply with learning curves
    • Basic cases first with qualified assistants
    • Then progress to more complicated cases
  • Maintenance “Currency”:
    • Establish minimum guidelines for numbers of cases to maintain surgical skills
    • Encourage the use of simulators to maintain skills
    • If minimums not met, require re-training and re-certification (proctoring)
  • Competency Certification:
    • Establish standards, utilize simulation, consider “check rides” and/or do case review

Dr. Lenihan is a firm believer in establishing proficiency through simulation. “The key to developing proficiency is practice, practice, practice,” Lenihan says, “you have to do each exercise until you have passed it at least five times with at least two consecutive passes.” All this within a structured approach with defined curriculum for basic and advanced users as well as specific curricula developed for annual credentialing.

Lenihan has taken this philosophy and applied to his own institution at MultiCare Tacoma. Between 2008 & 2009, competency was initially evaluated on outcomes. Surgeons were not expected to deviate more than 2 standard deviations away from hospital or national norms in key metrics such as operative times, blood loss, complications, etc. From 2009 to the present day, surgeons are expected to demonstrate proficiency annually using simulators. If there are poor outcomes, these are reviewed by the robotic committee and corrective actions, including simulation training, will be put in place.

More recently, Dr. Lenihan has been investigating the possibility of initiating a continuous improvement program through the use of the C-SATS platform to offer performance evaluation through crowd sourcing. Videos can be reviewed and technical weakness using a GEARS score can be calculated looking for such things as depth perception, bi-manual dexterity, efficiency, force sensitivity, and overall robotic control. When weaknesses are assessed then surgeon can be given specific curricula on their Mimic dV-Trainer that will allow them to improve and practice in those key areas. The improvement can be validate again via crowd sourcing before a surgeon operates again on a patient.

“The fundamentals are simple,” says Dr Lenihan, “you establish a credentialing and privileging system that relies in simulation. You use simulation to improve and maintain skills during period of inactivity. You can then use video review to help document proficiency and help low volume surgeons with tailored skill improvement curricula.”


Click here to learn more about how Mimic can help you incorporate credentialing and privileging into your robotics program.



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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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Building a Surgical Robotics Training Program: The Importance of Simulation

The Experience at Boston Children’s Hospital

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As a teaching hospital, Boston Children’s Department of Pediatric Urology has a strong commitment to training both residents and fellows with a heavy emphasis on minimally invasive surgery (MIS). About 60% of its MIS cases are done robotically, mainly Pyeloplastys and Partial Nephrectomies, and usually around 16 residents and 2 fellows are trained each year.

When exploring robotic surgery training options, the staff at Boston Children’s decided to invest in the dV-Trainer because it would be available 24 hours a day and could be located close to the operating room, but not necessarily in it. They also felt there was a strong need to provide a quantitative record of each trainee’s performance, which the dV-Trainer’s MScore scoring system provides.

Next, when building out the program, their training objectives were simple. First, they wanted to teach residents the foundational skills for robotic surgery, including instrument & tissue handling. Second, they believed it would be valuable to provide them with a protected, structured time for simulation education and to also provide supervised guidance during introductory training course. Finally, they wanted to offer comprehensive, individualized feedback using the standardized scoring system.

To achieve this, a structured curriculum was developed that included the following elements:

  1) Didactic components that include, Intuitive online training, AUA online – Urologic Robotic Surgery Course, FLS Training, and Video Library

2) Trainees would also be offered hands-on experience – bedside & console on the da Vinci, and simulation training using the dV-Trainer as well as components of team training

Ashley Wietsma (BCH Research Fellow 2014) was able to work with Todd Larson, Vice President & Chief Clinical Officer for MimicMED on developing a specific simulation curriculum that would meet Boston Children’s needs.

The final curriculum was divided into 6 sections including an introduction, warm up, pre-test, core, post-test and games that included approximately 20 exercises.

Since the system was acquired, 50% of the usage has been around the Boston Children’s curriculum. Twenty-five users have averaged over 80 sessions each with the power users doing significantly more than that.

“Providing training in a safe environment that helps improve handling and familiarity of the robotic console is critical,” says Richard Yu, Department of Urology, “skills such as camera control and clutching as well as developing muscle memory and improving hand-eye coordination while improving the non-dominant hand are all reasons why simulation is so important.”

 For more information: www.MimicSimulation.com

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