Arnold Advincula, MD and Sarah Sherwood wrote “Augmented Reality, Other Trainers for Complex Disease” for the September issue of OBGYN.net. Below is an excerpt from the article.
“A four-year residency is not enough,” says Mona Orady, MD, director of Robotic Surgery Education at Cleveland Clinic. “I see women after they have had unfinished, poorly performed surgeries every single day.” Orady believes hospitals need to adopt stratification where they designate what is routine and what requires simulation and other forms of surgical training. “There are higher levels of care and, for that, high-quality training is essential.”
Orady encourages simulation training by incentivizing it. She sets the bar and requires passage in order to operate. Many other centers of excellence are now setting their own requirements. The Robotic Training Network (RTN) has unified robotics training and testing at over 50 institutions, with participating hospitals including Johns Hopkins and Harvard. The RTN curriculum, which includes cognitive testing and skills evaluation through physical models and simulation, is growing rapidly in popularity.
At Columbia, we have begun implementing the RTN curriculum on both the resident and fellow training level. As the Vice-Chair & Chief of Gynecology at Columbia University Medical Center, I can tell you that the days of learning-as-you-go on patients are not acceptable. Surgeons must simulate to proficiency before entering the actual operating room.
Most hospitals that use the da Vinci® robot also use simulation training to some degree. This technology, created by Mimic Technologies, has been independently validated by research and academic medical centers around the country. Mimic has also recently developed training technology for traditional laparoscopic surgery that supports the surgical assistant in robotic procedures. The goal is to help all members of a robotic surgical team perform at a high level.
Mimic’s training director, Todd Larson, is a former Walter Reed Army Medical Center specialist, and agrees with Orady that most surgeons coming directly out of residency have not reached a level of competency that allows them to perform advanced surgical procedures. Consequently, they will seek Fellowship training or some other advanced training to acquire those skills. Mimic Technologies has partnered with the Florida Hospital Nicholson Center to develop simulation training to aid the specialist in safely acquiring advanced skills.
According to Larson, most surgeons who participate in simulation training note improvement. They are evaluated through technology called M-Score, which measures performance and provides an actual score on areas that represent their strengths and weaknesses. This type of assessment is meant to improve training efficiency, since the surgeon can then focus on his or her own specific deficiencies.
Once surgeons complete their training, they must meet the credentialing standards of the hospital where they are practicing. Currently, there are no universal standards or benchmarks for robotic surgery. Each individual hospital has its own standards for credentialing and privileging. There is an effort through the American College of Surgeons to develop the Fundamentals of Robotic Surgery; however, these standards are still in development. Since the Joint Commission requires ongoing professional practice evaluation to ensure surgeon competency, simulation can serve not only as an objective performance measure but also as a tool to maintain competency utilizing advanced technology, such as robotics. Surgeons claim that individual high surgical case volumes lend themselves to maintaining one’s skills. This is why objective-based simulation can serve as a great tool for skills maintenance and overall competency. As Orady and Larson point out, surgical skill is individualistic and skills decay will vary with each individual practitioner. However, by continuing to use simulation, a surgeon can continue to evaluate and maintain his or her skills.
“There is a lot of equipment in the hospital that has the potential to cause harm. Robotics is certainly no different,” says Larson. “What is unique about robotics is the means to safely acquire and maintain a surgeon’s skills through simulation and advanced training.”
Since gynecology is becoming more specialized, the need for advanced training is even more necessary. Mimic is also working on an augmented reality product that will simulate hysterectomy, coming out this fall. Augmented reality combines three-dimensional (3D) computer-generated objects and text and superimposes them onto real images and 3D surgical video footage, all in real time. The surgeon then has the feeling of being in an actual surgery. This accompanying video provides a brief example of how this augmented reality training software will work.
Larson says this is needed because the current controlled basic training environment is incomplete: “The current animal model used in training does not adequately emulate actual practice. What would be ideal is to perform the procedure in a simulated environment and be objectively evaluated on your performance.” Hospitals are constantly looking for the safest way to acquire skills, learn the specifics of the surgical procedure, and learn how to manage potential complications.
“We believe this is the future of GYN training,” says Mimic CEO Jeff Berkley, PhD. “Practicing surgery on animals will only take us so far. Through augmented reality, we hope to expose surgeons to a wide variety of surgical scenarios that they would not normally encounter as a part of the typical case load. This approach may help limit the amount of learning that must not take place on real patients.”
Berkley explains that it was gynecologists who were the first to make the aggressive push toward simulation testing to gain surgical privileges. This is due, in part, to the access issues of training in the OR. “Gynecology training is special—it is tougher to get to the volume of surgeries you need,” he says. “It can be tough to keep up those needed skills. That is why we have made women’s health a priority, because skills maintenance through simulation should play a larger role in gynecology.”
The following is an except from OBGYN.net’s September article.
” An advanced, procedure-specific training software for physicians who perform robotic surgeries has been developed by Mimic Technologies. This new augmented reality software, Maestro AR, is to be used with the dV-Trainer and gives surgeons the look and feel of being in an actual surgery. This software is suitable for surgeons in training who want to master their skills or for those with a lower surgical volume who want to preserve their skills. This preview of the software features a partial nephrectomy and uses actual surgical footage from Inderbir Gill, MD, Chairman, Department of Urology, Founding Executive Director of the USC Institute of Urology and Associate Dean for Clinical Innovation. According to Mimic Technologies, augmented reality training software for hysterectomy will be introduced this fall.” – Continue reading full article on OBGYN.net
Don’t miss this year’s Robotic Olympic Games taking place at the 2014 Society of Laparoendoscopic Surgeons Annual Conference in Las Vegas. This year, some of the nation’s top surgeons will be competing for excellent scores for training for the daVinci Robot
Minimally invasive surgery is becoming the norm in a variety of areas of medicine, but it is complex, causing a high percentage of surgeons to opt out, even though studies show less invasive surgeries are much better for the patient. On Sept. 10-12, during the SLS Minimally Invasive Surgery Week / Annual Meeting and Endo Expo, researchers will come together to compete and train using the latest training technology—simulation of the daVinci robot on the dV-Trainer. Top surgeons and technology experts will be on hand to show how the latest in minimally invasive surgery is now done.
Dr. Jeffrey Berkley, Founder and CEO, Mimic Technologies
Dr. Paul Wetter, president of the Society of Laparoendoscopic Surgeons
Jacques Hubert, former president, Minimally Invasive Robotic Association (MIRA), and creator of the first Robotic Olympic Games
Dr. James “Butch” Rosser, FL Hospital Celebration Health
Dr. Mona Orady, Cleveland Clinic
Two Rounds of Competition:
Wed., 9/10 at 7PM and 8:30PM (Qualifying Rounds)
Thurs., 9/11 at 7AM to 2PM (Qualifying Rounds)
Friday, 9/12 at 9-10AM in the General Session (FINALS BEGIN)
Caesars Palace Hotel, Las Vegas: 3570 S Las Vegas Blvd, Las Vegas, NV 89109
Society of Laparoendoscopic Surgeons Annual meeting Booth #110
DIRECTIONS/PARKING: http://www.mapquest.com/us/nevada/restaurants-las-vegas/caesars-palace-266320278 (702) 731-7110
“One of the most powerful equalizers in any system is technology, and as medical equipment manufacturers work to improve their positions in an increasingly competitive and outcomes-based marketplace, some are considering the specific needs of women in their product development,” writes Matthew N. Skoufalos in his cover story for MedicalDealer Technology: The Great Gender Equalizer – A look at trends in women’s health.
In the article, CEO and Founder of Mimic Technologies Jeff Berkley explains that an improvement in surgical techniques — especially for procedures such as hysterectomies — can have a profound impact on health outcomes.
He believes that women’s healthcare can benefit from an emphasis on minimally invasive surgeries, particularly if the barrier of training surgeons is removed from the equation.
The following is an excerpt from the August 2014 cover story:
“I personally think that the impact simulation can make on women’s health is probably more profound than it would be on other disciplines,” Berkley said.
“People have been doing laparoscopic hysterectomies since the 1970s, and yet there is still some resistance to adopting what is clinically a better approach,” he added. “We feel a lot of this has to do with the fact that people don’t have access to the training.”
“It is an enabling technology,” Berkley said, “but the reality is it hasn’t been out that long, and even though a lot of robotics are being done for hysterectomies, endometriosis, and other surgeries, people are still going to try to make a comparison to laparoscopics. It’s not an apples to apples comparison.”
Robotics can allow surgeons to achieve “expert status” faster, Berkley said, and even carry advantages over the traditional laparoscopic approach. Wristed instruments allow greater access to tissue. A trimmer scales back motion to allow for greater precision and accuracy. Surgical robots even offer 3D vision.
But the key advantage, potentially, is that surgical robotics also offers the possibilities of simulation, which helps keep surgeons primed for practice.
“If you’re a urologist, you might do three to seven prostatectomies a day,” Berkley said; “but if you’re an OB-GYN, you’re very likely helping people deliver babies. It’s not uncommon that a GYN may only do a surgery once a month. People are going to have less practice on the job and your skills can deteriorate pretty fast in a month.”
“If you have 24-7 access to a simulator and you have some time between cases, or you want to simulate a case, you can maintain your skills,” he said.
The following is a transcript from Mimic’s Art Director Gordon Nealy who spoke about Mimic’s approach to training, instruction and education during the recent Association of Medical Illustrators (AMI) Annual Conference. In his speech, Nealy explains how Mimic has created new training, instruction, and educational approaches to robotic surgery simulation and how surgeons and patients are benefiting.
“At the core of our training for robotic surgeons is the performance and assessment of psycho-motor skills. We train medical students, residents, fellows, experienced surgeons, and practicing robotic surgeons.
I want to draw your attention to the master grips which are the interactive element of the Simulator.
They manipulate the virtual instruments within the skills exercise environments. Performing these exercises is how the learner acquires and develops psycho-motor skills for application to the surgical robotic system. Surgeries on the da Vinci are performed using hand/eye coordination only. It is truly amazing how these surgeons can operate without tactile feedback from the tissues, the cavity walls, sutures and needles.
In psycho-motor training, competence requires practice. At Mimic, we have devised over 59 exercises that trainees can use to advance their skills on the da Vinci robotic system.
However, a well-structured simulation program contains not only performance based exercises, but also a solid assessment program.
Our simulator uses an assessment program we developed called MScore™. MScore is an objective and reliable evaluation of the user’s performance because it breaks down exercises into individual actions. From these, we’ve created the measurements, or metrics, that we use to score the completion of tasks within an exercise. It allows us to evaluate how many times a user dropped an object, whether they collided their instruments, if they missed any targets, and whether the activity was completed within the time limit. The scoring is important for two reasons – one, it provides feedback to the individual as to how they are progressing and two, it informs us how effective the instruction is and if we need to alter it.
Simulation is one of the few areas where one has permission to fail because it is a safe environment. Learning to perform surgery on the da Vinci system is difficult. One of our principal intentions is to reduce the steep learning curve associated with developing robotic surgical skills.
We’ve created instructional materials in the form of text and images, video, and user guides. This step- by- step text instruction example provides the trainee with learning objectives, what they will learn, as well as specific task objectives and what actions are they expected to accomplish in the exercise. The instructional materials also describe the layout of the foot pedals, the types of targets, tips for obtaining a better score, and tips for developing a good technique.
For those who learn better by watching we’ve created video instructions which also contain audio narration. These videos demonstrate how to perform the skills as executed by an accomplished user. By watching the videos users can observe insightful techniques for correct instrument positioning, hand-offs, avoiding pitfalls, task transitions, and principally absorb a mental image of how to perform the exercise.
It is extremely important to develop proper techniques because the ultimate goal is patient safety. Nothing replaces practice but these instructions will assist in advancing the user more quickly and therefore reduce the steep learning curve.
A while ago, our company created a division called MimicMED to address educating the novice and practicing robotic surgeons. MimicMED teaches classes using the dV-Trainer, surgical associated anatomy, and surgical procedure to provide a complete educational experience. Ultimately, this improves the learner’s cognitive and psycho-motor skills.
Why are established robotic surgeons using this additional practice? Because there may be long periods of time when they haven’t performed a robotic surgery because they are performing open surgeries. This means that their skills can get a little rusty. They come to MimicMED to take a class and refresh their skills. Afterwards, they can get back on the robot with confidence.
We recently created a couple of products that further the cognitive skills of our trainees, one of which is the Xperience Team Trainer™. This setup enables two users – a console-side surgeon (who sits at the dV-Trainer) and an assistant (who stands at the Team Trainer). The two hardware units are connected allowing the two users to collaborate in performing the same skills exercise. We’re hoping this will educate them in team dynamics through their practice of collaboration and communication on the simulators.
The other product is our Augmented Reality video exercise. This exercise features virtual instruments, layered over actual surgical video (with actual instruments). The exercise walks robotic surgeons through a partial nephrectomy procedure performed by an expert robotic surgeon.
During this procedure the learner’s cognitive skills are challenged. The user is quizzed on things such as the sequence of steps of the surgery and what was accomplished in a step. They must also identify anatomy and pathology and where to cut or cauterize tissue.
In short, these are the important considerations of our company’s approach to simulation as defined by training, instruction and education.”