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
It has now been 15 years since Mimic Technologies was launched as a company and 12 years of providing robotic surgery simulation training. 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 simluation 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.
- Curriculum 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 making sure 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
The big question that many doctors and hospitals continually ask themselves, “will this time I spend on a simulator actually end up having an impact on my patients?”, plays a big part in how training is structured. In terms of validation, correlating time spent on a simulator to improving patient outcomes is referred to as predictive validity.
The first research study to look into this for robotic surgery was published by Dr. Patrick Culligan in 2014, which developed the “Morristown Protocol”. Using the Morristown Protocol curriculum, Dr. Culligan, et al., demonstrated predictive validity by setting an expert-based proficiency benchmark and asking 14 attending surgeons to complete a curriculum of 10 exercises to this same level of proficiency as the experts that were benchmarked. After completing the simulation training, the attending surgeons were able to complete their first robotic hysterectomy case within the same or better parameters as the experts. These parameters included things such as operative time, blood loss, and technique as assessed by experts. While this study was done using Mimic software, the simulation training was carried out using the Intuitive Surgical Skills Simulator hardware.
The table below gives the data for the experts as well as a control group of surgeons who had privileges at the institution but had not spent any time on a simulator for training:
More recently, Dr. Gokhan Sami Kilic of the University of Texas Medical branch at Galveston carried out a study that looked at the impact of simulation training on surgical outcomes for Hysterectomies that not only looked at robotic surgery but also included open surgery, laparoscopic, and vaginal approaches to Hysterectomy.
Unlike Dr. Culligan’s study, Dr. Kilic also focused on residents as opposed to already trained surgeons. The average age of the surgeons who went through the Morristown protocol was just under 50 years old. Dr. Kilic’s study, however, was focused on surgeons who were in their residency and were grouped in PGY2, PGY3, and PGY4, typically under the age of 40.
This study looked at patient outcomes such as estimated blood loss, postoperative hospital stay, intraoperative adverse events, and mean operative time. The study was retrospective and covered a period from 2009 to 2014.
Simulation was introduced in 2010 at the institution for all modalities except robotics. Robotics was introduced in 2011 with the acquisition of Mimic’s dV-Trainer. The simulators were from a wide range of manufacturers in addition to Mimic including, 3-Dmed and Limbs&Things. Residents followed a structured simulation-based training program for Total Abdominal Hysterectomy (TAH), Vaginal Hysterectomy (VH), Total Laparoscopic Hysterectomy (TLH) and Robot Assisted Hysterectomy (RAH).
In total, 1,397 patients were included in the study and 41% (n = 576) underwent TAH, 22% (n = 305) underwent VH, 20% (n = 272) underwent TLH and 17% (n = 244) underwent RAH.
The patient populations did demonstrate some variations between the modalities and there were no statistically significant variations in relation to age, BMI, parity, or the number of previous surgeries.
The results can be seen in the table below
As you can see in the table, the average estimated blood loss before and after simulation-based training was significantly different in TAH and RAH groups, but no significant difference was found for VH and TLH. The mean of length of hospital stay was also significantly different before and after simulation-based training for each technique.
It is interesting that there was no statistical impact for OR time, though perhaps understandable as OR time is more related to overall team performance and thus requires team simulation as opposed to surgical skill. Intraoperative complications did not seem to be impacted either by simulation, though they did trend downward in the robotic cohort.
Although the study was not intended to look at this specifically, it does seem to indicate that while robotic surgery might have marginally longer operative times it does seem to have a lower level of intraoperative complications, lower blood loss, and the lowest length of stay along with Vaginal Hysterectomies.
At Mimic, the dV-Trainer was developed with the objective of helping surgeons master the da Vinci ® robotic system allowing them to improve outcomes for patients. It is great to see a research study that validates in this general direction not only for robotics but for other modalities that incorporate simulation training as well.
By: Christopher Simmonds
One of the questions I have often pondered is why do patients choose certain procedures and certain surgeons. So I conducted some research which showed that there were three clear factors that influenced patient choice.
The first was the surgeon they were initially referred to. In the majority of cases, patients will do what their surgeons tells them is the best treatment modality for them. The second most important was family and friends. As soon as you have a diagnosis that will involve a surgical intervention people will talk to their extended network and listen to feedback on similar procedures or interventions. In today’s connected world it is very easy to connect with a friend of a friend who has faced the same medical challenge. The last major factor was the internet. While the majority of people will go on the web to browse health care information and to help reinforce decisions made with their healthcare providers, only a small percentage, around 10%, will change their physician and treatment choice based on the internet alone.
This is completely logical as any surgical intervention is really about trust that the surgeon and institution will carry out the procedure and that you will come out the other side as planned. Most people will choose to trust someone once they have met them or rely on the advice of family and friends and are less likely to trust what they have read on the web.
A few years ago I was able to publish a paper that looked at the aspect of patient satisfaction on patients’ willingness to recommend their treatment modality to others.
Hystersisters.com is an online community that was created in 1998 to act as a support group for women to women, dedicated to medical and emotional issues surrounding the hysterectomy experience and gynecologic-related conditions and illnesses, supporting women from diagnosis, to treatment, to recovery.
The research group sent out a questionnaire to the 300,000 members and received over 10,000 responses (however, only 6,263 met the inclusion criteria). We essentially were asking about their perception of their surgical experience and if they would recommend the procedure to someone else in the same position as themselves and, if faced with the same situation would go through the same procedure again.
The table below shows the answers across a variety of modalities and the % who would definitely recommend or choose the same procedure again.
As you can see, there was a significant difference between the types of surgical treatment offered and the willingness to recommend or have the surgery again.
What does this have to with Surgeon skill? I would hope this is obvious. Surgeons who have higher skills and have higher volumes will tend to have better outcomes. We have discussed this fact in earlier blogs.
Better outcomes lead to more satisfied patients who are more likely to recommend the surgeon and institution to family and friends. This will lead to more referrals which will continue as a virtuous circle. The reverse is also true when outcomes are not so positive they can have a negative impact on referrals.
At Mimic, we have always believed that helping surgeons master their tools through simulation is ultimately about helping patients have a better surgical experience and allowing them to get on with their lives as quickly as possible.
“The Impact of Different Surgical Modalities for Hysterectomy on Satisfaction and Patient Reported Outcomes” Published on 17/17/04 in Interactive Journal of Medical Research
Michael C Pitter1*, MD; Christopher Simmonds2*; Usha Seshadri-Kreaden3*, MS ; Helen Hubert4*, MPH, PhD