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
There are many aspects to a training simulator that can be considered when making the initial investment in simulation training. For robotic surgery, we believe the top factors to consider are:
- Validation studies conducted on and using the simulator
- Fidelity of the controllers
- Accessibility of the simulator
- Data, data, data!
Since Mimic launched its first version of the dV-Trainer in 2007, there has been a growing number of new robotic surgery simulators entering the market. The real impetus for simulation training was made clear in 2010 when Intuitive Surgical decided to launch their own Skills Simulator, a backpack-like addition for the da Vinci® Si platform.
Intuitive Surgical chose to license 27 exercises that Mimic had already developed or were in the process of developing especially for ISI. This was made possible by the new design of the system, which allowed for the console to operate independently of the patient side cart and core. Since 2010, both the ROSS Simulator from Simulated Surgical Systems and the Robotix Mentor from Simbionix (now 3D Systems) have entered the playing field.
The installed base of da Vinci® surgical systems is now over 3,500 systems around the world and close to 2,000 simulators have been installed and used to support this installed base. The majority of training simulators are da Vinci® Skill simulators (with Mimic’s licensed software) and close to 12% of robotic surgery simulators are Mimic’s dV-Trainers.
Our estimate is that over 70% of institutions performing robotic surgery have access to a simulator of some form or another and that close to 90% of robotic surgeons will at some point have tried a simulator. In fact, since 2007 we believe that between the dV-Trainer and the da Vinci® Skills Simulator over 6.25 million exercise sessions have been completed.
So has all of this simulation training activity been valuable you may ask? One way to look assess simulation training is through validation studies. There are currently five different ways of determining validity. Starting with the basics Face, Content, and Construct and moving to more valuable validation such as Concurrent and Predictive, the definitions are:
Face validity: Does the simulator have a realistic look and feel, compared to the actual surgical system?
Content validity: Is the simulator useful as a training tool for the surgical system?
Construct validity: Does the simulator have the ability to distinguish between Novice and Expert users?
Concurrent validity: How does the simulator compare to a similar or related construct (Dry Labs, Tissue Lab, etc.) carried out on the real robotic surgical system?
Predictive: validity: Can the simulator be used to predict actual performance in the O.R.?
Face and Content are of relatively low value as they are subjective and the most highly valued validation studies are Construct and Predictive validity. The table below shows the number of papers that have been published on various types of validation. As you can see there have been over 30 papers published on Mimic software either on the dV-Trainer or the da Vinci® Skills Simulator platform.
Recently, simulation was a large part of the discussion at the FDA town hall meeting in Washington. Roger Smith from Florida Hospital presented a comparison of the different simulators led by himself (the table above is adapted from his presentation). The data presented was clear that the most focus in researching the simulators was on the controllers and how close they emulated the real robotic surgeon’s console. Obviously, the da Vinci® Skills Simulator, which uses the real console is the real thing. However for the other simulators, this is where concurrent validity because extremely important, as essentially you are replicating (using the simulator) the same activity a surgeon would be doing on the real robotic surgical system.
A direct head to head study was done by Prof. Jacques Hubert and his team at the STAN Institute in Nancy, France between Mimic’s dV-Trainer and the da Vinci® Skills Simulator. During the study, participants completed the same exercises on the both systems and researchers found that on average there was only a 3% difference in overall score between the two systems. (89.9% vs 86.8%). This varied by the type of exercise but remained consistent with some internal bench-marking carried out by Mimic. No studies have been done to the same extent on the Ross and Robotix Mentor systems.
Another component to take in consideration when choosing a robotic surgery simulator is the accessibility to the system. While the great thing about the da Vinci® Skills Simulator is that it uses the real console, this can also be very detrimental and a negative for the da Vinci® Skills Simulator that it uses the real console. Very few hospitals can afford to have a dedicated console outside the OR that is used purely for training and simulation. If an institution is lucky enough to have a dual console system they will have the simulator on the second console but that is still kept in the OR. The value of the second console is in allowing programs with residents to keep training new surgeons without interrupting the flow and efficiency of the OR. Data shows that simulation systems in the OR are used less than systems outside the OR. This is due to the simple fact that as robotic programs become more successful and utilization increases there is just not enough time for training.
All things considered, any learning experience is only as good as the objectives and goals that are being set for the student and how well they are being tracked. The MScore system allows tailored pass marks, proficiency levels and curricula to be set for the students based on their learning objectives. A multitude of metrics and data can be reviewed to allow a student to learn from their mistakes and improve their psychomotor skills.
So when looking for a simulator, make sure to find one that is validated, has high fidelity controllers, can be accessed 24/7 outside the OR, and has a flexible management and scoring system that can be tailored to meet your learning objectives. In the Tanaka study that was referred to in Roger Smith’s presentation to the FDA meeting, an observation was made that while the majority of study participants preferred the usability of the da Vinci® Skills Simulator, 70% felt the dV-Trainer was the best value for money spent when taking all things into consideration.
by: Christopher Simmonds, VP Business Development & Marketing, Mimic Technologies
While Mimic has been actively focused on simulation for robotic surgery over the past 15 years, I thought it would be interesting to see how simulation was valued for medical training, in general. While trawling through the internet I came across a study published by the Association of American Medical Colleges (AAMC) in 2011. The survey was sponsored by a number of other societies including: IMSH, ASPE and AACN. While it is five years old, I do believe it probably still holds true.
The questionnaire was sent to 133 AAMC member medical schools and 263 teaching hospitals in January through March of 2010. It is interesting to note that the use of simulation increased over time with medical students in both medical school or a teaching hospital environment. While with residents the reverse pattern was seen to occur with more simulation taking place in the first years of residency than in the later years.
These observations reflect what we have seen in many of the teaching hospitals using Mimic’s dV-Trainer. Residents are asked to develop psychomotor skills on the simulator before being allowed to migrate to the OR. Many institutions set a specific curriculum with proficiency levels that must be attained before the resident can sit down on the real robotic surgery console and start performing only very specific steps of a procedure.
An interesting part of this AAMC survey looked at how simulation is being used for education and assessment as well as part of a quality improvement program. What sparked my interest was the fact that the researchers differentiated between a number of skills that are very important to Mimic, such as psychomotor skills in addition to clinical thinking/decision making, team training and interpersonal communication skills.
Teaching hospitals were asked to indicate how simulation is used across the three domains of education, assessment, and quality improvement or research. All 64 respondents answered this question. Similar to medical schools, overall responses demonstrate simulation is largely used for educational purposes at 87 percent average usage across all competencies, less so for assessment at 61 percent, and much less frequently for quality improvement and research at only 34 percent.
Teaching Hospital Use of Simulation by selected areas:
In online questionnaires carried out by Mimic Technologies, we were able to see that over 90% of robotic surgeons had used Mimic simulation products either on Mimic’s dV-Trainer or on the da Vinici® Skills Simulator. This simulation training was primarily for the development of psychomotor skills as part of the surgeons’ initial training on robotics. In our experience fewer hospitals are using simulation for assessment, though we do know of some residency programs who include simulation in their recruitment process. We are also aware of institutions that have implemented a short curriculum that all surgeons need to pass annually to prove that they have the maintained their skill level for the surgical robot.
When it comes to quality improvement the picture is less clear. Given surgeons’ the time constraints, very few hospitals have initiated QI programs that leverage simulation to help improve the skill sets of lower performing surgeons.
As mentioned previously, this paper is five years old and I am sure the situation has continued to evolve. The implementation of the affordable care act is shining a spot light on patient outcomes and thus indirectly on variations in surgical performance. We can see that many institutions are trying to see how they can help improve the outcomes of their lower performers and we believe simulation will have a key role to play.