Robot-assisted Surgery Training Research Articles

Assessment of validity evidence for the RobotiX robot assisted surgery simulator on advanced suturing tasks

BackgroundRobot assisted surgery has expanded considerably in the past years. Compared to conventional open or laparoscopic surgery, virtual reality (VR) training is an essential component in learning robot assisted surgery. However, for tasks to be implemented in a curriculum, the levels of validity should be studied for proficiency-based training. Therefore, this study was aimed to assess the validity evidence of advanced suturing tasks on a robot assisted VR simulator.MethodParticipants were voluntary recruited and divided in the robotic experienced, laparoscopic experienced or novice group, based on self-reported surgical experience. Subsequently, a questionnaire on a five-point Likert scale was completed to assess the content validity. Three component tasks of complex suturing were performed on the RobotiX simulator (Task1: tilted plane needle transfer, Task: 2 intracorporal suturing, Task 3: anastomosis needle transfer). Accordingly, the outcome of the parameters was used to assess construct validity between robotic experienced and novice participants. Composite scores (0–100) were calculated from the construct parameters and corresponding pass/fail scores with false positive (FP) and false negative (FN) percentages.ResultsFifteen robotic experienced, 26 laparoscopic experienced and 29 novices were recruited. Overall content validity outcomes were scored positively on the realism (mean 3.7), didactic value (mean 4.0) and usability (mean 4.2). Robotic experienced participants significantly outperformed novices and laparoscopic experienced participants on multiple parameters on all three tasks of complex suturing. Parameters showing construct validity mainly consisted of movement parameters, needle precision and task completion time. Calculated composite pass/fail scores between robotic experienced and novice participants resulted for Task 1 in 73/100 (FP 21%, FN 5%), Task 2 in 85/100 (FP 28%, FN 4%) and Task 3 in 64/100 (FP 49%, FN 22%).ConclusionThis study assessed the validity evidence on multiple levels of the three studied tasks. The participants score the RobotiX good on the content validity level. The composite pass/fail scores of Tasks 1 and 2 allow for proficiency-based training and could be implemented in a robot assisted surgery training curriculum.

Structured robot-assisted surgery training curriculum for residents in Urology and impact on future surgical activity.

To gain insight into the availability of training for robot assisted surgery (RAS) and the possibility to perform RAS during Dutch residency curriculum and to analyze the effects on surgical skills by the introduction of an advanced course in RAS for residents. A combination of a validated snap shot survey and a prospective cohort study. Structured advanced RAS training including virtual reality (VR) simulation, dry and wet lab facility at ORSI academy (Belgium). A snap-shot survey has been sent to all the residents and specialists in Urology graduated during the years 2017-2020 in Netherlands. Among residents, only last year residents (5th and 6th year) have been considered for the RAS training. Although most of the residents (88.2%) and young urologists (95%) were asked to follow a basic training or meet basic requirements before starting RAS, the requirements set by the educators were different from center to center. Some of them were required to attend only an online course on RAS, whereas others were asked to achieve threshold scores at VR simulator and participate in a standardized course at a training institute. The attendance to a structured advanced course in RAS showed a significant increase in surgical skills. Our study shows residents in urology are allowed to perform RAS during their residency though the criteria for starting RAS differ significantly amongst the teaching hospitals. To guarantee a basic level of skills and knowledge a structured, (multi-step) training and certification program for RAS should be implemented.

Skill-Oriented and Performance-Driven Adaptive Curricula for Training in Robot-Assisted Surgery Using Simulators: A Feasibility Study.

Virtual Reality (VR) simulators represent a remarkable educational opportunity in order to acquire and refine surgical practical skills. Nevertheless, there exists no consensus regarding a standard curriculum of simulation-based training. This study introduces an automatic, adaptive curriculum where the training session is real-time scheduled on the basis of the trainee's performances. An experimental study using the master console of the da Vinci Research Kit (Intuitive Surgical Inc., Sunnyvale, US) was carried out to test this approach. Tasks involving fundamental skills of robotic surgery were designed and simulated in VR. Twelve participants without medical background along with twelve medical residents were randomly and equally divided into two groups: a control group, self-managing the training session, and an experimental group, undergoing the proposed adaptive training. The performances of the experimental users were significantly better with respect to the ones of the control group after training (non-medical: p < 0.01; medical: p = 0.02). This trend was analogous in the non-medical and medical populations and no significant difference was identified between these two classes (even in the baseline assessment). The analysis of the learning of the involved surgical skills highlighted how the proposed adaptive training managed to better identify and compensate for the trainee's gaps. The absence of initial difference between the non-medical and medical users underlines that robotic surgical devices require specific training before clinical practice. This feasibility study could pave the way towards the improvement of simulation-based training curricula.

Training in robot-assisted surgery.

The aim of this narrative review is to identify the currently available training programs in the field of robotic-assisted surgery. The lack of well trained robotic surgeons represents the main obstacle facing robotic surgery. This calls for development of structured robotic training programs in order to improve patient safety and outcomes. Structured curriculum should consist of theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and final evaluation. Tele-mentoring might reveal mandatory in future curricula development. To date, several training programs are currently available for robotic surgery. However, the majority lack of clinical modular training that consists of progressive, proficiency-based training through surgical steps with increasing levels of complexity. Moreover, many of these curricula lack validation. This recent literature analysis suggests that there is an urgent need to develop and validate new structured training curricula for robotic surgery. This allows to improve the skills of the surgeons and of their team and to prevent patients from being used as a training module optimizing their safety.

A comprehensive review of robotic surgery curriculum and training for residents, fellows, and postgraduate surgical education.

In 2017, the utilization of robotic-assisted surgery had grown 10-40-fold relative to laparoscopic surgery in common general surgery procedures. The rapid rise in the utilization of robotic-assisted surgery has necessitated a standardized training curriculum. Many curricula are currently being developed and validated. Additionally, advancements in virtual reality simulators have facilitated their integration into robotic-assisted surgery training. This review aims to highlight and discuss the features of existing curricula and robotic-assisted surgery training simulators and to provide updates on their respective validation process. A literature review was conducted using PubMed from 2000-2019 and commercial websites. Information regarding availability, content, and status of validation was collected for each current robotic-assisted surgery curriculum. This review did not qualify as human subjects research, so institutional review board approval was not required. The daVinci Technology Training Pathway and Fundamentals of Robotic Surgery are purely web-based and self-paced robotic-assisted surgery training. The Society of American Gastrointestinal and Endoscopic Surgeon Robotic Masters Series, Fundamental Skills of Robot-Assisted Surgery training program, and the Robotics Training Network curriculum require trainees to be on site in order to provide expert feedback on surgical techniques and robot maintenance. Currently, there are few virtual reality simulators for robotic-assisted surgical training available on the market. Didactic courses are available in all of these training programs, but their contents are inconsistent. Furthermore, the availability and nature of hands-on training offered by these curriculums are widely variable.

Robotic simulation training for urological trainees: a comprehensive review on cost, merits and challenges.

Simulation in surgery is a safe and cost-effective way of training. Operating room performance is improved after simulation training. The necessary attributes of surgical simulators are acceptability and cost-effectiveness. It is also necessary for a simulator to demonstrate face, content, predictive, construct and concurrent validity. Urologists have embraced robot-assisted surgery. These procedures require steep learning curves. There are 6 VR simulators available for robot-assisted surgery; the daVinci Skills Simulator (dVSS), the Mimic dV Trainer (MdVT), the ProMIS simulator, the Simsurgery Educational Platform (SEP) simulator, the Robotic Surgical Simulator (RoSS) and the RobotiX Mentor (RM). Their efficacy is limited by the lack of comparative studies, standardisation of validation and high cost. There are a number of robotic surgery training curricula developed in recent years which successfully include simulation training. There are growing calls for these simulators to be incorporated into the urology training curriculum globally to shorten the learning curve without compromising patient safety. Surgical educators in urology should aim to develop a cost-effective, acceptable, validated simulator that can be incorporated into a standardised, validated robot-assisted surgery training curriculum for the next generation of robotic surgeons.

Current status of robot-assisted urologic surgery in Saudi Arabia: Trends and opinions from an Internet-based survey.

Objectives:The objective of this study is to assess the current status of urologic robot-assisted surgery (RAS) in Saudi Arabia and evaluate perceptions of its importance and utility.Methods:A 59-item questionnaire was E-mailed to urologists and trainees in Saudi Arabia to assess the demographics and individual and institutional surgical practices of minimally invasive surgery (MIS) with a focus on RAS and urologic subtypes.Results:Ninety-five surveys were completed. Nearly 53%, 46%, and 21% of respondents were formally trained in laparoscopic surgery, MIS, and RAS, respectively. Forty percent had used a robot console during training. Nearly 72% of participants felt that RAS training should be included to accomplish their career goals and stated that it would strengthen the department academically and financially. The absence of a robotic system (45%) and administrative disinterest with lack of support (39%) were the most common deterrents. Robot-assisted radical prostatectomy (RARP), robot-assisted radical cystectomy (RARC), and robot-assisted radical nephrectomy (RARN) were regarded as the gold standard for 34%, 23%, and 17% of respondents, respectively. Respondents would recommend RARP (74%), RARC (50%), and RARN (57%) for themselves or their family. The greatest perceived benefits of RAS were its ease of use and improvement in the patient's quality of life.Conclusion:Urologists in Saudi Arabia recognize the superiority of RAS over traditional surgical methods but lack exposure, training, and access to RAS. This survey reveals increasing acceptance of RAS and willingness to incorporate the technology into practice.

Validation of ergonomic instructions in robot-assisted surgery simulator training.

Training in robot-assisted surgery focusses mainly on technical skills and instrument use. Training in optimal ergonomics during robotic surgery is often lacking, while improved ergonomics can be one of the key advantages of robot-assisted surgery. Therefore, the aim of this study was to assess whether a brief explanation on ergonomics of the console can improve body posture and performance. A comparative study was performed with 26 surgical interns and residents using the da Vinci skills simulator (Intuitive Surgical, Sunnyvale, CA). The intervention group received a compact instruction on ergonomic settings and coaching on clutch usage, while the control group received standard instructions for usage of the system. Participants performed two sets of five exercises. Analysis was performed on ergonomic score (RULA) and performance scores provided by the simulator. Mental and physical load scores (NASA-TLX and LED score) were also registered. The intervention group performed better in the clutch-oriented exercises, displaying less unnecessary movement and smaller deviation from the neutral position of the hands. The intervention group also scored significantly better on the RULA ergonomic score in both the exercises. No differences in overall performance scores and subjective scores were detected. The benefits of a brief instruction on ergonomics for novices are clear in this study. A single session of coaching and instruction leads to better ergonomic scores. The control group showed often inadequate ergonomic scores. No significant differences were found regarding physical discomfort, mental task load and overall performance scores.

The Society of European Robotic Gynaecological Surgery (SERGS) Pilot Curriculum for robot assisted gynecological surgery

PurposeTo set forth experiences in the context of the SERGS Pilot Curriculum—the first standardized educational program for robotic use in gynecological surgery—in terms of feasibility, effectiveness and potential for certification.MethodsThe Society of European Robotic Gynecological Surgery (SERGS) outlined a Pilot Curriculum for standardized education in robot-assisted laparoscopic gynecological surgery. Its feasibility and acceptance were checked in the form of a fellowship pilot program conducted at four European Centers of Excellence for robot-assisted surgery. Results and conclusions derived from this pilot program are presented.ResultsThe SERGS Pilot Curriculum defines criteria for a standardized training and assessment of performance, boosts the learning curve of the candidate and increases contentment at work. Regarding face validity, it proves valuable as finally all candidates could perform the outlined procedure safely and efficiently without supervision.ConclusionDue to the immense increase of robotic procedures in gynecology standardized training curricula are indispensable. This seems highly necessary to ensure patients’ safety and surgical outcome. The SERGS Pilot Curriculum sets standards for a stepwise theoretical and practical training in gynecological robotic procedures. It seems feasible as instrument for accreditation as gynecologic robotic surgeon. Though as a general applicable guideline for systematic training in robot-assisted surgery, a definite curriculum should have a more definite timeline and implementation of a structured assessment of performance.

A decade of robot-assisted radical prostatectomy training: Time-based metrics and qualitative grading for fellows and residents

ObjectivesAs modern urology residency and fellowship training in robot-assisted surgery evolves toward standardized curricula (didactics, dry/wet-laboratory exercises, and surgical assistance), additional tools are needed to evaluate on-console performance. At the start of our robotics program in 2006, we set-up a time- and quality-based evaluation program and aim to consolidate this data into a simple set of metrics for self-evaluation. Materials and methodsUsing our index procedure of robot-assisted radical prostatectomy (RARP), we prospectively collected data on 2,215 cases over 10 years from 6 faculty surgeons and 94 trainees (43 urologic oncology fellows and 51 urology residents). The steps of the operation were divided into 11 consistent steps, and the metrics included time to completion and quality using a 6-level grading system. Time metrics were consolidated into quartiles for benchmarking. ResultsThe median times for trainees to complete each step were 15% to 120% higher than those of the staff (P<0.001). Each step can be presented with quartile-based time metrics by pooled trainee and staff results. Steps performed by trainees were carefully chosen for a high success rate, and on our Likert-like scale were graded 4 to 5 in more than 95% of cases. There were no grade 0 (very poor) cases, and grades 1 (multiple technical errors) and 2 (could not be completed but without safety issues) were rare (<1%). ConclusionsRARP training can be evaluated with a time-based metric that allows a quartile-based comparison to a large experience of trainees and staff. As a trainee progress through a rotation, these benchmarks can assist in prioritizing the need for more attention to a basic step vs. progression to more advanced steps.

Surgical robot simulation with BBZ console

This paper presents a lean approach to training in robot assisted surgery. Minimally Invasive Surgical procedures can be decomposed in a sequence of tasks, each surgical task can be further decomposed in basic gestures. Each surgical gesture seems similar to perform rather in laparoscopic than in robot assisted technique, but surgeon posture, tools dexterity, force and vision feedback are different. As a consequence, performing a robot-assisted procedure needs specific training. Currently, the most used robot in in abdominal and pelvic surgery is the da Vinci Surgical System and a different set of skills is needed to master the human-machine interface of this device. The training with the real robot is very expensive due to the high initial cost of purchasing and maintaining the robotic surgical system, and the ethic involved in vivo practice. For these reasons, different training systems based on virtual reality were developed. The simulation physics realism and the objective metrics collected during the task execution are the main features for the effectiveness of a virtual reality based training device. Availability of training systems is another issue. To help surgeons to train in virtual reality, BBZ presents a compact, lightweight and portable console, suitable also for "home" training.

PD41-06 ROBOT-ASSISTED TRAINING - EXPERT PERFORMANCE IN FULL IMMERSION SIMULATION, SETTING THE BENCHMARK (CONCURRENT VALIDITY)

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment II1 Apr 2017PD41-06 ROBOT-ASSISTED TRAINING - EXPERT PERFORMANCE IN FULL IMMERSION SIMULATION, SETTING THE BENCHMARK (CONCURRENT VALIDITY) Talisa Ross, Nicholas Raison, Lauren Wallace, Thomas Wood, Catherine Lovegrove, Henk Van der Poel, Prokar Dasgupta, and Kamran Ahmed Talisa RossTalisa Ross More articles by this author , Nicholas RaisonNicholas Raison More articles by this author , Lauren WallaceLauren Wallace More articles by this author , Thomas WoodThomas Wood More articles by this author , Catherine LovegroveCatherine Lovegrove More articles by this author , Henk Van der PoelHenk Van der Poel More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1885AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate surgical trainee performance, technical and non-technical skills can be assessed during full immersion simulation. This study aimed to define the benchmark that novices must attain before achieving competency in urethro-vesical anastomosis (UVA). Benchmark scores are important to reflect when a trainee is safe to perform the task on a real patient by providing an objective assessment of a trainee's performance. METHODS 14 expert and intermediate robotic surgeons were assessed for technical and non-technical skills whilst performing UVA in full immersion simulation, with actors playing the roles of scrub nurse and anaesthetist. UVA requires suturing the urethra to the bladder. A series of stressors were applied during the task to enable full assessment of non-technical skills. Data was compared to the performance of 22 medical student novices to establish construct validity. Video footage was assessed by an international expert using GEARS and NOTSS. Mean expert scores were then used to define a competency benchmark. RESULTS There was a statistically significant difference in technical and non-technical skills between novices, intermediates and experts (p = 0.031, p = 0.047 respectively). As construct validity was displayed, mean expert scores were used to define a benchmark score of 2.9 for technical skills and 2.8 for non-technical skills. There was no significant difference between laparoscopic and robotic experts, suggesting there may be some transference of skill from previous laparoscopic experience. CONCLUSIONS Trainees should aim to achieve a mean GEARS score of 2.9 and a mean NOTSS score of 2.8 to achieve competency in performing UVA. Using these benchmark scores will help to deem whether a trainee is competent to perform an unassisted UVA on a patient and can be incorporated into robot-assisted surgery training programmes to monitor progression. Future work must be carried out to further evaluate whether there is a role for transference of skills from laparoscopic experience to robot-assisted surgery. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e809 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Talisa Ross More articles by this author Nicholas Raison More articles by this author Lauren Wallace More articles by this author Thomas Wood More articles by this author Catherine Lovegrove More articles by this author Henk Van der Poel More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Simulation-Based Training in Robot-Assisted Surgery: Current Evidence of Value and Potential Trends for the Future

Robot-assisted surgery has changed the landscape of surgery. Implementation of robotics into most surgical specialties has left many educators challenged to develop the tools necessary to train and credential surgeons. Advances in robot-assisted surgery have led to the development of simulators and tools to assess skills that transfer to surgical practice. We report on current trends in robot-assisted surgical training, focus on simulation-based education, and anticipate future developments.

Robotic pancreaticoduodenectomy for pancreatic adenocarcinoma: role in 2014 and beyond.

Minimally invasive surgery (MIS) for pancreatic adenocarcinoma has found new avenues for performing pancreaticoduodenectomy (PD) procedures, a historically technically challenging operation. Multiple studies have found laparoscopic PD to be safe, with equivalent oncologic outcomes as compared to open PD. In addition, several series have described potential benefits to minimally invasive PD including fewer postoperative complications, shorter hospital length of stay, and decreased postoperative pain. Yet, despite these promising initial results, laparoscopic PDs have not become widely adopted by the surgical community. In fact, the vast majority of pancreatic resections performed in the United States are still performed in an open fashion, and there are only a handful of surgeons who actually perform purely laparoscopic PDs. On the other hand, robotic assisted surgery offers many technical advantages over laparoscopic surgery including high-definition, 3-D optics, enhanced suturing ability, and more degrees of freedom of movement by means of fully-wristed instruments. Similar to laparoscopic PD, there are now several case series that have demonstrated the feasibility and safety of robotic PD with seemingly equivalent short-term oncologic outcomes as compared to open technique. In addition, having the surgeon seated for the procedure with padded arm-rests, there is an ergonomic advantage of robotics over both open and laparoscopic approaches, where one has to stand up for prolonged periods of time. Future technologic innovations will likely focus on enhanced robotic capabilities to improve ease of use in the operating room. Last but not least, robotic assisted surgery training will continue to be a part of surgical education curriculum ensuring the increased use of this technology by future generations of surgeons.

Uncontrolled manifold analysis of arm joint angle variability during robotic teleoperation and freehand movement of surgeons and novices.

Teleoperated robot-assisted surgery (RAS) is used to perform a wide variety of minimally invasive procedures. However, current understanding of the effect of robotic manipulation on the motor coordination of surgeons is limited. Recent studies in human motor control suggest that we optimize hand movement stability and task performance while minimizing control effort and improving robustness to unpredicted disturbances. To achieve this, the variability of joint angles and muscle activations is structured to reduce task-relevant variability and increase task-irrelevant variability. In this study, we determine whether teleoperation of a da Vinci Si surgical system in a nonclinical task of simple planar movements changes this structure of variability in experienced surgeons and novices. To answer this question, we employ the UnControlled manifold analysis that partitions users' joint angle variability into task-irrelevant and task-relevant manifolds. We show that experienced surgeons coordinate their joint angles to stabilize hand movements more than novices, and that the effect of teleoperation depends on experience--experts increase teleoperated stabilization relative to freehand whereas novices decrease it. We suggest that examining users' exploitation of the task-irrelevant manifold for stabilization of hand movements may be applied to: (1) evaluation and optimization of teleoperator design and control parameters, and (2) skill assessment and optimization of training in RAS.

Medicolegal Review of Liability Risks for Gynecologists Stemming from Lack of Training in Robot-Assisted Surgery

The advances in robot-assisted surgery in gynecology evolved after most practicing gynecologists had already completed residency training. Postgraduate training in new technology for gynecologists in practice is limited. Therefore, gynecologists with insufficient training who perform robot-assisted surgery may potentially be at risk for liability. In addition to the traditional medical negligence claims, plaintiff attorneys are seeking causes of actions for lack of informed consent and negligent credentialing. Thus, it is essential that gynecologists be aware of these potential liability claims that arise in a robot-assisted malpractice suit. This commentary provides an overview of the current medicolegal liability risks originating from lack of training in robotic surgery and seeks to raise awareness of the implications involved in these claims. A better understanding of the doctrine of informed consent and seeking assistance of proctors or experienced co-surgeons early in robotics training are likely to reduce the liability risks for gynecologic surgeons.

Comparative Analysis of Global Practice Patterns in Urologic Robot-Assisted Surgery

To determine and compare the status of urologic laparoscopic and robot-assisted surgery (RAS) across the world. Two hundred ninety-one surveys were completed by urologists at various national and international conferences in 2008. The 58-item questionnaire assessed the individual and institutional practice patterns of minimally invasive surgery with a focus on RAS. Surveys from Europe and North American continents (ENA) were compared with surveys from the Middle East and Asian continents (MEA). One hundred sixty-six (57%) surveys were completed by urologists from MEA and 125 (43%) from ENA. Eighty percent of respondents performed minimally invasive surgery, with 64% having prior formal training. Respondents in ENA were more likely to have had formal training in RAS and performed more RAS cases (p < 0.01). Sixty percent of those surveyed from ENA had used robotic consoles in training courses compared with only 20% in MEA (p < 0.01). Dedicated RAS support teams were less common in MEA (p < 0.01). Lack of a robotic system was the most common deterrent for RAS in MEA (56%). Respondents in ENA performed more robot-assisted radical prostatectomy, robot-assisted radical cystectomy, and robot-assisted nephrectomy. In the more established robotic environment of ENA, robot-assisted radical prostatectomy, robot-assisted radical cystectomy, and robot-assisted nephrectomy represented the gold standard in 34%, 14%, and 26% of surveys, respectively. Comparatively, MEA respondents were more likely to believe RAS represented the gold standard. Usage of RAS in urology continues to grow across the globe, though to most it represents a surgical alternative rather than benchmark. Even with reduced exposure, training, and access, more urologists in the MEA considered RAS to be the surgical standard for prostatectomy, cystectomy, and nephrectomy. The evolution of attitudinal change should be the focus of further study.