The published paper on which the poster is based may be found after the poster.

Procedure specific simulations: the future of robotic surgery training

Setty Yaki, PhD
3D Systems – Simbionix, Airport City, Israel
Intl J CARS (2015) 10 (Suppl 1):S45-47

Purpose

Robot-Assisted Laparoscopic Surgery is rapidly gaining momentum as an approach for minimally invasive surgery. It provides a more precise and safer platform for a wide variety of laparoscopic surgeries along with a number of other benefits. Robotic systems demand training, however, before surgeons can handle them precisely and efficiently. One way to accelerate the training period is to employ virtual reality robotic simulations to provide a realistic surgical platform for practice. Virtual simulations replicate the robotic surgery environment and serve to train new users effectively and at lower cost. In contrast with traditional training on animals and physical models, computer simulations can be used repeatedly with no complicated setup or preparation.

Virtual reality robotic simulations provide a set of tasks, normally derived from physical models that allow novices to train their basic skills. These tasks identify key skills required in robotic surgery and provide a virtual reality platform on which to practice them. These skills include hand-eye coordination, needle handling, tool manipulation, and others. An example of such a task is provided in Fig. 1. In this task the user moves a ring off of one tower and transfers it to another in the shortest time possible. The user must maneuver the ring over the two S-shaped towers while minimizing collisions between the ring, tool and wire. Penalties are counted for ring-tower collision, ring drop, etc. By practicing the task novices build their ability to manipulate the tools precisely. Examples for basic skill training modules include Fundamental of Robotic Surgeries (FRS) and Robotic Training Network (RTN). These modules are based on a set of real physical models that have been designed specifically for basic skills practice.

Fig. 1 A representative example of a robotic basic skill training simulation. A snapshot of the ring transfer task simulation of the Fundamental of Robotic Surgery (FRS). Users transferring the ring from one tower to the other in order to enhance robot handling skills such as eye-hand coordination and tool manipulation.

While the benefits of basic skill simulations are clear and based on models that are largely clinically validated, computer simulation can be extended for practicing specific procedures. Modules of this type simulate entire surgical procedures in a realistic fashion. The user confronts a virtual reality environment that reproduces the actual anatomy he would face in a specific surgical procedure. In contrast with basic skill simulation, the user has to handle real world scenarios. Procedure specific simulations may serve, therefore, not only to improve surgical skill but to improve knowledge of specific surgical scenarios.

Methods

We employ a unique platform inspired by game design to develop virtual reality simulations in three dimensions. The 3D visualization supports stereo vision, providing a fully realistic view of the simulation. In principle, the software can be executed of any robotic surgery platform. Specifically, we tested the simulation under windows environment on the RobotiX Mentor, which is a comprehensive educational solution suitable for surgeons to practice the skills required to perform robotic surgery (http://simbionix.com/simulators/robotix-mentor/).

Results

In recent years, we have completed two full procedure simulations: Hysterectomy and Vaginal Cuff Closure. These simulations support the entire procedure covering all steps required to successfully complete the surgery. The simulations provide visual step-by-step guidance to educate the user on procedural technique along with error reporting. Nonetheless, our simulations are not restricted to guidance and allow testing any possible technique in a free training environment.

They track performance metrics and can be executed with or without guidance and to allow users to independently train and test their skills. Therefore, procedural specific simulations go beyond basic skill simulations and form a flexible educational tool, configurable to provide detailed instruction to a novice user as well as a useful practice environment for an experienced surgeon. Figure 2, presents a snapshot from the hysterectomy procedure in which the surgeon must extract a patient’s uterus. The module provides training in the key components of the procedure: Uterine manipulation, Superior pedicle division, Bladder mobilization, Exposure and division of the uterine artery and Colpotomy. The simulation includes a variety of complications and emergency situations such as ureteral injuries, injury to the bladder, uterine artery and superior pedicles bleeding that may occur during key steps of the procedure, etc.

Fig. 2 A representative example of a procedure specific robotic simulation. A simulation of the hysterectomy procedure in which a surgeon extracts a patient’s uterus. The simulation covers the entire steps required to successfully complete the surgery and offers a variety of complications and emergency situations

Conclusion

Procedural specific simulations are a very powerful tool for novice training and a comprehensive educational solution for surgeons on all levels. Novices can use guided simulations to practice a specific technique in order to improve their skills and gain a better knowledge of the procedure. Ideally, trainees would be provided with fewer cues as their performance increases over time. In a similar vein, procedure specific simulations in a free training mode could serve as a realistic environment to test and develop surgical techniques. Varity of technique can be tested and screened in order to identify a safer and more efficient one. As currently surgical techniques are not standardized, this can be particularly useful in developing new surgical methodologies as well as validated and accredited existing techniques. Currently, we are in the process of extending the library of procedure specific simulation to support a wide range of procedures as demanded by the scientific community. In parallel, we will be expanding to develop patient specific simulations in which records and anatomy of individual patients are embedded into virtual practice scenarios. This will allow surgeons to practice on a simulation which is true to the patient condition and anatomy and may provide a safer surgery and reduce related risks thus increasing success rate of operations.