A Curriculum for Simulation-based Robotic Surgery

Professors Khurshid Guru and Thenkurussi Kesavadas, talk to AZoRobotics about a new curriculum for simulation-based robotic surgery.

Can you tell me about the new curriculum for simulation-based robotic surgery?

The problem that every center and every practitioner have to overcome in performing robot-assisted surgeries is bridging the gap between the technological and human elements.

The purchase of a surgical robot is just the beginning of building a robotics program, and it’s absolutely critical that centers commit sufficient resources to help their surgeons comfortably, confidently, and safely gain proficiency in the basic skills of robotic surgery.

We based the FSRS curriculum on research we’ve been doing at Roswell Park Cancer Institute since 2006. Several expert robotic surgeons worked with a simulation expert, Dr. Kesavadas, looking at ways to address the known limitations of simulation-based modules: availability, cost and the time it takes to develop them.

We incorporated that analysis into the curriculum and then tested it over a period of time. And now we have a multi-institutional, validated, randomized trial that shows the curriculum’s effectiveness.

How does the robotic surgical simulator work in relation to the curriculum?

The FSRS curriculum focuses on imparting basic console operation skills, psychomotor skills required to operate the robot, and a wide range of basic and intermediate surgical skills.

The Robotic Surgical Simulator, also known as RoSS, includes specific virtual-reality modules that address each of the main components of the curriculum. For example, lessons in tissue cutting and needle handling impart basic surgical skills.

What are the four basic areas required in robot-assisted surgery?

The fundamental pillars of robot-assisted surgery education are orientation, motor skills, basic surgical skills and intermediate surgical skills.

Orientation is about building familiarity with the robot. Motor skills are key because they’re how you bridge that gap between the console and the patient. You’re remotely placed, so you have to know exactly how to make the machine execute the steps you need to perform.

The third step is translating those motor skills into the basic steps involved in a surgery, adapting to the system’s operative field. When you’re at the console with your head under the monitor hood, you have no tactile feedback. You can’t touch or feel anything, so you have to almost start doing everything based on your visual feedback.

The last piece is the intermediate skills — once you’ve mastered the machine, mastered the interaction with your assistant and mastered the cognitive skills required to perform the surgery from a distance, this is where the rubber meets the road. You get to see how tissue reacts, how it looks, how magnified it is when you’re so close.

Our curriculum integrates all these things together using simulation so that surgeons and medical students can learn these basics in a completely safe, risk-free environment.

A recent study focused on measuring key skills in simulation-based robotic surgery based on a novel curriculum. Can you discuss how you tested the participants and what parameters were measured?

The participants were divided into two groups — a control group that went through traditional training and an experimental group that went through the FSRS curriculum.

Both groups were asked to perform three tasks on the da Vinci robot: ball placement, fourth-arm manipulation and suture pass. Several metrics were compared, such as the time to complete the task, number of slips, arm-to-arm collision, the number of times the clutch and camera were used and the number of times the instrument went out of view.

Following the study, the control group was given an opportunity to finish the FSRS curriculum on the RoSS and repeat the test again.

Image Credits: Doug Levere/University at Buffalo.

What were the main findings from this study and what does it indicate about the performance of robotic-assisted surgeries?

Our research showed that trainees who complete a structured, simulation-based curriculum are more competent in performing the fundamental tasks of robot-assisted surgery as a result of that training, and execute those steps much more accurately and more successfully than those who do not train on the curriculum.

The field of robotic surgery by and large has failed to fully deliver in the area of patient safety, and that’s because we have not adequately stressed the importance of training and learning.

This study drives home the message that we have to develop structured training programs and curricula so that surgeons who are going to be performing robot-assisted surgeries can do so safely, that they have mastered the use of the robotic console before they start operating on patients.

How will this structured curriculum benefit the practitioner?

A structured curriculum helps practitioners to care for their patients safely — the first and most important tenet of robot-assisted surgery.

But a structured curriculum is only the first step. Finishing the FSRS curriculum does not make someone an expert surgeon, it only gives him or her a basic feel for how to safely operate these machines. The trainee’s confidence increases as his or her competence increases, and that helps to make them more comfortable and composed when they get to the operating room.

How is the introduction of surgical robotic technology transforming the way practitioners handle patient care?

I don’t think surgical robotic technology is dramatically transforming the way practitioners handle patient care. The mental considerations for a surgeon and the key elements of how you should interact with your patient, those don’t change with technology.

What surgical robotic technology brings into play is that, by bringing scientific and technological advances to surgery, it can lead to better outcomes in terms of magnification, less pain and smaller incisions. So when it’s used appropriately — for the right patients, and by surgeons who’ve been adequately trained in robotic procedures — then it can make significant impacts on patient outcomes and quality of life.

Will this curriculum be integrated into all institutions that offer robot-assisted surgeries?

The FSRS curriculum has been scientifically validated and hence is available to any institution interested in establishing a formal training program.

Several leading training programs in the U.S. and abroad have already adopted the curriculum. We hope that most institutions that train surgeons or offer robotic surgeries will adopt it in the future.

Robotic surgery is common in urology and gynecology. If this curriculum and surgical technique is ingrained in the residents, is there a risk that the younger doctors may not be trained to perform traditional open surgical procedures?

The traditional open-surgery skills have to be there for a surgeon to learn how to deal with surgical principles. The basic surgical tenets are always dependent on safe acquisition of surgical skills. We always have to think of doing things safely, for the patient’s interest and benefit.

As surgeons master these newer technologies and get enough experience to the point that we’re all experts, we will slowly start letting go of our traditional open-surgery skills. This might be hard to imagine today, but a few decades from now that’s how it’s going to be.

What are the main areas of application for surgical robots?

Surgical robotics is growing at a rapid pace. Currently, the da Vinci Surgical System — the only surgical robot in clinical use — is used mainly in urological, gynecologic, colorectal, head and neck and thoracic surgeries.

Are there any emerging applications for surgical robots?

Image-guided robotic surgery is an emerging application. This technology is helping to improve accuracy of biopsy for brain tumors. And endovascular surgery for percutaneous coronary intervention is another new area of robot-assisted surgery.

Do you think that research in this field could be progressing too quickly to take into account the risks associated with this technique?

The current clinical application of robotic surgery is a result of development of many years, and hence is not premature by any standards.

While every technology has some risks, in my opinion, it is no more dangerous than traditional procedures. However, I think the training required to utilize such advanced technologies has not received enough attention, and this continues to be a major hurdle.

Can you describe what you think next-generation surgical robotics will be able to deliver over the next decade?

I think the future surgical robots will be more intelligent, easier to control and better integrated with imaging technologies, giving surgeons much more flexibility in terms of planning and execution of the procedure.

We will also see more flexible-arm robots capable of accessing regions of human body that are out of reach of current surgical robots.

About Professors Khurshid Guru and Thenkurussi Kesavadas

Khurshid Guru, MD, is Robert P. Huben Professor in Urologic Oncology and Director of the Center  for Robotic Surgery at Roswell Park Cancer Institute (RPCI). Thenkurussi Kesavadas, PhD, is a Professor of Mechanical and Aerospace Engineering and Director of the Virtual Reality Lab at the University at Buffalo (UB).

They are co-founders of Simulated Surgical Systems LLC and co-developers of the Robotic Surgery Simulator (RoSS), one of the first simulators to accurately simulate the da Vinci Surgical System.

Drs. Guru and Kesavadas, along with collaborators from the Henry Ford Health System, the Cleveland Clinic and Kings College, London, UK, developed the Fundamental Skills of Robotic Surgery (FSRS) curriculum as a way to train surgeons in the basics of robot-assisted surgery.

In a study published in Urology in April, Drs. Guru and Kesavadas reported that 53 participants trained in the FSRS curriculum executed key skills with greater precision than those who did not receive training. “The implications for improvements in patient safety and long-term outcomes,” Dr. Guru said in a press release announcing the study, “are tremendously encouraging.”

For further information please visit personal website for both Professors Khurshid Guru and Thenkurussi Kesavadas.

References

• Stegemann A.P., et al. Fundamental Skills of Robotic Surgery: A Multi-Institutional Randomized Controlled Trial for Validation of a Simulation-based Curriculum. Urology. 2013;81(4):767-774.
• Simulated Surgical Systems LLC