Training for New Techniques and Robotic Surgery in Minimal Access Surgery

© Springer-Verlag London 2015
Nader Francis, Abe Fingerhut, Roberto Bergamaschi and Roger Motson (eds.)Training in Minimal Access Surgery10.1007/978-1-4471-6494-4_9

9. Training for New Techniques and Robotic Surgery in Minimal Access Surgery

Jung-Myun Kwak  and Sungsoo Park 

Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine/MIS & Robotic Surgery Center, Korea University Medical Center, Inchon-ro 73, Seongbuk-gu, Seoul, 136-705, South Korea

Division of Upper GI Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine/ MIS & Robotic Surgery Center, Korea University Medical Center, Inchon-ro 73, Seongbuk-gu, Seoul, 136-705, South Korea



Jung-Myun Kwak


Sungsoo Park (Corresponding author)

TrainingSimulationRobotic SurgeryMinimal Access Surgery


Laparoscopic surgery, which was regarded as an innovative technique over the past two decades, is now more often considered “traditional” or “conventional” in many comparison studies. The growing enthusiasm for even less invasive surgical techniques has led laparoscopic surgeons to try to reduce the number of skin incisions or even avoid them altogether, with single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) emerging as experimental alternatives to conventional laparoscopic techniques [13]. These methods are becoming increasingly popular among surgeons and the field is expanding. Development of new techniques and technological advances in laparoscopes, instruments, and ports have enhanced the potential for use of SILS and NOTES in a wide variety of surgical procedures, and since Kaouk et al. reported the first successful series of robot-assisted SILS in humans in 2009, there has been a growing interest in development and application of robot-assisted SILS in several surgical specialties [4].

Robotic surgery is increasingly implemented to overcome the technical drawbacks and steep performance- or proficiency-gain curve of traditional laparoscopic surgery. Among the perceived advantages of robotic surgery are the three-dimensional vision, the availability of seven degrees of freedom of movement that truly mimics the movements of the surgeon’s hands, a lack of tremor, and the ergonomics of the robotic surgical system. The number and variety of robotic surgical procedures continues to grow, and clinical outcomes are now sufficiently mature to demonstrate safety, efficiency, and reproducibility of some procedures, as well as addressing oncologic and functional outcomes [57].

However, at present, there are no standard guidelines for training or safe adoption of robotic techniques. To keep pace with the recent technical and technological advances in minimal access surgery (MAS), training and credentialing paradigms are shifting from traditional mentor-trainee tutorships towards standardized objective and, ideally, safer training programmes. There is a growing consensus that education in MAS should be expanded and begin outside the operating theatre, and that more objective assessment of a surgeon’s skills should be introduced to ensure quality of care [8]. Separately, supplementary education for surgeons who have already completed training is also necessary. Designing a training programme to allow experienced surgeons to safely and efficiently implement new technologies and state-of-the-art surgical techniques is essential.

This chapter describes education and training modalities for new MAS and robotic surgery techniques that will support establishment of optimal training programs.

Simulation-Based Training

The adoption of any new technique or new technology comes with the potential risk of injury to the patient. The evolving field of MAS and the need for patient safety requires surgical training by standardized curricula with simulation-based components. Preclinical simulation-based training has been proposed as a useful means of training, and should be considered before new surgical techniques or technologies are applied to actual patient care [9]. The American Board of Surgery now requires that all general surgery graduates provide documentation of successful completion of Fundamentals of Laparoscopic Surgery (FLS) course before sitting for board certification exams [10]. The FLS course is a comprehensive web-based education module that includes a hands-on skills training component and an assessment tool designed to supply fundamental knowledge and teach the physiology and technical skills required for basic laparoscopic surgery. The program features a simulation-based skills laboratory with uniform metrics and assessment criteria.

In addition, the literature suggests that for complex surgical procedures, simulation outside the operating theatre in specially equipped training facilities, such as animal or surgical skills laboratories, may improve the performance- or proficiency-gain curve [1113]. Traditional and innovative simulation-based training methods that encompass both surgical tasks and skills without risk to patients should be considered when establishing a training programme.

Knowledge Development

Before implementing a new technique or technology, it is essential for the surgeon to gain basic knowledge of appropriate patient selection and indications, proper pre-operative preparation, patient positioning and trocar placement, types of complications and their management, as well as to understand the new devices and equipment. Trainees should be fully aware of procedural steps for a new technique.

In this regard, the manufacturer of the da Vinci robotic surgical system has established training centers worldwide to provide an introduction to the robotic surgical system and preparation for its use, as basic product training before clinical training. Thus, trainees have the opportunity to acquire knowledge and understanding of the technology, devices, basic functions and limitations of the system.

Structured Inanimate Skills Tasks

Inanimate models (box trainers) are available for minimal access surgery, and can be helpful to trainees. An inherent problem with training on these models, however, is that the training is heavily dependent on the trainee. Unless a mentor is available to monitor a given trainee’s progress on an inanimate trainer, which is usually not the case, the trainees are left to assess their own surgical skills, and overestimation of skill acquisition is likely.

Virtual Reality Simulator

A virtual reality (VR) simulator is a useful training tool, particularly for minimal access surgical techniques and robotic surgery. It has now been proven with level 1 evidence that VR simulation-based training can improve operating room performance among surgical residents who are preparing for laparoscopic cholecystectomy [14]. In contrast to the inanimate trainer, a VR simulator provides a computer-based platform with artificially generated virtual environments. It can also provide a virtual instructor and apply standardized metrics to assess performance and identify errors and areas of improvement to promote proficiency.

A number of factors in the current surgical environment have prompted the development of simulators. Concerns about operative times and economic issues can limit a surgical trainee’s experience in the operating room, and having the novice surgeon achieve a certain level of competency before participating in actual operating room procedures has been proposed as method of improving efficiency and safety in the operating room [1517]. Other issues surrounding surgical training include medico-legal concerns, limits to the number of work hours permitted for trainees, and ethical considerations related to a trainee learning basic skills on humans and animals [18]. Since developments in computer technology have now led to the introduction of VR simulators that allow standardized and objective training and evaluation of surgical skills, many of these issues can potentially be avoided [19].

Robotic surgical training presents some unique challenges in comparison to laparoscopic training. While good hand-eye-coordination is necessary for laparoscopic surgery, robotic techniques require different skills involving foot-hand-eye coordination in order for the surgeon to manage the robotic console. Dry laboratory practice with robotic instruments for exercise of these psychomotor skills requires the purchase of a separate robot system for training purposes. Robotic surgical training with a live animal model or a fresh frozen cadaver is generally too expensive for regular training practice. Furthermore, traditional supervised interventions on patients are potentially hazardous during robotic surgical training. During conventional laparoscopic surgery, the mentoring surgeon is adjacent to the trainee, has the same view of the procedure, and can take over at any given moment where patient safety may be compromised. However, as only one surgeon can be at an operating console (although some alternatives are discussed below), this is usually not the case in robotic procedures [20].

Therefore, the use of a VR simulator is an appealing option for robotic surgical training. The VR simulator provides surgeons with safe and extensive training in preparation for surgery on patients, and presently it offers the greatest potential for improved surgical skills. Surgical skills training in a virtual environment has a significant learning effect and the learned skills are consistent with and transferable to actual robotic procedures [2123].

There are several commercially available high-fidelity VR simulators. The RossTM, manufactured by Simulated Surgical Systems (Williamsville, NY, USA), has both validated basic orientation modules and basic skill modules. It is the only robotic surgery simulator featuring full-length surgical procedures and has a patent-pending procedural task for robotic prostatectomy. Other procedural components are also being developed [24].

The dV-TrainerTM by Mimic Technologies (Seattle, WA, USA) was the first commercially available simulator for robotic surgery. Several validation studies have demonstrated face, content, construct, and concurrent validity (chapter 2) of this VR simulator [2528]. Through a partnership with Intuitive Surgical, Inc. (Sunnyvale, CA, USA), the manufacturer of the da Vinci robotic surgical system, the dV-TrainerTM uses the da Vinci robot kinematics, instrument design, and vision display. The dV-TrainerTM software is suitable for use within the robotic console, allowing virtual tasks to be performed in a real-life environment. There are more than 50 exercise modules, but currently there are no procedural components.

The da Vinci Skills SimulatorTM was presented by Intuitive Surgical in partnership with Mimic Technologies to integrate the software of the dV-TrainerTM into the da Vinci Si console through the backpack. Thus, there is no actual hardware for this VR simulator, and the actual da Vinci Si console becomes the hardware. As with dV-TrainerTM, there are no procedural components.

Surgical Tasks in a Live Animal Model

The live animal simulation model has been considered one of the most important components of training in robotic surgery and has been incorporated in several courses [2931]. Although the anatomy is different, operating on an animal model provides good replication of the visco-elastic properties of human tissue and its response to manipulation, dissection, ligation, and other operative manoeuvres. However, live animal simulation models are costly and veterinary assistance and separate equipment and location are required. Furthermore, it may raise ethical concerns.

Nonetheless, the live animal model is still considered the simulation model with the highest fidelity in terms of close replication of intra-operative conditions, even as wet laboratories are limited and many surgical trainees will complete their training without an opportunity to operate on an animal model.

Surgical Tasks in the Fresh Frozen Cadaver

The fresh frozen cadaver simulation model has the advantage of presenting real human anatomy and can be useful for procedural training. Surgical anatomy, tissue consistency, and anatomical planes are usually well preserved, and participants report high levels of satisfaction [32].

However, such a training programme is not easily reproducible, and is costly, requiring special preparation and separate equipment, as with the live animal simulation model. Another limitation is the lack of in vivo physiology such as bleeding and actual tissue compliance. There is a paucity of studies exploring the true effectiveness of fresh frozen cadaver training [33].

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Sep 26, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Training for New Techniques and Robotic Surgery in Minimal Access Surgery
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