Robo-Simulator Gives Shaky New Surgeons The Strokes Of Smooth Operators

Hands on surgical training (HoST) actually helps move the hands of surgeons in training to help them experience what it's like to make the cut. But are they actually learning?

surgery haptics

A teaching method that allows novice med students to instantly move with the same dexterity as the world's most seasoned surgeons sounds like the kind of science fiction quackery that'd get patients killed. But it's real.

Acting as a virtual master surgeon, an advanced software program called HoST (Hands on surgical training) can use a robotic surgical simulator to physically guide the hands of novice surgeons in the exact same movements utilized by experienced surgeons to perform extremely complex operations.

It's the latest innovation of Dr. Thenkurussi Kesavadas, Head of the Virtual Reality Lab, University of Buffalo and Dr. Khurshid A.Guru, Director of the Center for Robotic Surgery, Roswell Park Cancer Institute, who jointly released what they call a "flight simulator for robotic surgery" early last year. The RoSS (Robotic Surgical Simulator) simulates the operations of the only robotic surgical system in existence, the da Vinci, and the new HoST software takes it to the next level by using augmented reality based real-time operative scenarios and a form of haptic feedback to help the trainee "feel" the movements made by an experienced surgeon.

"Two robotic devices hold the hands of the trainee and guides him or her through the complex motions required to carry out the surgical steps," said Dr Kesavadas. "The software immerses the trainee into a real surgical scenario based on a real case performed by master surgeons."

Augmented scenarios also allow the trainee to get a feel of how actual organs and tissues move. The software virtualizes the entire procedure making the video only part of the mix; the surgical view is merged with anatomical drawings, text and audio instructions, and graphical cues which are overlayed with the haptics. This is a far cry from the cartoon-like virtual images rendered by the handful of robotic surgical simulators out there.

"The HoST system is nothing less than a game-changer in the world of surgical education," says Dr. Ronney Abaza, Director of Robotic Urologic Surgery, OSU Medical Center and James Cancer Hospital, Ohio. "Why nobody thought of it before is hard to fathom in hindsight."

The system works by recording every single movement that a surgeon makes during an operation with the da Vinci robot. This is stored as procedure, which the trainee selects from a menu. The software operates in a checklist mode, guiding the trainee through the movement, stops, and asks them to take over. It only proceeds to the next step if the movement is done correctly. Currently it stores procedures for four different types of minimally invasive, robot-assisted surgeries--removing the prostrate gland, uterus, bladder, and lymph-node dissection; the eventual goal is to develop a huge library of procedures to train surgeons in a variety of surgical procedures.

Robot-assisted surgical training has become increasingly critical, since increasing numbers of people are opting for this type of surgery with its promise of smaller incisions, quicker recoveries, and less pain. However, the one million dollar plus da Vinci robot can't really be used for extensive training by the hospitals that can afford them. The machine itself requires training. "Some surgeons with extensive robotic experience say it takes at least 200 surgeries to become proficient at the da Vinci and reduce the risks of surgical complications," the Wall Street Journal recently reported.

Robotic surgical simulators have helped partially bridge the gap between the cost-effective uses of surgery bots, but virtually simulating the actual movements of organs has never been precise or realistic enough to make them right for training.

"It is time we gave up on VR for surgical training--the HoST system allows a view of real anatomy, bleeding, and tissue characteristics that would take an immense amount of programming to replicate," says Dr. Abaza. "The real point of simulation is not to show that we can make a simulation that looks real, but to teach our surgeons in training how to make the connections between their brain and hands to execute the complex steps of an operation." And it's that rigorous, step-by-step process that others find most effective.

"Checklist-based learning, a lesson medicine is learning from the military. i.e. to do things 'by the book' though check listing vs. memory, which can be faulty when fatigued or stressed and performance metrics to track progress is a good idea," says Dr. Tony Errichetti, Chief of Virtual Medicine, New York College of Osteopathic Medicine, New York. "The ability to 'prescribe' specific problems (i.e. creating scenarios) for physicians to practice their skills as needed or warm up before surgery is also a big plus."

Like any new technology, particularly where actual lives are at stake, not everyone is eager to leap forward with this system.

"Surgery does not get taught in 'passive' mode while a surgeon is guiding your hand. It is taught on 'active' mode while the trainee him or herself learns how to train the muscles to perform an effective motion," says Dr. Eduardo Mendez, Assistant Professor, Department of Otolaryngology, University of Washington, Seattle. "I would be concerned that 'guiding' a surgeon's hand through this process could hamper that active 'try and re-try' process which is so critical for learning, and it might be too constricting."

Dr. Guru agrees but says the safety of the patient is paramount, and he adds that the majority of their tries should be performed outside the body of the patient in order that they may succeed within. "This technology creates that bridge," he says.

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