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#19 – Minimally Invasive Surgery

Simulators Guide 21st-Century Robotic Surgery Training

da Vinci simulator (Courtesy of Intuitive Surgical)

As robotic surgery proliferates across the globe, a handful of research scientists are leading the charge for high-quality training. No consensus exists yet on the best teaching methods, but one thing is clear. Robotic surgery is a major departure from all other surgery before it, in its use of remote operation, robotic arms, and team communication that is not face-to-face. Accordingly, training has to be revamped.

Techniques First Used in the Military

“The paradigm of see-one, do-one, train one no longer fits in learning robotic surgery,” Roger Smith, PhD, robotic scientist and Chief Technology Officer at Florida Hospital Nicholson Center, Celebration, Florida, told MedicalExpo e-Magazine. Relying on simulation techniques first used in the military, Nicholson is able to train many cost-effectively. The Nicholson Center is a major hub for research and training in robotics. It houses the largest medical robotics simulation center in the world.

The training program uses da Vinci robots from Intuitive Surgical, da Vinci Skills Simulator or “backpack” along with Mimic Technologies dv-Trainer software. With grants from the US Department of Defense and an unrestricted grant from Intuitive Surgical, makers of the da Vinci Robot, Smith’s team is leading the way towards standardized, education and training for robotic surgeons.

Unique Challenges

Smith and robotic scientist Alyssa Tanaka at Nicholson described the unique challenges that robotic surgery poses in operating safely in an interview with MedicalExpo e-Magazine. Notably, the surgical team does not work face to face, as the lead robotic surgeon and assistant are looking at consoles, with other members of the team across the room at the bedside. Part of the training is geared towards making sure that team members are working in accordance with the World Health Organization Safety Checklist.

Trainees are taught “how to interact, to close loops, and how to check back for assistance during surgery,” said Tanaka.

The stakes are high when doing robotic surgery in the abdomen and errors must be avoided. Therefore, a very routinized briefing, intraoperative, and recovery checklists are used to ensure all team members are on the same page.

Besides sitting at a remote console to operate robotic arms and foot pedals that guide the surgery, “robotic arms permit far more freedom of movement and strength than human hands,” added Smith.

Simulators Teach Fine Tissue Manipulation, Control

Even though the Nicholson Center has 6 da Vinci robots, the training is done with simulators primarily, which offer students far more engagement in how they will work than would six robots spread over many trainees.  “We are able to put seven core exercises into one device that is portable, storable, and reusable and doesn’t tear up,” Smith said.

The simulators do a great job of manipulation.

The training approach is often compared to video games, but the similarities are more in terms of it having a video game graphics engine and its basic input mechanics, according to Tanaka. Students are asked to pick up reach in and grab some colored clips, pick up a ring without disturbing a blood vessel, and with the foot peddle, they are taught to cauterize a very small area.


da Vinci simulator (Courtesy of Intuitive Surgical)

Students do develop facility, as in a game, with tests like “ring and rail” or “suture sponge”, said Tanaka. “What we are looking for is learning to do this better over time,” she explained.

Basic skills covered include knot tying, dissection, and suturing, which become progressively more difficult. Skill acquisition is broken down into three areas: cognitive, psychomotor, and team communication. Ergonomics are also important because robotic surgeons sit at a console for long periods of time doing surgery.

The curriculum is discussed at the Fundamentals of Robotic Surgery webpage at With further research and testing, Smith and Tanaka hope that specialty societies endorse the training and use it for credentialing.


About the Author

Laura Newman is a New York-based medical writer that writes frequently about medical technological advances and health policy. She writes for the medical trade press, national health entities, and health care insurers.

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