Despite the fast growth of robotic surgery and its clinical application, as well as the acceptance of this technology as a tool of the modern operative room, the training and education aspect in this field is still at an early stage.

Training new surgeons is expensive, regardless of whether the machine is in a dedicated laboratory setting or if it is shared in a clinical setting. Few models are available for the dry lab and the cost of the instruments is still high. Furthermore it is very complex to assess the skills of the trainee in an objective way.

While there has always been a lot of emphasis on the mechanical characteristics and performance of the robotic system, an important element of this revolution is sometimes missed: the concept of virtuality.

This is one of the most revolutionary features fundamental to robotic surgery and it holds significant relevance for the way in which new surgeons can be trained at the daVinci console.

The surgeon is no longer in direct contact with the patient and the interface is operated by a computer.

The enormous potential of virtuality in robotic surgery training is obvious: a computer can recreate a surgical scenario and replicate the surgical output on a virtual model.

Both easy tasks can be reproduced for novice users and complex procedures can be reproduced for skilled users. Additionally, this can facilitate the objective assessment of skills and can dramatically reduce costs.

Two companies are developing dedicated software and hardware for robotic surgery training: MIMIC (Seattle, WA), with the dv Trainer™, and Simulated Surgical System (Williamsville, NY), with the ROSS™.

Both of these simulators are able to reproduce the robotic instrument kinematics in a realistic tridimensional environment and feature a hardware console that is similar in feel and function to the real daVinci®.

The use of these simulators facilitates familiarization with the console and the way it operates, including the basic troubleshooting. Additionally, it allows users to develop general skills in regards to camera and instrument operation, as well as compensation for the loss of tactile feedback.

Overall, significant advantages of these machines include the opportunity to develop skills in an “off-line” risk-free environment and the ability to objectively asses these acquired skills through a performance metrics system. In addition, this method of training is more cost effective in comparison to a skills lab.

Indeed, a few evaluation studies have been published on the use of these simulators with encouraging results.

As of now the simulation capabilities of this software is restricted to some simple tasks and very limited surgical procedures. The wet labs are still necessary to learn the patient side skills and to develop confidence with robot use in a clinical setting, but the use of the simulator can definitely speed up this clinical transition. It will be a future goal to develop software that is able to reproduce an entire surgical procedure with improved dependability.

Starting from this baseline in virtual training, the close future seems to be even more exciting. For instance, several academic institutions are working on software algorithms that will enable the creation of training models using the actual anatomy of a patient starting from a High resolution CT scan.

In light of this, one can imagine that in the future it will be possible to perform a “warm-up” procedure on the tridimensional anatomical reconstruction of a patient before the “real” surgery.

The digital age keeps changing healthcare and it is changing it for good.

Francesco Bianco, MD

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