Surgical Robotics and Laparoscopic Training Drills

JOURNAL OF ENDOUROLOGY Volume 18, Number 1, February 2004 © Mary Ann Liebert, Inc. Surgical Robotics and Laparoscopic Training Drills RICHARD SARLE, M.D., ASHUTOSH TEWARI, M.D., ALOK SHRIVASTAVA, M.D., JAMES PEABODY, M.D., and MANI MENON, M.D., FACS ABSTRACT Purpose: We investigated the impact of robotics on surgical skills by comparing traditional laparoscopy with the da Vinci Surgical System in the performance of various laparoscopic training drills. Subjects and Methods: Twenty-one surgeons performed eight timed drills of increasing difficulty with a laparoscopic trainer and the da Vinci Surgical System (Intuitive Surgical Sunnyvale, CA). The mean time to drill completion, drill time variance, and statistical analysis were performed. Surgeons were also questioned about their perception of the robotic technology following completion of the drill series. Results: The mean time required to complete the first drill was 69 seconds with laparoscopy and 57 seconds with the robotic system. The mean times for drill two were 67 seconds with laparoscopy and 44 seconds with robotics; for drill three, the times were 88 seconds for laparoscopy and 61 seconds for robotics, and for drill four, 186 seconds with laparoscopy and 71 seconds with robotics. Only the first drill failed to show a statistically significant difference between the laparoscopic and robotic groups. Conclusions: The robotic system allowed surgeons to complete drills faster than traditional laparoscopy. Novice laparoscopic surgeons performed three of the four drills faster robotically than did expert laparoscopic surgeons. These findings may indicate that the attributes of the robotic system level the playing field between surgeons of different skill levels. The next generation of surgeons must focus on this evolving technology and its application in the operating room of the future. with traditional laparoscopic techniques objectively. This study will require surgeons to identify those complex surgical maneuvers that would benefit significantly from use of robotics. With this aim in mind, we designed a series of robotic and laparoscopic exercises involving surgeons with various levels of laparoscopic experience. The results are presented herein. INTRODUCTION OBOTIC TECHNOLOGY may reduce the learning curve for complex laparoscopic procedures, leveling the playing field between open-surgery practitioners and laparoscopists. The attributes of robotics, such as motion scaling, three-dimensional visualization, and articulated instrumentation, allow complex reconstructive procedures to be performed with greater dexterity, more quickly, and more easily by a greater number of surgeons. With only four of six degrees of freedom in traditional laparoscopy, the acquisition of the skills required for reconstructive procedures is extremely time consuming and difficult. Robotic technology allows the surgeon six degrees of freedom and the ability to throw and tie a laparoscopic knot with the same dexterity as the human hand. Even with these theoretical advantages, there are scant data in the medical literature that show that robotic technology can actually improve surgical procedures. Given the cost issues involved, it is both prudent and scientifically appropriate to compare robotic R SUBJECTS AND METHODS Twenty-one general surgeons or urologists participated in this study. Each participant was given a brief introduction to the robot and its controls. Surgeons were divided into three levels based on laparoscopic experience: novice (N 5 6), intermediate (N 5 10), or expert (N 5 5). Three participants had previous exposure to the robot and were placed in the intermediate or expert skill group. The participant’s level of experience ranged from fellowship training in laparoscopy to an intern level surgery resident. Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan. 63 64 SARLE ET AL. TABLE 1. PARTICIPANT SURVEY 1. Which drill set was harder: robotic or laparoscopic? 1a. Did the robot become more advantageous as the drills became harder? 2. Which would you learn faster on, robotic or laparoscopic? 3. What attribute of the robot did you find most helpful: 3-D visual system? Endowrist technology? Camera movements? Other? After the 3- to 5-minute orientation, the drills commenced. We used the da Vinci™ Surgical System (Intuitive Surgical, Sunnyvale, CA) and a standard laparoscopic trainer with video monitor set-up. The mean time to drill completion and the variation in drill completion time were recorded. Participants were surveyed following the completion of the exercise (Table 1). A literature review was performed to examine the various laparoscopic drills used in surgical training programs.1–5 The authors then designed four drills intended to accomplish several goals. The drills increased in complexity, challenged depth perception, and required the surgeon to use both hands. The four drills are pictured and outlined in the appendix and in Figures 1 and 2. The drills were performed in order of increasing difficulty. RESULTS The mean times were faster in the robotic group for all drills. Only the least complicated drill, the pipe cleaner, failed to show a statistically significant difference between the robotic and laparoscopic groups. In the pipe cleaner drill, 10 of 21 surgeons were faster with the robotic system. In the ring drill, 16 of 21 were faster with the robot. In the bead drill, 16 of 21 were faster with the robot. In the knot drill, 20 of 21 were faster with the robotic system. No novice performed any drill faster laparoscopically. Participants were also questioned following completion of the exercise. Nineteen participants found the drills easier to perform with the robotic system than laparoscopically. As the drills became more difficult, surgeons’ perception of the robotics’ superiority over laparoscopy became even greater. Twenty participants felt that the robot would be easier to learn than tradi- A B C D FIG. 1. Pipe cleaner and ring drills. (A) In pipe cleaner drill, surgeon is required to pass pipe cleaner from one tube to other using both hands. (B) Completed drill. (C) In ring drill, surgeon removes ring and transfers it to opposite wire, passing it from one hand to other. (D) Drill half completed. 65 ROBOTIC AND TRAINING DRILLS A B C D FIG. 2. Bead and knot drills. (A) In bead drill, surgeon must pick up beads and place them on a wire. (B) Completed drill. (C) In knot drill, surgeon must remove 8-cm string from alligator clip, thread it through black ring, and tie knot. (D) Completed drill. tional laparoscopy. Half of the participants felt that the threedimensional visualization was an important factor in improving drill times, but all participants felt that the Endo-wrist technology was the most important attribute of the robotic system. DISCUSSION The robotic system allowed participants to perform the drills faster than did traditional laparoscopy. When comparing the novice with the expert laparoscopic surgeon, the robotic system did truly level the playing field. With minimal training, our figures illustrate the degree to which the novice gains in skill when using the robotic system. Another interesting finding involves the small standard deviation within the robotic data when compared with the wide variability of the laparoscopic data. This may reveal that the robotic system has a very short learning curve compared with laparoscopy. Laparoscopic skill increases with practice, and as such, participants had a wide range of skill levels, as shown by the wide standard deviation. But those variances were more than cut in half in the robotic group. The limitations of our study design are several. The baseline skill level of the participants ranged from surgical intern to fellowship-trained laparoscopic surgeon. Skill levels were assigned on the basis of the years of training and the amount of laparoscopy performed by the surgeon. Those with less laparoscopic skill found the robot to be easier and preferable to traditional laparoscopy. Interestingly, only the most senior laparoscopic surgeon found the robotic system to be frustrating at times. Our total study population of 21 included only 5 expert laparoscopic surgeons, and this may limit our conclusions. CONCLUSIONS In the performance of laparoscopic drills, surgical robotics can outperform traditional laparoscopy. Robotic technology can give the novice laparoscopic surgeon the ability to perform at the level of an expert despite minimal robotic training. As surgical robotics become more commonplace, future work should focus on those specific procedures that would benefit most from this new technology. In addition, the techniques we use to train future surgeons should be examined to help determine the optimal method of passing on these unique skills. 66 SARLE ET AL. APPENDIX EDITORIAL COMMENT Drill 1: Pipe Cleaner Drill Two hollow tubes are secured to the surface and placed at a 90° angle to one another. A pipe cleaner is placed in one tube. The surgeon is required to pass the pipe cleaner from one tube to the other and must use both hands (Fig. 1). Completed drill is shown in Figure 1B. Drill 2: The Ring Drill Two rings are placed on wires. The participant is required to remove the ring and transfer it to the opposite wire. The surgeon must pass the ring from one hand to the other. The second ring is then moved. This drill challenges the surgeon’s depth perception, as well as instrument manipulation skills (Fig. 1C). Drill half completed in shown in Figure 1D. Drill 3: The Bead Drill Three beads are placed at the base of the field. The surgeon must pick up a bead and place it on one of the wires. All three beads must be placed (Fig. 2A). Because of the narrow diameter of the bead center, this drill was of increased complexity. Completed drill is shown in Figure 2B. Drill 4: The Knot Drill An 8-cm string is placed through an alligator clip. The surgeon must remove the string and thread it through the black ring and tie one knot. This was the most difficult of the drills (Fig. 2C). Completed drill is shown in Figure 2D. Even the most severe critics of robot-assisted surgery are forced to agree that the future of minimally invasive surgery will certainly be shaped by our robotic “colleagues.” Contemporary robotics, although very expensive, already offers surgeons computer-enhanced skills for complex tasks and facilitates the transition between traditional open surgery and laparoscopy. In this in vitro model, Dr. Sarle and colleagues have nicely demonstrated how the da Vinci robot allows the novice laparoscopic surgeon to perform complex tasks. The data presented are consistent with those of prior in vitro comparative reports.1,2 All studies demonstrate that robot-assisted laparoscopic surgery increases efficiency for complex in vitro laparoscopic tasks, particularly marked improvement being noted in the naïve laparoscopist. These in vitro findings are also consistent with anecdotal clinical reports of traditional open surgeons with little laparoscopy experience performing complex ablative and reconstructive operations by laparoscopy using robotic assistance. In this regard, contemporary robotic technology has been of great value, as an expanded population of surgeons has been able to offer their patients the benefits of minimally invasive approaches. In contrast, the greatest potential advantage of robotic surgery should be outcome based, and greater efficiency, efficacy, or both must be documented. To date, despite several small comparative trials of laparoscopic and robot-assisted surgery, enhancement of the individual surgeon’s abilities to perform procedures has yet to be realized clinically. The few available comparative data confirm the feasibility of robot-assisted laparoscopic surgery, but no advantages have been established, and overall costs and operative times have suffered.3,4 The discrepancy between the significant advantages documented with robot-assisted laparoscopy in vitro and the limited advantages demonstrated clinically to date relates to the procedures being performed, the limitations of contemporary robotics, and the surgeons performing these procedures. The in vitro data consistently demonstrate correlation of the efficiency of robot-assisted laparoscopic surgery with the level of difficulty of an individual exercise. However, few surgical procedures demand this additional level of precision. The majority of the tissue dissection for even highly demanding urologic procedures such as laparoscopic radical prostatectomy and laparoscopic pyeloplasty does not require precision greater than can be achieved with standard manual laparoscopy. Although the technically demanding components of these procedures may be facilitated by robotic assistance, the advantages of robotics for the entire procedure have not been realized. It should be noted, however, that the clinical evaluations of robotics to date have been performed by expert laparoscopists, who would be least likely to benefit from robot-assisted laparoscopy. As demonstrated by the authors, the advantage of contemporary robot-assisted laparoscopy is clear: the open-surgery practitioner can use the three-dimensional imaging and additional degrees of freedom provided by the robot to complete individual complex tasks efficiently. However, clinical data on increased efficiency and efficacy of robot-assisted laparoscopic surgery remain unavailable and speculative. Because of the high cost of robotic systems, the investigative focus should turn to randomized clinical trials comparing manual and robot-assisted laparoscopy. Similarly, our technology partners must work aggressively to reduce the cost and increase the capabilities of robotic systems. REFERENCES 1. Schulam PG. New laparoscopic approaches [editorial]. J Urol 2001;165:1967. 2. Scott DJ, Valentine RJ, Jones D, el al. Evaluating surgical competency with the American Board of Surgery in-training examination, skill testing, and intraoperative assessment. Surgery 2000;128: 613–619. 3. Traxer O, Gettman MT, Cadeddu JA, et al. The impact of intense laparoscopic skills training on the operative performance of urology residents. J Urol 2001;166:1658–1661. 4. Matsumoto ED, Hamstra SJ, Cusimano MD, et al. A novel approach to endourological training: Training at the surgical skills center. J Urol 2001;166:1261–1266. 5. Gill IS. Laparoscopic radical nephrectomy for cancer. Urol Clin North Am 2000;27:718. 6. Shalhav AL, Dabagia MD, Lingeman JE, et al. Training postgraduate urologists in laparoscopic surgery: The current challenge. J Urol 2002;167:2135–2137. 7. Guillonneau B, Jayet C, Tewari A, Vallancien G. Robot assisted laparoscopic nephrectomy. J Urol 2001;166:200–201. 8. Abbou CC, Hoznek A, Chopin D, et al, Laparoscopic radical prostatectomy with a remote controlled robot. J Urol 2001;165:1964–1966. 9. Intuitive Surgical: System sales increase from 2001–2002. Sunnyvale, CA: Intuitive Surgical, 2003. Address reprint requests to: Mani Menon, M.D., FACS Henry Ford Hospital 2799 West Grand Blvd. Vattikuti Urology Institute 9th Floor, Clinic Building Detroit, MI 48202 E-mail: mmenon1@hfhc.org 67 ROBOTIC AND TRAINING DRILLS Finally, until robotic technology becomes cost-effective and globally available, urologic training programs must make efforts to assure that future generations of urologists are laparoscopically skilled. Jaime Landman, M.D. Washington University School of Medicine St. Louis, Missouri vs. standard laparoscopic antireflux surgery. J Gatrointest Surg 2002;6:11–15. 4. Guillonneau B, Jayet C, Tewari A, et al. Robot assisted laparoscopic nephrectomy. J Urol 2001;166:200–201. E-mail: landmanj@yahoo.com We agree with Dr. Landman that the clinical benefits of robotic technology were largely unproven at the time this paper was submitted. However, this is not the case now, at least for robotic radical prostatectomy.1 REFERENCES 1. Prasad SM, Maniar HS, Soper NJ, et al. The effect of robotic assistance on learning curves for basic laparoscopic skills. Am J Surg 2002;183:702–707. 2. Yohannes P, Rotariu P, Pinto P, et al. Comparison of robotic versus laparoscopic skills: Is there a difference in the learning curve? Urology 2002;60:39–45. 3. Melvin WS, Needleman BJ, Krause KR, et al. Computer-enhanced REPLY BY THE AUTHORS REFERENCE 1. Menon M, Tewari A, Vattikuti Institute Prostatectomy Team. Robotic radical prostatectomy and the Vattikuti Urology Institute technique: An interim analysis of results and technical points. Urology 2003;61(suppl 1):15–20.