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Procedure-Specific Simulation Training: From the OR to the Classroom

Dr. Hung AUA Speech

The following blog post is a transcript of a speech Andrew J. Hung, MD (Director, Surgical Simulation & Education at USC Institute of Urology) gave during this year’s American Urological Association Annual Meeting in Orlando, Florida.

Dr. Hung AUA Speech“Existing robotic virtual reality simulators have been focused on basic surgical skills. This has been a very appropriate entry point for surgeons who want to adopt robotic surgery into their practice. Procedure specific simulation is the next frontier.

In developing Procedure-Specific Simulations we have learned the following:

First, the collaboration between the surgeon and the software developer is absolutely critical.  A surgeon brings to the table an intricate understanding of the anatomy as well as the procedure.  The software developer brings engineering, and very specific technical capabilities, such as the 3D artist who brings our ideas into a 3D environment that’s interactive and engaging.

Second, our whole process starts with the storyboard.  In our case, the robotic Partial Nephrectomy scripted from beginning to end, skin-to-skin, not leaving out a single detail.  And, we record the operating room procedure. The High Definition Stereo 3D is very sophisticated recording device capable of recording the procedure with the absolute highest graphic definition.

Dr. Hung AUA SpeechThird, we then take the whole procedure, edit it, introduce anatomy, and ask users to point out main parts, as a baseline test, before they are allowed to move on to the next step in the operation.  The procedure step leads to another cognitive type question. We ask users ‘what is the next step coming up?’ because it is important to know what to anticipate in the surgeon’s mind.

Finally, because this is now called ‘Procedure-Specific,’ we’re teaching advanced skills such as tissue retraction.  We ask the surgeon, ‘Where do you grab the tissue?’  and ‘which direction do you pull it?’  and ‘with what amount of force should it be pulled?’ The intent is to create tissue manipulation that appears to be real.

Dr. Hung AUA SlideIn the past, procedure simulation was designed by engineers and then validated in retrospect by surgeons.  But now we have flipped this process around. Now, during design development, the surgeons and engineers have to collaborate and really test their user studies.  We invited faculty, expert surgeons, novice surgeons, and we’ve had them form the basic validation steps.  We ask the experts, ‘is this realistic?  Is this going to be a useful training tool?’ And, importantly, we compare and look in very close detail at novice performance versus expert performance because we want to see that there is an ability to distinguish between the two.

We not only look at which questions had a good difference between a novice user and an expert user, but actually focused on the questions that failed to meet current validation.  And we looked at the very visual questions or exercises, and thought about how we could improve this particular question. As a result, we now have the ability to test augmented reality experiences, and this is where more and more procedure specific simulation is going.

AUA Robotic Surgery Training SpeechThe emphasis here is that during development, validation begins.  The more advanced levels of validation, for example being able to bring or correlate the performance on this platform and real tissue, happens immediately as part of the development process. The next few steps that we want to take include integrating global assessment; sophisticated assessment into a procedure specific environment; and, full virtual reality integration.

Today everybody wants to manipulate that tissue.  They want it to be real.  And finally, the ultimate goal of what we do, and I think all of the folks at simulation want to do, is go beyond Procedure-Specific and into Patient-Specific rehearsal.”