The Value of Procedural Simulation and the Maestro Approach

Growing in popularity, robotic surgery is still not without challenges. Before the benefits of robotic surgery can be fully realized, the highest level of patient safety must be ensured, while remaining cost effective and at the same time allowing new surgeons the ability to be trained and access the technology without impacting safety and cost-effectiveness.

The Halstedian Method of “see one, do one, teach one” is clearly no longer sufficient for surgical training. Many comparisons between the training of pilots and the training of surgeons have been made over the years. In 2013, the FAA updated their rules to state that to be qualified as a First Officer, a pilot needed 1,500 hours total time. This includes both real and approved simulation time. Looking at a typical Resident training program, the calculations for a general residency that will last 4 years is approximately 16,600 hours. If within this a surgical trainee chose to focus on Gynecology for 20 months they would receive 6,400 specialty hours. If a surgeon focused on minimally invasive surgery, such as robotics, the Accreditation Council for Graduate Medical Education (ACGME) guidelines recommend 105 hours exposure to a variety of cases. Even tripling this minimum, a surgeon would be only at 300 hours of surgery, which is only a fraction of the 1,500 hours the FAA recommended training time for pilots.

Just as in aviation, simulation has been seen to be a solution allowing surgeons to develop their skills without impacting patient safety. Mimic’s MSim software, found on both the dV-Trainer and the da Vinci^® Skills Simulator, has been one of the most researched and validated simulation software in the surgical field. Table 1 below shows the range of validation studies that have been carried out on either platform as well as other simulators.

The studies, and in a particular the predictive validity study looking at simulation and operative outcomes, carried out by Dr. Culligan, have helped shape recommendations for surgical training being developed by medical societies such as those developed by the American Association of Gynecologic Laparoscopists (AAGL) in 2014.

All of these studies and simulation programs focused on the psychomotor component of learning how to “drive the robot” and not necessarily the cognitive training requirements that would help train the next generation of surgeons. Augmented reality was developed under the Maestro AR name to help solve this issue. It is best to think of Maestro AR as a curriculum incorporating both psychomotor tasks and cognitive questions supported by a moderated guide on a procedural approach and technique.

The basic premise is that a student will learn more if the psychomotor skills that they require are placed within their procedural context as opposed to in a vacuum. As students are learning how to use the robotic device they are also being tested on tissue recognition, procedural choreography, as well as learning from the narration about the decision making process behind this specific approach.

The Benign Hysterectomy Maestro AR module, for example, is divided into 9 modules starting with a Pelvic Anatomy survey and working through clear steps on how to deal with the ligaments and uterine vasculature before finishing with the Colpotomy and the Vaginal Cuff Closure.

“Maestro AR addresses the next frontier of training by developing a pathway that incorporates Didactics with Augmented Reality through virtual reality simulation,” says Mireille Truong, Virginia Commonwealth University Medical Center, “I am confident that research will show that adding didactic elements to simulation training will continue to improve surgeon performance when they enter the OR.”

As with the airline industry, simulation is becoming a vital part of the armarmentarium required for surgeons to ensure that through all stages of their career, they have the correct level of skills for the task ahead of them. Just as pilot is able to land a plane in virtually any airport around the world on their simulator, it is hoped that surgeons will also be able to develop their skills within a procedural scenario in an augmented reality environment.