Simulation is increasingly recognized as being an important component when learning how to drive a surgical robot. However, very little discussion has been held about where the best place is to learn and does the location of the simulator make a difference in its utilization.
Essentially there are three places where simulation can be used for training:
• Inside the OR using the actual robot console connected to a simulator
• In a dedicated space outside the OR, such as a Sim Center, using a surgeon console emulator
• Wherever you can find an appropriate space using a portable simulator
Let’s look at these options in a little more detail:
Inside the OR
Back in 2010, Mimic helped Intuitive Surgical develop a simulation training product that uses the da Vinci® Surgeon Console. The da Vinci® Skills Simulator can be attached to a robot’s second console or the primary console.
The second console is a device where a second surgeon can sit and watch the operative field and have the same immersive feel as the primary surgeon. Although not a simulator, it can be an effective training tool. The users can swap controls of the robotic arms between the two consoles so the student can be allowed to intervene at the appropriate time while proctor can regain control as necessary. As long as space is not an issue, it is felt that the use of a second console helps with the overall efficiency of an OR hence their popularity; approximately 20% of all da Vinci® Systems are sold with a second console, although the percentage is higher on the new Xi systems and also in the US. In theory, a second console can be moved outside of the OR when not in use, which would allow for training both inside and outside the OR. Practically speaking, the second console can be cumbersome to move and is rarely moved outside of the OR. The primary console rarely leaves the OR. Even so, 50% to 60% of customers purchasing a single console robot also purchase a da Vinci® Skills Simulator with their system.
The advantage of the Skills Simulator is that it uses the real surgeon console for input, which means the hardware fidelity is 100%. The downside is that Skills Simulators are almost always in the OR and not always accessible. The more successful the robotic program, the less time there is to use the Skills Simulator in the OR because case volume dominates OR usage. Also, some institutions also do not like giving people access to the OR outside of the normal working day. A common concern is that the system may not be shut down properly, which costs OR time the next day, or worse, the console cable may be damaged as the trainee switches it between the real robot and the simulator.
Outside the OR
Many larger institutions have been fortunate enough to invest in dedicated simulation centers. These vary from small dedicated rooms to large purpose-built buildings. These have been good locations for console emulator products such as Mimic’s dV-Trainer®. The positive is that these are often in a location that is accessible 24/7 and are often supported by dedicated staff that have knowledge of the systems and can act as proctors. The downside is that some of these centers are not in a convenient location, which will act as a deterrent to utilization. Some users are also looking for higher fidelity than the 85% to 90% offered by the dV-Trainer®.
It is still too early to say where will be the best location for a portable simulator, but the picture below illustrates just how versatile the FlexVR™ simulator is. It can be set up on nearly any table, including a spare table in the hall outside of the OR! The fidelity of the FlexVR™ has not been independently measured, but without force feedback to help hold ones hands in the air, it is expected that fidelity will fall just below Mimic’s dV-Trainer®.
The real question is, does location influence usage?
One of Mimic’s high utilization customers has been using simulation for over 5 years. They have systems in the OR, in a separate room in the OR area, and in the sim center located 2 blocks away. We have been able to track the usage of all three systems. The graph below shows the number of sessions carried out on the simulator over the past 5+ years. In total, over 200 users have done 16,000 exercises spending on average around 4 hours each on the simulator.
As we can see, the most simulation was carried out when the first system was installed. After a dip in 2013, simulation has evolved into a steady average of around 2,500 sessions per year.
The graph above shows the relative usage between the different simulators. Beginning in 2007, the dV-Trainer® was the only option and all the simulation activity took place outside of the OR. In 2011, the Si Skills Simulator was made available for training with the surgeon console. This led to an initial reduction in the usage of the dV-Trainer®, though over the next 3 years the two systems were used evenly. During 2016, the da Vinci® Xi began to supplant the Si and a new Xi Skills Simulator was required. The initial usage of the DVSS for the Xi was high, however, as time has gone on, the usage has decreased and been replaced by usage of the dV-Trainer® which accommodates both Si and Xi simulation.
It is still too early to say how simulation utilization will be affected by Mimic’s release of the portable FlexVR™ simulator. However, drawing a parallel to training inside the OR versus outside the OR, it is expected that more access will lead to higher utilization. All said, simulator access is an important consideration when deciding where to locate a simulator and the beauty of the FlexVR is that location is no longer a primary concern – the price, size, and portability make it a system that can be used virtually everywhere!