Proficiency Training On a Virtual Reality Robotic Surgical Skills Curriculum

Justin D Bric, BS, Michael J Connolly, BS, Matthew I Goldblatt, MD, Andrew S Kastenmeier, MD, Jon C Gould, MD. Department of Surgery, Division of General Surgery, Medical College of Wisconsin.

INTRODUCTION: This study sought to evaluate proficiency based virtual reality simulation training in developing robotic surgery skills. The clinical application of robotic surgery is increasing, and the skills necessary to perform robotic surgery are unique from those required in open and laparoscopic surgery. A validated laparoscopic surgical skills curriculum (Fundamentals of Laparoscopic Surgery or FLS™) has transformed the way surgeons acquire laparoscopic skills. There is a need for a similar skills training and assessment tool specific for robotic surgery. Our research group previously developed and validated a robotic training curriculum in a virtual reality (VR) simulator. Proficiency levels were established based on the trimmed mean performance of experienced robotic surgeons. We hypothesized that novice robotic surgeons could achieve proficiency levels on the VR robotic curriculum, and that this would result in improved performance on the actual daVinci Surgical System™.

METHODS AND PROCEDURES: Twenty-four medical students with no prior robotic surgery experience were recruited. Prior to VR training, subjects performed 2 FLS tasks 3 times each (Peg Transfer, Intracorporeal Knot Tying) using the daVinci Surgical System™ docked to a video trainer box. Task performance for the peg transfer tasks was assessed according to the formula: 300 – [time to complete (sec)] – [penalty for dropped pegs]. For the knot tying task, the formula was: 300 – [time to complete] – [penalty for slipped or loose knots]. Subjects then practiced on the VR simulator (daVinci Si™ Surgeon Console and Mimic™ simulator) until proficiency levels on all 5 selected tasks (Pick & Place, Camera Targeting 2, Peg Board 2, Matchboard 2, and Suture Sponge 3) were achieved before completing a post-training assessment of the 2 FLS tasks on the daVinci Surgical System™ in the video trainer box.

RESULTS: There was a significant improvement in performance on the FLS tasks following completion of the VR training curriculum. Subjects reached proficiency on all VR tasks in an average of 71 (± 21.7) attempts, accumulating 164.3 (± 55.7) minutes of console training time. Following completion of the VR training curriculum, there was no significant difference between subjects and experienced robotic surgeons on the Peg Transfer task (220.9 vs. 229; p=0.36); however experienced surgeons significantly outperformed trained subjects on IC knot tying (213.5 vs.104.7; p<0.001). 

Mean Peg Transfer and IC Knot Scores Pre and Post VR Proficiency Training
n=24Peg ScoreIC Knot Score% Successful Knots
Pre VR Training175.5 ± 54.120.2 ± 40.038% (27/72)
Post VR Training220.9 ± 25.0104.7 ± 56.488% (63/72)

CONCLUSIONS: Novice robotic surgeons are able to train to established proficiency levels on a VR simulator. Training to proficiency on a simulator leads to improved performance in the actual daVinci surgical platform on simulated tasks. Training to proficiency on a VR robotic surgery simulator is an efficient and viable method for acquiring robotic surgical skills.

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