Articulus Surgical

Improving Access to Surgical Robotics Training: Challenges and Opportunities

Saurya Mishra — Tue, 25 Apr 2023 04:46:27 +0000

Improving Access to Surgical Robotics Training: Challenges and Opportunities

By : Saurya Mishra

March, 28th 2023

Surgical robotics is a rapidly growing field that has revolutionized the way surgeries are performed. Robotic surgery allows for greater precision, less invasive procedures, and faster recovery times for patients. However, this new technology has limited availability. This is not only due to the high cost of the devices, but also the limitations in training opportunities for medical professionals. The lack of access to surgical robotics can significantly impact medical education and training, making it more difficult for medical professionals to gain the necessary skills and experience to use the technology effectively.

One of the biggest issues with expensive surgical robotics is the cost of training. Surgical residents and fellows are required to complete a certain number of procedures before they can become certified in their specialty.

Contemporary Surgical Training

Training for surgical robots is typically conducted through a combination of theoretical and practical instruction. Theoretical instruction involves classroom lectures and online courses that provide an overview of the robotic system, its capabilities, and its applications. This instruction covers topics such as system setup, calibration, instrument handling, and troubleshooting.

Practical instruction involves hands-on training with surgical simulators, which replicate the experience of using the robotic system in a realistic environment. Simulators allow surgeons to practice their skills and gain confidence in using the technology, without the risk of harming patients. This type of training allows surgeons to become familiar with the robotic system’s interface, the control console, and the instruments, as well as to practice specific surgical procedures using the technology.

Observation of experienced surgeons using the robotic system is another critical aspect of training. This type of training involves watching and learning from experienced surgeons using the robotic system in real surgical procedures. Observing experienced surgeons can help trainees learn the nuances of the technology, such as how to position the robotic arms, manipulate the instruments, and perform complex maneuvers.

Proctored surgical robotics training or expert-led robotics training is often the final leg of robotic training and can be an effective way to ensure that surgeons are properly trained and equipped to use surgical robotics technology. This type of training involves a highly experienced expert who provides hands-on guidance and supervision during the training process. The expert can help the trainee learn the nuances of the robotic system, offer guidance on how to perform specific surgical procedures using the technology and provide real-time feedback on performance. This type of training can help ensure that the trainee is fully prepared to use the technology in a surgical setting, ultimately resulting in improved patient outcomes.

Training for surgical robots is typically provided by the manufacturer of the system or by specialized training centers that have experience with the technology. Ongoing training and education are also required to keep up with advancements in technology and to maintain proficiency in its use. Continuous learning and improvement are essential to ensure the safe and effective use of surgical robots in the operating room.

Limitation of contemporary surgical robotics training

However, the cost of training on a surgical robot is often prohibitive for many institutions. The cost of a single surgical robot can be in the millions of dollars, and maintenance costs and upgrades can add up quickly.

As a result, many hospitals and medical schools are struggling to provide their residents and fellows with the necessary training on surgical robotics, especially in light of the fact that the install base of such systems is very limited as well. This can lead to a shortage of trained surgeons who are capable of using the technology, which can limit the availability of robotic surgeries for patients who would benefit from them. This seems very counter-productive as one of the reasons surgical robots were invented in the first place was to reduce surgical training time and hence improve the availability of skilled surgeons.

In addition to the financial costs of training on surgical robotics, there are also logistical issues that can affect training. Robotic surgeries require a highly skilled team of technicians, nurses, and anesthesiologists to assist the surgeon. This means that training on surgical robotics is not just about the surgeon, but also about training the entire surgical team. Coordinating this kind of training can be difficult, especially if the hospital or medical school does not have access to a surgical robot on a regular basis.

The current state of surgical robotics is creating a self-perpetuating cycle that is hindering its wider adoption. The lack of access to surgical robots is limiting the number of surgeons who can be trained to use the technology. Since surgical robotics requires a proctored training program, the shortage of experienced surgeons means that there are fewer qualified proctors available to train the next generation of robotic surgeons. This situation exacerbates the shortage of trained surgeons, further restricting the spread of surgical robotics.

Additionally, the operational costs associated with surgical robotics can result in suboptimal utilization of robotic systems in some surgical centers. This limitation can translate into fewer opportunities for trainees to gain exposure to the technology, ultimately leading to longer training times. These constraints not only impede the development of expertise in the use of surgical robotics but also add to the already high costs of training, which can be prohibitive for many institutions. Addressing these challenges will require collaborative efforts across the medical community to ensure that surgical robotics training programs are accessible, efficient, and effective in preparing the next generation of surgeons to harness the benefits of this technology.

How can Surgical Robotics training be improved?

Improving surgical robotics training is crucial for increasing the adoption of this technology and enhancing patient outcomes. There are several steps that can be taken to enhance surgical robotics training programs:

Affordability: Making surgical robots more affordable would increase the number of installations, resulting in more surgeons being trained. The cost of training is currently prohibitive for many institutions, and increasing accessibility to surgical robotics technology would expand the pool of trained surgeons and improve patient outcomes.
Generalized training: Training for surgical robotics needs to be technology and skill specific, rather than product-specific, conducted by manufacturers to mitigate risks associated with medical devices. Generalized training would be possible if residual risks could be eliminated or minimized. The emergence of Assistive and Watchdog AIs means that surgical robots of the future will be self-corrective, detecting and mitigating mistakes before they happen.
Integration with medical curriculum: Surgical training should be included as part of the medical curriculum, not just as an elective discipline. This approach would ensure that all medical students are exposed to surgical robotics, improving the availability of trained surgeons in the future.
Focus on ease of use and standardization: The ease of use and standardization of surgical robots should be a priority in training programs. The more standardized surgical robotics technology becomes, the easier it will be to train surgeons and surgical teams to use it effectively, reducing training times and costs. Additionally, standardized training will improve patient outcomes by ensuring that all surgeons are using the technology consistently and effectively.

In Conclusion

In conclusion, the high cost of surgical robotics is certainly affecting surgeon training, but there are steps that can be taken to improve the situation. As the technology continues to evolve, it is likely that the cost of training will decrease, making it more accessible to a wider range of medical professionals. With continued investment and innovation, we can ensure that surgical robotics remains a valuable tool in improving patient outcomes.

Manual to Robotic: Why surgeons are adopting robotic procedures

Saurya Mishra — Tue, 14 Mar 2023 03:04:06 +0000

Manual to Robotic : Why surgeons are adopting robotic procedures?

By : Saurya Mishra

March, 28th 2023

One would often agree that we Humans are at the peak of evolution. The intellect of the human brain, the vision in the eyes, and the dexterity of the human hands and fingers are possibly unparalleled in nature. This allows humans to do things unheard of in the last million years of evolution.

One of these is to intervene with the way our body works and fix it in case of an ailment. Thanks to medical sciences and surgery, today we live longer and more fulfilling lives than our ancestors.

Since the earliest recorded instances of surgery, around 2600 years ago, it’s this trifecta – brain, vision and dexterity of our bodies, that has helped heal other humans through interventional procedures. And while this trifecta has helped up achieve what was thought impossible in the domain of surgery, it has also proven to be the core limiting factor.

This was until the advent of surgical robotics in the late 1990s and early 2000s, with Intuitive Surgical’s DaVinci Surgical Robotic system. Today, robotic surgery has become an integral (although with limited access) part of the surgical domain. Surgeons are readily switching to robotic platforms and procedures, representing perhaps one of the best examples of man-machine amalgamation. In essence, surgical robots and technologies have enhanced the surgeons’ sensory, motor and decision-making abilities enabling surgeries to be performed better, faster, and more predictably. Let us have a closer look at how surgical robots are augmenting the surgeon’s abilities, with a focus on minimal access surgical robots in particular but even other types of robots in general.

1.) Better Vision

The human eyes are limited by resolution, aperture and magnification and the spectrum of light they can detect. The earliest example of surgeons using optical augmentation was the surgical loop, enabling better magnifications for the surgical region and hence improving vision. Improvement in optics and illumination has resulted in the development of better surgical vision systems, including surgical microscopes, surgical telescopes and, critically important to minimal access surgery, the endoscope.

The surgical endoscope has enabled surgeons, in both laparoscopic surgeries as well as robotic surgery to get a clear view of the surgical area inside the body, with just a small incision on the skin. Even endoscopes have evolved over the years, providing much better resolution, with the state of the art being the 4k endoscopes; better illumination; articulating tips to look around the surgical area; special forms of visualization – e.g. in spectrums not visible to the human eye; and finally the latest – 3D endoscopes.

Some types of visualization, especially 3D vision, in the opinion of surgeons, make more sense when the surgeon is dissociated from the patient during the surgery, e.g. seated on a console than during a standard manual laparoscopic surgery. 3D vision enables surgeons to distinguish between targets that are very close to each other in the surgical field, and often have similar appearances. On the other hand, another school of thought advocates the use of 4k endoscopes as it eliminates the use of 3D glasses or immersive consoles while providing almost the same level of clinical information at a much better comfort level for the surgeon.

Add to this the fact that now surgeons can precisely control the illumination, zoom, and position of the endoscope on the fly while performing the surgery, without the need for an assistant. This eliminates the need to communicate with the surgical assistant, and hence provides more control to the surgeon himself.

It is often agreed that good vision even on its own boosts the confidence of the surgeon when performing complex procedures. Hence it reduces the surgical time drastically and also drastically reduces the chances of human error.

2.) Natural Motion

Have you ever tried to ride a bicycle with your hands crossed? I.e the left hand holding the right handlebar and vice versa. Even if you haven’t, I am sure you can guess what will happen. The reason for this is very simple, the human brain is wired to operate our extremities in a certain way. When we think left, it moves left. When it thinks right, it moves right.

The same is applicable to surgeons when performing surgeries. Imagine if the motion of the surgical tools in the hands of the surgeon was inverted. This is the exact situation that happens in manual laparoscopic surgery. The long surgical tools used in these types of minimal access surgery, are ‘fulcrum’ at the abdominal wall and hence when the motion of the surgeons’ hands is inverted.

And hence laparoscopic surgeons need years of motor skill training in order to achieve the level of control required to perform complex surgeries. Procedures that are simple in conventional open surgeries like suturing or knotting are extremely complex when it comes to laparoscopic surgeries.

This is perhaps where surgical robots make their true mark. The surgical robot is a drive-by-wire system. This means motions are first captured in a surgical console, processed and then replicated in the robot arms and robot tool tips. The processing ensures that the signals are inverted and hence match the motion vector of the surgeon’s hands to that of the surgical tool inside the patient’s body.

This brings down the training time for motor skill development for surgeons by nearly 5x, as has been thoroughly researched and published by multiple researchers. The surgeon, when looking at the console screen or looking into the immersive display almost feels as if the tooltip is their hands.

3.) Better dexterity and precision

The hands of a surgeon are almost synonymous with precision, control and dexterity. They are able to perform very fine motions with little to no vibrations. It is for this reason that some institutes/hospitals of repute often hire younger surgeons to perform a certain type of procedure e.g. microvascular surgeries – anastomosis of vessels little more than a millimetre in diameter.

It is not only about the inherent vibration in the human hand, even the surgical tools that we use to perform most surgeries have a single degree of freedom at the tooltip. A degree of freedom is the number of independent motions that a system can have. Simply put, for a surgical tool, it’s the number of joints at the tip of the tool. For standard laparoscopic tools, this number is one – the grasping.

Modern surgical robotic tools allow three or more degrees of freedom at the tooltip. This is almost analogous to the human wrist. And therefore this allows the surgeon to perform complex manoeuvres during an endosurgery as if they are using a tiny version of their wrist inside the patient’s body to perform the surgery.

The real challenge is being able to control all these joints in a synchronised manner. This cannot be done without incorporating some level of robotic control into the mix. The robotic control ‘reads’ the motion of the surgeon’s hands and then replicates the motion at the tip, by moving every actuator in a certain controlled manner.

Precision is the next big contribution of surgical robots. It is not only about how small a motion can be made but also about how repeatably can one move/orient to the same location or orientation over a period of time. Repeatability and precision ensure that surgical robots are able to perform procedures, manoeuvres and actions that are at least a dozen times smaller than what a human hand can. One way of doing this is simply by scaling the motion of the hands of the surgeon. For example, if a surgeon makes a 1 cm motion at the console, it can be replicated as a 0.1 cm motion at the tooltip. Achieving precision and repeatability is also about ensuring that the vibrations of the human hand are filtered out and that the machines themselves have little to no inherent vibrations.

4.) Machine in the Middle

This is perhaps one of the most important yet overlooked aspects of surgical robotics, and definitely one of the most controversial so to speak. It brings into discussion words like AI and Machine Learning that are often construed in a negative light, especially in the healthcare domain.

Most of us have been fascinated by the self-driving car revolution that is happening around us. If we think about it, cars have existed for a very long time, so why did it take this long to for the advent of self-driving cars? We believe it was the drive-by-wire that ultimately enabled it.

Drive-by-wire is a concept where the controller (in our case the surgeon sitting on the surgeon’s console) is connected to the actuator (in our case the complex surgical robot) only by wires passing signals back and forth – i.e. there are no physical connections like mechanical links, or hydraulics or pneumatics connecting one to the other. It also means there is a plethora of sensors at both ends ensuring that many different kinds of information like velocity, force, torque, orientation, and current, are received, recorded and processed.

Long before self-driving cars were a thing, a lot of smaller changes happened that have now become almost second nature. The fact that the car can detect if a door is open, automatically adjust the temperature in the car, detect a low pressure in the car tyre, engine trouble to something as critical as deploying airbags in case of an adverse event. This is what we like to call a watchdog.

An artificially intelligent watchdog during surgery ensures that errors are avoided to the highest possible degree. It could be something as simple as detecting the tools moving away from the surgical field and stopping them, to something as complex as detecting fatigue in the motion of the surgeon’s hands and alerting them. An AI watchdog can do things as simple as displaying or alerting the surgeon about the vitals of the patient during the surgery to complex tasks for example dynamically adjusting anaesthesia, Insufflation and drugs to ensure that the patient’s vitals are maintained.

Coming back to self-driving cars, the question remains, will artificially intelligent systems come to the surgical domain, if yes, how is it going to impact the ecosystem – the hospitals, the surgeons, and the patient? Will it be safe? Will it be ethical? To be honest there is no simple answer to this. Innovation will move in the direction of demand. It is up to us to ensure that its boundaries are set. It is our job to ensure that patient safety takes a paramount position when it comes to anything and everything in healthcare.

And this is exactly what surgical robots have done to the healthcare domain. Today we are able to do more complex surgeries, solve more complex problems, and ensure a better quality of life for millions of patients globally due to these advancements.