Page 32 - Jourmal of World Association of Laparoscopic Surgeon

Shamanique Shamona Bodie

surgery, there are other benefits. Standard endoscopic Comparing surgical skill acquisition and proficiency using
instruments offer a magnified view, haptic feedback. conventional laparoscopy and robotic interfaces may help
However, there is monocular vision with some depth clues, improve the education in these areas.
only 4º of freedom, and reduced operative dexterity and Laparoscopic education has been an important part of
tremor amplification. 12 surgical education for the last two decades. So much so,
starting in 2008 United States, The Accreditation Council
Robotics for Graduate Medical Education (ACGME) changed the

The da Vinci (Intuitive Surgical, Inc., Sunnyvale, CA) requirements for laparoscopic cases for surgical graduates.
surgical system is being used by surgeons across several Moreover, the Fundamentals of Laparoscopic Surgery
surgical specialties. The da Vinci Robotic System is program that was introduced over a decade ago as a method
FDA-approved for surgical robotics, consists of three of measuring competency with laparoscopic techniques is
17
components: A surgeon console, the InSite vision system a mandatory component of laparoscopic education.
(which provides three-dimensional (3D) stereoscopic Computer technology including virtual reality simulators
imaging), a patient-side cart with EndoWrist instruments, offers an adjunct for surgical training. Having the ability to
and either 3 or 4 robotic arms. teach psychomotor skills, they help the progression along
The console includes a stereoscopic viewer with an the learning curve for this rapidly developing surgical
infrared sensor and hand and foot controls that allow the technique within a safe training environment. Hence, basic-
surgeon to control positioning and focus of the camera and and intermediate-level minimally invasive surgical
activation of monopolar or bipolar energy sources. The maneuvers can be learned and practiced by trainees and
vision system creates a 3D image, as the endoscope is instructors using computer-based virtual environments, and
composed of two parallel 5 mm telescopes with 0° or 30° performances can be assessed objectively before trainees
18-20
lenses. The image is magnified 10 to 15 times. The proceed to patients in the OR.
laparoscopic surgical instruments articulate in 7° of freedom Training centers and training programs are readily
and 90° of articulation, allowing movements that imitate available in the area of laparoscopy, making the training of
the surgeon’s hand. They also decrease tremors and motion future surgeons possible. Education costs are manageable.
artifact. Laparoscopic instruments include energy sources Although not necessary it is also possible to the theater staff
21-23
such as monopolar and bipolar cautery, the Harmonic ACE, trained in laparoscopy.
the PK dissecting forceps, and laser. Graspers, needle Education in Robotic Surgery
drivers, retractors and specialized instruments are also
designed for the robotic arms. A fast learning curve to a competent level using the da Vinci
The robotic interface is different not only to open system is possible helped by the system’s intuitive motion.
surgery, but also to laparoscopy because it involves remote Motion analysis is a useful tool to measure performance in
surgical control, stereoscopic vision and lack of haptic the da Vinci system compared to OSATS and time alone. 24
feedback. However, in summary, advanced surgical robotic Currently, on the market, five different robotic surgery
systems offer precise instrument articulation, a magnified simulation platforms are available. One meta-analysis
3D visualization, camera stabilization and direct control, looked at 11 studies that sought opinion and compared
tremor filtration, motion scaling and improved ergonomics. 13,14 performance between two different groups; ‘expert’ and
‘novice’. Experts ranged in experience from 21-2, 200
EDUCATION IN LAPAROSCOPY AND ROBOTICS robotic cases. The novice groups consisted of participants
with no prior experience on a robotic platform and were
Medical Education
often medical students or junior doctors.
®
®
Nine fundamental manipulations of tissues by surgical The Mimic dV-Trainer , ProMIS , SimSurgery
®
instruments that surgeons must learn are [both visual and Educational Platform (SEP) and Intuitive systems have
haptic (touch)], aspiration/injection, incision, excision, shown face, content and construct validity. The Robotic
extraction, evacuation, purposeful injury, closure and Surgical Simulator TM system has only been face and content
implantation/transplantation. 15,16 Learning curve and validated. All of the simulators except SEP have shown
surgical dexterity are two measurement tools that are used educational impact. Feasibility and cost-effectiveness of
to compare surgical learning and training. Medical education simulation systems was not evaluated in any trial. Virtual
usually uses skill training and various exercises to decrease reality simulators were shown to be effective training tools
the learning curve and improve surgical dexterity. for junior trainees. 25
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