Portal de Periódicos da CAPES

The role of the dual console in robotic surgical training

2013; Elsevier BV; Volume: 155; Issue: 1 Linguagem: Inglês

10.1016/j.surg.2013.06.023

1532-7361

Eduardo Fernandes, Enrique F. Elli, Piercristoforo Giulianotti,

Anatomy and Medical Technology

A good teacher is one who makes himself progressively unnecessary.—Thomas CarruthersSurgery is a practical discipline, and proficiency comes through practice. Surgical education is evolving under the pressure of an increasing body of knowledge, working hour restrictions, and subspecialization. Modern surgeons are required to play multiple roles: A professional, a scholar, a health advocate, a manager, a collaborator and, above all, a teacher. One of the most important skills of an academic surgeon, however, is his/her ability to teach operative technique.The fast-paced and ever-changing nature of the surgical profession includes numerous challenges of surgical education and how best to teach technical operative skills. Surgery started as a discipline with no medical dignity, delegated to barbers. Today, it has grown into a field where technology finds one of its greatest expressions. As a result, there is now an enormous gap to be filled with strategies needed to teach the new technology. Education research has established that individuals learn through 4 different learning styles: Convergent (problem solving), accommodative (hands-on experience), assimilative (reflective observation, watching), and divergent (abstract conceptualization, thinking).1Kolb D. Experiential learning: experience as the source of learning and development. Prentice-Hall, Englewood Cliffs, NJ1984Google Scholar In the era of open surgery, the techniques of traditional learning of surgical teaching were convergent (problem solving) or accommodative (hands-on experience).2Baker 3rd, J.D. Reines H.D. Wallace C.T. Learning style analysis in surgical training.Am Surg. 1985; 51: 494-496PubMed Google Scholar These 2 learning styles, which represent the foundation of apprenticeship, continue to play a major role in surgical education today. Coincidently, they are also the preferred styles of the majority of surgery trainees,3Drew P.J. Cule N. Gough M. Heer K. Monson J.R. Lee P.W. et al.Optimal education techniques for basic surgical trainees: lessons from education theory.J Royal Coll Surg Edinburgh. 1999; 44: 55-56PubMed Google Scholar but these classic, time-honored approaches face new challenges. Laparoscopic, and more recently robotic, surgeries have challenged this learning paradigm.The very nature of laparoscopic surgery gives the perception of distance between the teacher and the student. The interposition of laparoscopic instruments and the camera between the surgeon's hands and tissues makes the classical "4-handed" technique more cumbersome. Switching the first operator function between the teacher and the trainee is a long and complex action (exchanging camera, temporarily losing vision, resetting the operative field to the "preswap" status) and requires a great amount of time and patience from the proctor. Furthermore, the perception by the proctor surgeon of not being in control may contribute to increased anxiety. For these reasons, the learning styles of abstract conceptualization (thinking) and reflective observation (watching) have possibly become predominant in the first stages of the laparoscopic learning curve. The initial hands-on experience of laparoscopy has been delegated to simulation, which has become in many places the mainstay of early stages of laparoscopic training.With the advent of robotic surgery, this teaching gap has widened even further. With the robotic setup, in addition to the difficulties related to the remotely controlled instruments, the teacher and the learner operate at an even greater physical distance, which may seem dangerous when considering the delicate action of certain maneuvers being performed and supervised, especially with the loss of haptic feedback.To close such distance, the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) has developed a "dual console" setup, which has become a very powerful tool that allows surgeons to overcome many of the drawbacks of robotic as well as laparoscopic surgical training. With the dual console setup, the proctoring surgeon and the proctored surgeon sit at the master and the secondary console, respectively.Obviously, this teaching modality requires extra manpower, because another assistant surgeon is needed at the patient table to maneuver the instruments via the assistant ports, exchange the robotic instruments, and troubleshoot for glitches related to the robotic platform.However, the dual console allows the proctoring surgeon to swap the control of the robotic instruments, immediately at any time. If 2 consoles are present, the function buttons "give" or "take" and "swap all" appear on the console touch pad (Fig 1).The give or take function refers to each instrument in use, the control of which can be given singularly to the learning surgeon. The swap all function allows the master surgeon to gain full control of all the instruments at 1 time. This console also allows the learning surgeon to operate the robot in a "simplified" fashion, with 2 operating arms, while the proctor surgeon controls the third arm for retraction, exposure, or even pointing.Either surgeon can control the camera in the usual way, and because one of them does so, all instruments go "out of following" and cannot be moved.The virtual pointer is another useful tool of the dual console that facilitates surgical training. The pointer is a 3-dimensional, cone-shaped graphic icon that appears on the live video image when activated. It enables the operator or proctor to point and refer to specific anatomic features on the live video image intraoperatively. The proctor can activate and control the virtual pointer by gripping any master controller (the robotic "joystick") that is not associated with an instrument arm. If the proctor surgeon is not using either master, 2 virtual pointers (one for each master) can be used simultaneously. Finally, there is also the emergency stop button, which can be pressed at any time, should the situation require a sudden cessation of activity (Fig 2).Fig 2Virtual pointers. The cone-shaped pointers are activated by the "nonoperating" console and provide a useful tool to guide the learning surgeon.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The dual console platform is a powerful teaching tool that has unique advantages, especially compared with conventional laparoscopy. Even though teacher and learner are physically at a distance, they are always in communication through the microphone system of the consoles. Both surgeons have the same view, and the learning surgeon can be guided by the proctoring surgeon through intermittent swapping of all commands, the 3-dimensional pointer, the third arm, and frequent camera readjustments. This teaching method is time efficient, and the perception of being removed from the procedure almost disappears.Disadvantages of the dual console are due to the greater cost of an additional console and the need for an additional assistant. The added cost of an additional console is difficult to offset in a short amount of time. Furthermore, the bedside assistant has to be proficient with the minimally invasive setup and with the troubleshooting of problems with the robotic platform. Junior surgical staff can be trained to this purpose, but the challenges of the robotic assistance should not be underestimated. Difficult retraction, on-demand assistant port placement, and arm collision troubleshooting can be difficult situations for the inexperienced surgeon, and may turn a simple, robotic procedure into an irreversible disaster.Nevertheless, the Da Vinci dual console is a powerful teaching tool. Conceptually, the commands can be exchanged between the 2 consoles such that the proctoring surgeon can "take over" during a procedure performed by the trainee whenever she or he is experiencing difficulty.One of the most common initial difficulties of robotic surgery relates to the lack of tactile feedback from the robotic instruments. Adequate traction is essential for exposure of surgical planes. The console "novice," for fear of exerting excessive traction and causing tissue damage, often exposes the surgical field inadequately. Visual cues often provide valuable information about the degree of tissue deformation, such that with time, the trainee learns how to "feel" by looking at the traction of different tissues and is able to overcome this problem. The ability to quickly and repeatedly swap instruments by this dual console modality is a great tool for the proctor to teach the trainee about proper exposure and tissue handling. This approach becomes most useful when a proctor and a trainee operate together, and the trainee can learn about maximum traction by comparing his or her actions with those of the proctor.Operating with only 2 arms while the proctor maneuvers the third arm is also an effective way of building experience at the console. During a single-operator procedure, the fixed, nonmotile fourth arm represents an intrinsic limitation to the continuous traction–counter traction required for tissue dissection. Only the proficient robotic surgeon is able to exploit the fourth arm at its best with continuous adjustments, which may need to be done without having full vision of the surgical field. Delegating the third arm to the proctor makes its use more dynamic and also improves the surgical exposure. Gradually, the trainee is able to take increasing responsibility of the third arm and control it as needed independently.Future development of the Da Vinci platform may render such set up even more effective. Integrated warning systems of anatomy recognition (sizable vessels) and enhanced anatomy software4Kim Y.M. Baek S.E. Lim J.S. Hyung W.J. Clinical application of image-enhanced minimally invasive robotic surgery for gastric cancer: a prospective observational study.J Gastrointest Surg. 2013; 17: 304-312Crossref PubMed Scopus (25) Google Scholar are already being developed. Such improvements will make robotic surgery and its training even safer.Another potential advantage of the Da Vinci Platform is the possibility of remote proctoring. The technology for using the dual console platform from a long distance is theoretically available and attractive. Ethical issues regarding the surgeon's remote location and technical issues concerning delay between sites have limited this use, but these problems will be solved in the near future and should turn remote surgery into reality. Presently, there is the ability for a remote use of the visual pointer. This action, called "telestration," allows the remotely connected proctor surgeon to move and draw lines on the live images that are seen simultaneously by the proctored surgeon operating on site. This powerful tool allows the experienced surgeon literally "to make suggestions" or "give caveats" to the learning surgeon who may be experiencing difficulties related to the lack of landmarks caused by the narrow anatomic field typical of robotic surgery. Preliminary successful experiences of telementoring with different communication platforms have been reported by Johns Hopkins University and University of California.5Agarwal R. Levinson A.W. Allaf M. Makarov D. Nason A. Su L.M. The RoboConsultant: telementoring and remote presence in the operating room during minimally invasive urologic surgeries using a novel mobile robotic interface.Urology. 2007; 70: 970-974Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 6Ali M.R. Loggins J.P. Fuller W.D. Miller B.E. Hasser C.J. Yellowlees P. et al.3-D telestration: a teaching tool for robotic surgery.J Laparoendoscop Adv Surg Techniques A. 2008; 18: 107-112Crossref PubMed Scopus (21) Google ScholarFinally, another aspect that plays a major role in robotic surgical training is simulation. An additional training module can be attached to the Da Vinci console to provide virtual training of basic robotic surgical skills (Da Vinci Surgical Skills Simulator). Other independent platforms (Mimic Technologies), provide similar training abilities by taking advantage of the shared software available from Intuitive Surgical.7Liss M.A. Abdelshehid C. Quach S. Lusch A. Graversen J. Landman J. et al.Validation, correlation, and comparison of the da Vinci trainer and the daVinci surgical skills simulator using the Mimic software for urologic robotic surgical education.J Endourol. 2012; 26: 1629-1634Crossref PubMed Scopus (73) Google Scholar Such software programs of virtual surgery will become more sophisticated and increasingly better at reproducing the challenges of procedures beyond simple basic surgical skills. The value of such advanced, virtual surgical training is promising, although this remains matter of debate.8Perrenot C. Perez M. Tran N. Jehl J.P. Felblinger J. Bresler L. et al.The virtual reality simulator dV-Trainer (R) is a valid assessment tool for robotic surgical skills.Surg Endosc. 2012; 26: 2587-2593Crossref PubMed Scopus (125) Google Scholar, 9Abboudi H. Khan M.S. Aboumarzouk O. Guru K.A. Challacombe B. Dasgupta P. et al.Current status of validation for robotic surgery simulators - a systematic review.BJU Int. 2013; 111: 194-205Crossref PubMed Scopus (176) Google Scholar The age of robotic surgery is approaching fast, and surgery programs worldwide need to prepare to face a new era of surgical training. A good teacher is one who makes himself progressively unnecessary.—Thomas Carruthers Surgery is a practical discipline, and proficiency comes through practice. Surgical education is evolving under the pressure of an increasing body of knowledge, working hour restrictions, and subspecialization. Modern surgeons are required to play multiple roles: A professional, a scholar, a health advocate, a manager, a collaborator and, above all, a teacher. One of the most important skills of an academic surgeon, however, is his/her ability to teach operative technique. The fast-paced and ever-changing nature of the surgical profession includes numerous challenges of surgical education and how best to teach technical operative skills. Surgery started as a discipline with no medical dignity, delegated to barbers. Today, it has grown into a field where technology finds one of its greatest expressions. As a result, there is now an enormous gap to be filled with strategies needed to teach the new technology. Education research has established that individuals learn through 4 different learning styles: Convergent (problem solving), accommodative (hands-on experience), assimilative (reflective observation, watching), and divergent (abstract conceptualization, thinking).1Kolb D. Experiential learning: experience as the source of learning and development. Prentice-Hall, Englewood Cliffs, NJ1984Google Scholar In the era of open surgery, the techniques of traditional learning of surgical teaching were convergent (problem solving) or accommodative (hands-on experience).2Baker 3rd, J.D. Reines H.D. Wallace C.T. Learning style analysis in surgical training.Am Surg. 1985; 51: 494-496PubMed Google Scholar These 2 learning styles, which represent the foundation of apprenticeship, continue to play a major role in surgical education today. Coincidently, they are also the preferred styles of the majority of surgery trainees,3Drew P.J. Cule N. Gough M. Heer K. Monson J.R. Lee P.W. et al.Optimal education techniques for basic surgical trainees: lessons from education theory.J Royal Coll Surg Edinburgh. 1999; 44: 55-56PubMed Google Scholar but these classic, time-honored approaches face new challenges. Laparoscopic, and more recently robotic, surgeries have challenged this learning paradigm. The very nature of laparoscopic surgery gives the perception of distance between the teacher and the student. The interposition of laparoscopic instruments and the camera between the surgeon's hands and tissues makes the classical "4-handed" technique more cumbersome. Switching the first operator function between the teacher and the trainee is a long and complex action (exchanging camera, temporarily losing vision, resetting the operative field to the "preswap" status) and requires a great amount of time and patience from the proctor. Furthermore, the perception by the proctor surgeon of not being in control may contribute to increased anxiety. For these reasons, the learning styles of abstract conceptualization (thinking) and reflective observation (watching) have possibly become predominant in the first stages of the laparoscopic learning curve. The initial hands-on experience of laparoscopy has been delegated to simulation, which has become in many places the mainstay of early stages of laparoscopic training. With the advent of robotic surgery, this teaching gap has widened even further. With the robotic setup, in addition to the difficulties related to the remotely controlled instruments, the teacher and the learner operate at an even greater physical distance, which may seem dangerous when considering the delicate action of certain maneuvers being performed and supervised, especially with the loss of haptic feedback. To close such distance, the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) has developed a "dual console" setup, which has become a very powerful tool that allows surgeons to overcome many of the drawbacks of robotic as well as laparoscopic surgical training. With the dual console setup, the proctoring surgeon and the proctored surgeon sit at the master and the secondary console, respectively. Obviously, this teaching modality requires extra manpower, because another assistant surgeon is needed at the patient table to maneuver the instruments via the assistant ports, exchange the robotic instruments, and troubleshoot for glitches related to the robotic platform. However, the dual console allows the proctoring surgeon to swap the control of the robotic instruments, immediately at any time. If 2 consoles are present, the function buttons "give" or "take" and "swap all" appear on the console touch pad (Fig 1). The give or take function refers to each instrument in use, the control of which can be given singularly to the learning surgeon. The swap all function allows the master surgeon to gain full control of all the instruments at 1 time. This console also allows the learning surgeon to operate the robot in a "simplified" fashion, with 2 operating arms, while the proctor surgeon controls the third arm for retraction, exposure, or even pointing. Either surgeon can control the camera in the usual way, and because one of them does so, all instruments go "out of following" and cannot be moved. The virtual pointer is another useful tool of the dual console that facilitates surgical training. The pointer is a 3-dimensional, cone-shaped graphic icon that appears on the live video image when activated. It enables the operator or proctor to point and refer to specific anatomic features on the live video image intraoperatively. The proctor can activate and control the virtual pointer by gripping any master controller (the robotic "joystick") that is not associated with an instrument arm. If the proctor surgeon is not using either master, 2 virtual pointers (one for each master) can be used simultaneously. Finally, there is also the emergency stop button, which can be pressed at any time, should the situation require a sudden cessation of activity (Fig 2). The dual console platform is a powerful teaching tool that has unique advantages, especially compared with conventional laparoscopy. Even though teacher and learner are physically at a distance, they are always in communication through the microphone system of the consoles. Both surgeons have the same view, and the learning surgeon can be guided by the proctoring surgeon through intermittent swapping of all commands, the 3-dimensional pointer, the third arm, and frequent camera readjustments. This teaching method is time efficient, and the perception of being removed from the procedure almost disappears. Disadvantages of the dual console are due to the greater cost of an additional console and the need for an additional assistant. The added cost of an additional console is difficult to offset in a short amount of time. Furthermore, the bedside assistant has to be proficient with the minimally invasive setup and with the troubleshooting of problems with the robotic platform. Junior surgical staff can be trained to this purpose, but the challenges of the robotic assistance should not be underestimated. Difficult retraction, on-demand assistant port placement, and arm collision troubleshooting can be difficult situations for the inexperienced surgeon, and may turn a simple, robotic procedure into an irreversible disaster. Nevertheless, the Da Vinci dual console is a powerful teaching tool. Conceptually, the commands can be exchanged between the 2 consoles such that the proctoring surgeon can "take over" during a procedure performed by the trainee whenever she or he is experiencing difficulty. One of the most common initial difficulties of robotic surgery relates to the lack of tactile feedback from the robotic instruments. Adequate traction is essential for exposure of surgical planes. The console "novice," for fear of exerting excessive traction and causing tissue damage, often exposes the surgical field inadequately. Visual cues often provide valuable information about the degree of tissue deformation, such that with time, the trainee learns how to "feel" by looking at the traction of different tissues and is able to overcome this problem. The ability to quickly and repeatedly swap instruments by this dual console modality is a great tool for the proctor to teach the trainee about proper exposure and tissue handling. This approach becomes most useful when a proctor and a trainee operate together, and the trainee can learn about maximum traction by comparing his or her actions with those of the proctor. Operating with only 2 arms while the proctor maneuvers the third arm is also an effective way of building experience at the console. During a single-operator procedure, the fixed, nonmotile fourth arm represents an intrinsic limitation to the continuous traction–counter traction required for tissue dissection. Only the proficient robotic surgeon is able to exploit the fourth arm at its best with continuous adjustments, which may need to be done without having full vision of the surgical field. Delegating the third arm to the proctor makes its use more dynamic and also improves the surgical exposure. Gradually, the trainee is able to take increasing responsibility of the third arm and control it as needed independently. Future development of the Da Vinci platform may render such set up even more effective. Integrated warning systems of anatomy recognition (sizable vessels) and enhanced anatomy software4Kim Y.M. Baek S.E. Lim J.S. Hyung W.J. Clinical application of image-enhanced minimally invasive robotic surgery for gastric cancer: a prospective observational study.J Gastrointest Surg. 2013; 17: 304-312Crossref PubMed Scopus (25) Google Scholar are already being developed. Such improvements will make robotic surgery and its training even safer. Another potential advantage of the Da Vinci Platform is the possibility of remote proctoring. The technology for using the dual console platform from a long distance is theoretically available and attractive. Ethical issues regarding the surgeon's remote location and technical issues concerning delay between sites have limited this use, but these problems will be solved in the near future and should turn remote surgery into reality. Presently, there is the ability for a remote use of the visual pointer. This action, called "telestration," allows the remotely connected proctor surgeon to move and draw lines on the live images that are seen simultaneously by the proctored surgeon operating on site. This powerful tool allows the experienced surgeon literally "to make suggestions" or "give caveats" to the learning surgeon who may be experiencing difficulties related to the lack of landmarks caused by the narrow anatomic field typical of robotic surgery. Preliminary successful experiences of telementoring with different communication platforms have been reported by Johns Hopkins University and University of California.5Agarwal R. Levinson A.W. Allaf M. Makarov D. Nason A. Su L.M. The RoboConsultant: telementoring and remote presence in the operating room during minimally invasive urologic surgeries using a novel mobile robotic interface.Urology. 2007; 70: 970-974Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 6Ali M.R. Loggins J.P. Fuller W.D. Miller B.E. Hasser C.J. Yellowlees P. et al.3-D telestration: a teaching tool for robotic surgery.J Laparoendoscop Adv Surg Techniques A. 2008; 18: 107-112Crossref PubMed Scopus (21) Google Scholar Finally, another aspect that plays a major role in robotic surgical training is simulation. An additional training module can be attached to the Da Vinci console to provide virtual training of basic robotic surgical skills (Da Vinci Surgical Skills Simulator). Other independent platforms (Mimic Technologies), provide similar training abilities by taking advantage of the shared software available from Intuitive Surgical.7Liss M.A. Abdelshehid C. Quach S. Lusch A. Graversen J. Landman J. et al.Validation, correlation, and comparison of the da Vinci trainer and the daVinci surgical skills simulator using the Mimic software for urologic robotic surgical education.J Endourol. 2012; 26: 1629-1634Crossref PubMed Scopus (73) Google Scholar Such software programs of virtual surgery will become more sophisticated and increasingly better at reproducing the challenges of procedures beyond simple basic surgical skills. The value of such advanced, virtual surgical training is promising, although this remains matter of debate.8Perrenot C. Perez M. Tran N. Jehl J.P. Felblinger J. Bresler L. et al.The virtual reality simulator dV-Trainer (R) is a valid assessment tool for robotic surgical skills.Surg Endosc. 2012; 26: 2587-2593Crossref PubMed Scopus (125) Google Scholar, 9Abboudi H. Khan M.S. Aboumarzouk O. Guru K.A. Challacombe B. Dasgupta P. et al.Current status of validation for robotic surgery simulators - a systematic review.BJU Int. 2013; 111: 194-205Crossref PubMed Scopus (176) Google Scholar The age of robotic surgery is approaching fast, and surgery programs worldwide need to prepare to face a new era of surgical training.