Prior experience in micro-surgery may improve the surgeon's performance in robotic surgical training

Clinical, Preclinical, and Educational Applications of Robotic-Assisted Flap Reconstruction and Microsurgery: A Systematic Review

INTRODUCTION

Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field. We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included.

RESULTS

One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery.

CONCLUSION

Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Assessment of the training program for Versius, a new innovative robotic system for use in minimal access surgery

Objectives

The Versius surgical system has been developed for use in robot-assisted minimal access surgery (MAS). This study aimed to evaluate the effectiveness of the Versius training program.

Design

A 3.5-day program following 10 hours of online didactic training. Participants were assessed during the technical training using the Global Evaluative Assessment of Robotic Skills (GEARS).

Setting

Dry box exercises were conducted in classrooms, and wet lab sessions simulated an operating room environment using cadaveric specimens.

Participants

Seventeen surgical teams participated; surgeons represented general, colorectal, obstetrics/gynecology, and urology specialties. All surgeons had previous laparoscopic MAS experience, while experience with robotics varied.

Main outcomes measures

Participants were scored on a five-point Likert Scale for each of six validated GEARS domains (depth perception, bimanual dexterity, efficiency, force sensitivity, autonomy, and robotic control). Additional metrics used to chart surgeon performance included: combined instrument path length; combined instrument angular path; and time taken to complete each task.

Results

Participants demonstrated an overall improvement in performance during the study, with a mean GEARS Score of 21.0 (SD: 1.9) in Assessment 1 increasing to 23.4 (SD: 2.9) in Validation. Greatest improvements were observed in the depth perception and robotic control domains. Greatest differences were observed when stratifying by robotic experience; those with extensive experience consistently scored higher than those with some or no experience.

Conclusions

The Versius training program is effective; participants were able to successfully operate the system by program completion, and more surgeons achieved intermediate-level and expert-level GEARS scores in Validation compared with Assessment 1.

Reinforcing the effect of microsurgery practice during robotic suturing skill acquisition

BACKGROUND

This study aimed to examine the effectiveness of microsurgery practice during an interval in robotic surgical training.

METHODS

Two participant groups with 30 trainees each practiced Thread the Rings 1 on a dV-Trainer. There were four 2-h training sessions, with a 72-h interval between each session. Group A received no additional training during the study period. During every interval, Group B practiced a similar 2-h ring penetration exercise using a microscope three times (once every 24 h).

RESULTS

The 72-h delay between two sessions for Group A caused the forgetting effect. For Group B, additional microscope-based training aided memory retention. After the training session, Group B presented a significantly higher score than Group A in Thread the Ring 1 learning curves.

CONCLUSIONS

Adding microsurgical skill training into the basic robotic-surgery training curriculum could be helpful because additional trainings with a binocular microscope could improve robotic surgical skill levels.

Residency training in robotic surgery: The role of simulation

Simulation has become increasingly important in surgical teaching in recent years and the French National Authority for Health (HAS) recently underlined the goal and ethical priority: "never the first time on the patient". Simulation programs have been tested and validated for laparotomy and for laparoscopy, but there is not yet a validated program specific for robotic surgery. Due to substantial advances in this new technology, we have developed a program in Nancy dedicated to outside-the-operating room (OR) teaching of robotic surgery using the Da Vinci robot. This teaching is based on a combined program of theoretical teaching (e-learning) and learning of practical skills using virtual simulators (DV-Trainer®, Robotic Mentor®, DVSS®), mechanical simulators (Dome, Applied® abdominal simulators), microsurgery and wet lab using ex vivo animal organs, anesthetized animals, and cadavers. This program also emphasizes team training. The course is intended for residents in surgical training and is integrated into the specialized study diploma (DES) program for Visceral and Digestive Surgery; it also can be used by qualified surgeons who can integrate it with the Inter-University Diploma (DIU) in General Robotic Surgery for basic techniques and also for DIUs in other surgical specialties (digestive and gynecologic surgery) for robotic uses within their specialty. These courses are based on the concept of step-by-step skills acquisition and verification allowing a transition to safe clinical activity.

Contribution of Haptic Simulation to Analogic Training Environment in Restorative Dentistry

The aim of this study was to evaluate the contribution of virtual reality to the conventional analogic training environment and show the complementarity of conventional techniques and virtual reality in the learning of dental students. All 88 first-year dental students at a dental school in France in early 2019 were randomly assigned to one of two groups: group 1 (n = 45) was assigned to cavity preparations on a haptic simulator (Virteasy) and group 2 (n = 43) was assigned to conventional practical work on plastic analogue teeth (Kavo). Following three training sessions, the students in group 1 took a final exam on the same plastic analogue teeth exercise. The results showed improvement in the drilling skill of both groups. The simulator-trained group (group 1) had similar results to the plastic analogue-trained group (group 2) in the final test on a plastic analogue tooth. In this study, virtual reality allowed an assessment based on objective criteria and reduced the subjectivity of evaluations conducted on plastic analogue teeth. Considering the saving of supervision and teaching time as well as the material gain offered by virtual reality, the learning methods of haptic simulators are educational options that should be considered by dental educators.

Robot-Assisted Pterygium Surgery: Feasibility Study in a Nonliving Porcine Model

PURPOSE

This study aims to investigate the feasibility of pterygium surgery using the DaVinci Si HD robotic surgical system, and to describe a porcine model for pterygium surgery and evaluate its usefulness.

METHODS

The pterygium models were constructed using enucleated pig eyes and cold cuts. Robotically-assisted pterygium surgeries in nonliving biological pterygium models were performed using the DaVinci Si HD robotic surgical system. Twelve models were prepared, and 12 pterygium excision and conjunctival autografts were performed.

RESULTS

The DaVinci system provided the necessary dexterity to perform delicate ocular surface surgery and robotic tools were safe for the tissues. The mean duration of the surgical procedures was 36 minutes. There were no intraoperative complications and no unexpected events.

CONCLUSIONS

Robotic-assisted pterygium surgery is technically feasible for porcine eyes using the DaVinci Si HD robotic surgical system. The pterygium model that we describe could be of interest for surgical training.

TRANSLATIONAL RELEVANCE

Little research has been done in robotic microsurgery. Animal experimentation will allow the advantages of robotic-assisted microsurgery to be identified, while underlining the improvements and innovations necessary for clinical use.