It's time to standardize robotic surgery

Robots are common in the operating room, but there's no standard curriculum to train surgeons to use them.
Written by Greg Nichols, Contributing Writer

The global surgical robotics market is expanding rapidly and may soon be worth $120B. But is the medical training ecosystem ready for the shift to robot-assisted surgeries?

As more surgeons use robots in the OR, the approach for training on them and using them needs to be standardized. The truth is that all surgeons aren't approaching this innovative tech the same way. Standardized best practices are what set surgeons and patients up for success, and will help to make robotic surgery safer in the future. 

So how do we improve it?

There are a handful of new challenges the surgical team faces with robots: how to collaborate, how to coordinate (both the physical setup and the tasks), and how to communicate. What's needed is a concerted effort to make sure all surgeons are using the robots the way they were intended so surgery is efficient and effective. 

Two medtech startups that are leading the charge on this are Explorer Surgical, which is a digital playbook that walks every team member in surgery through the steps to be successful, and Osso VR, which trains surgeons using high-fidelity VR. I recently connected with Justin Barad, MD, CEO and co-founder of Osso VR, and Dr. Alex Langerman, MD, SM, FACS and Co-founder of Explorer Surgical, about the future of robot assisted surgery and the critical need to standardize training.

GN: What are some of the most difficult things for surgeons to adapt to when transitioning from traditional to robot-assisted surgery?

Dr. Alex Langerman: Physicians are faced with multiple challenges when transitioning to robot-assisted surgery. Still, the most significant has to do with learning the complexities of integrating a new device into a surgical workflow and overcoming a learning curve to operate as an experienced team. 

Robotic-assisted technology can be straightforward or very complex; there are many little things that a clinical team needs to learn when adapting to a new technique. For example, the placement of a robotic arm, the room set up, adjustment of the bed, and any registration needed for the patient and procedure. Aside from the technical setup, the complexities can also include customizing the physician's interface and preferences for 'must haves' in the OR.  This preparation minimizes the potential for intraprocedural delays or disruptions. Secondly, training the surgical team is as important as training the physician as with any new device. It's the physician's responsibility to make sure the procedure goes well for the patient and that every team member in the room knows what their specific tasks are regarding the device and its use. A digital playbook with every step related to the procedure, specific to each role in the OR, can bring significant support to ensuring that nothing is overlooked.

Justin Barad: Wow this is such a great question!  One of the most difficult things when switching to robotic surgery is that the workflow is significantly different.  It depends on the robot but using orthopedics as an example a typical joint replacement workflow will go: Patient positioning > Dissection/Approach > Bone resection > Implant Trialling > Final Implantation.

Now let's compare that with a robotic workflow: Robot setup and calibration > Patient positioning > Dissection/Approach > Registration > Planning > Robotic assisted Bone Resection > Trialing and Computer aided assessment > Final Implantation.

All of the steps in bold are significantly different and even if you are doing the same surgery the various robots from different manufacturers have their own unique workflows.  Further complicating things is these skills and concepts are not commonly taught during formal training (Residency & Fellowship), so practicing surgeons often are coming in at a relatively novice state. Finally, one of the major advantages of robotics is that they are powered by software which means they can be updated and improved over time, but that poses a significant challenge. This means that from one day to the next the way that you perform a surgery can change significantly following an over the cloud update. Without a rapid way to train on demand, you can run into a situation where you can potentially not know how to advance in a given procedure despite familiarity with the system.  I've even heard reports of people calling "tech support" mid-surgery for this very reason.

All that being said, robotics are an incredibly valuable and powerful tool that makes surgery more consistent and data driven which ultimately will drive significant value for global healthcare.

GN: How much is the current perception of robot-assisted surgery shaped by misconceptions or improper preparation? Why?

Justin Barad: I think on the patient side the perception of robotics is quite positive and there is accelerating demand to receive surgical care in a robotic manner if it is available. On the provider side I think there is more of a mixed opinion. Some providers feel that they can operate much faster with more traditional open techniques and view robots as "slowing them down" and being "too complicated."  However, most surgeons who I've spoken to  who have overcome the significant learning curve recognize the value and repeatability of switching to robotic platforms, including the advantage that the sophistication of the technology is improving at an accelerating rate given software updates and hardware investments. One other challenge to the adoption of robotics has to do with the makeup of the surgical team. Robotic surgery requires much more coordination from the team in contrast with traditional techniques which are more surgeon driven. There are surgeons who consistently work with the same surgical teams so training and coordination doesn't pose too much of a problem, however at many hospitals and surgery centers there is a very high level of team variability. One surgeon I spoke to recently told me he operates with 25 different surgical techs over the course of a month.  Without the ability to rapidly onboard additional team members, surgeons may be hesitant to constantly be in a situation where team members don't have a great sense of how to execute the procedure properly.

Dr. Alex Langerman: When robotic surgery was first introduced, the learning curve for adopting the technology had a substantial effect on the efficiency of the OR.  While there has been a significant effort from the industry to show that RAS can be better for the patient, there are misconceptions that it makes surgery easier for the physician.  The training of surgical teams typically happens when the device is delivered to the customer.  The time spent learning new technology can impact an OR's efficiency because every team member has a role in the setup and preparation.  Some physicians may be hesitant to adopt new technology because they have heard about experiences where new technology was introduced, but it was such a bad experience with those initial cases, it was barely used.  Those initial experiences can be shaped by the clinical team and their preparation for getting ready to operate. Unless physicians have access to experienced, dedicated robotic nursing and scrub teams, they might never get past the slow end of the "getting ready to operate" learning curve.

With a digital playbook like Explorer Live, each team member has their responsibilities mapped out before they ever do their first procedure.  It provides support throughout the entire surgery, helping them be more efficient in the learning process.  In addition, companies can provide real-time support and guidance with remote connectivity to someone dedicated to supporting cases or a peer considered an expert on the device.

GN: How does communication and coordination change when a robot is in the mix?

Justin Barad: As I mentioned above there are significantly more tasks for the surgical team to perform to successfully perform robotic surgery, especially for console operated robots where the surgeon is physically removed from the surgical site and relies on communication for troubleshooting and some repositioning of the equipment. For a seasoned team that works together frequently this can work quite well, however in highly variable environments such as the one mentioned above this can make the surgery extremely difficult to pull off without the surgeon and sometimes device representative running around trying to do everything themselves.

Dr. Alex Langerman: In traditional surgery, the surgeon, assistant, and scrub are all right next to each other, and communication is limited for the rest of the OR. Access to the surgical field can be impacted in robotic-assisted surgeries where they need to make room for the device, or the surgeon is physically separated from the patient.  Sometimes they are working at a console across the room. This inhibits the natural verbal interactions and non-verbal communication that keeps a team working smoothly.

To support efficient and effective communication and coordination in the OR, teams need to be on the same page. As the surgery progresses, everyone is working together without disruption to their workflow. With a digital platform, the physician can continue through surgery, knowing that the entire surgical team is working in tandem with a guide that is specific to their role.

GN: How can surgeons become better prepared for the transition to robot-assisted procedures, and whose responsibility should that be?

Justin Barad: The more training the better!  The only issue is surgeons have very little time and robots are difficult to transport and access for training purposes. In addition, surgeons need to make sure their team is always maintaining their proficiency so that they can set up and execute the procedures on a consistent basis. Virtual Reality provides an incredible opportunity to rapidly work your way up the learning curve anytime and anywhere given it's portability.  It also serves as a great on-demand training tool for situations where you have new team members coming into the OR and you need to rapidly get them up to speed. This is backed by the evidence which shows that training with Osso VR improves surgical proficiency anywhere from 230-306% in level 1 randomized peer reviewed trials.  In addition, intraoperative remote guidance technologies also are an intriguing tool to further support smooth execution of these cases.

Dr. Alex Langerman: Anytime a new technology is introduced, it has to demonstrate significant value for the patient for a physician to adopt a new way of doing a procedure and a hospital to make the financial commitment.  When a physician is transitioning to robot-assisted procedures, a learning curve is often associated with the adoption and integration into a new standard of care. In some cases, it can be significant. 

The responsibility falls on the manufacturer to support any training and education efforts on the proper use of new technology. Preparing their clinical team should also be a high priority. New technologies that offer simulated or virtual training have helped to provide physicians with exposure and practice environments, but it can't replace having experience in the room.  Using a platform like Explorer Live can support and facilitate the connection with expertise on the technology and key opinion leaders for training, peer-to-peer engagements, and mentorship.  Providing these resources can help to create a solid foundation of unlimited access to resources that can help to support a shift in clinical practice. Companies that support ongoing engagement will be vital to increasing the adoption of a new technique and support generating evidence that changing the way physicians operate is in the patient's best interest.

GN: What are some of the most effective methods for training surgeons to properly use robotic technology?

Justin Barad: Training on the robot is probably one of the best ways to learn but this is also the hardest to coordinate and has some of its own challenges.  Robots used for training see so much wear and tear they often break or don't work properly which can make training difficult.  They are usually so large they are very hard and expensive to ship out to training.  In addition, there usually isn't an easy way to objectively assess proficiency when using the real world equipment.  We are seeing more and more that in person training is being paired with some type of digital advanced training modality like virtual reality.  In this way you are able to rapidly work your way up the learning curve on your own time and then use valuable in person training time as "last mile training" rather than as introductory experiences.

Dr. Alex Langerman: Physicians will always want to get hands-on experiences when considering using new technology. Still, often the practical experience doesn't come until they are getting ready to do their first case. There are news training technologies that have made an impact in recent years that provide a simulated experience with haptic feedback. Like Osso VR, augmented and virtual reality platforms have enabled more physicians to have a realistic experience. 

Explorer Live complements training simulation by providing a platform to try the best practices that are shared.  For an OR team, a physician who has a comfort level with a procedure can bring their experience of procedural steps and support, creating efficiencies in the OR around setup, room configuration, and the use of supplies. Explorer Live also supports the ongoing efforts to keep an entire OR up to speed.  As their experience grows, physicians may take on more challenging cases with access to education and training content or the ability to remotely connect with peers to help minimize any downtime.

GN: How can training technologies improve patient outcomes?

Justin Barad: There is a groundbreaking study from Birkmeyer et al. published in the New England Journal of Medicine in 2013 titled: "Surgical Skill and Complication Rates after Bariatric Surgery."  This study asked the question "How does surgical skill affect patient outcomes."  What they found was illuminating and intuitive.  The more proficient the provider, the better the patient outcome, to the point where the higher skilled surgeons had a 5 times lower mortality rate than their lower skilled counterparts.  We are seeing some of this impact first hand with Osso VR.  Some of our users have been able to reduce their operating time by 50 percent (so from about 4 hours to 2 hours) which is incredibly compelling as we know generally more efficient operations will have better outcomes.  We are just starting to scratch the surface of this technology as it broadens its reach to the millions of HCPs who perform procedures around the world and the billions of patients they treat.

Dr. Alex Langerman: Training technologies that improve communication and coordination among surgical teams and reduce learning curves can significantly impact patient outcomes.  Physicians may be more willing to adopt new technology sooner if their initial experience is positive, leading to broader adoption by physicians and providing more patient access to game-changing innovation.

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