Robotic surgery turns surgical trainees into spectators
spectrum.ieee.org
spectrum.ieee.org
See the article on HN yesterday for which the comment section was chock full of “tear down the health bureaucracy” rhetoric. If the general public comes out saying “we want trainees working on us, if it creates better doctors and lowers health care costs” then the system can become much simpler and get back to the old days of higher autonomy for trainees in academic centers.
Until then, advice for future surgeons: if you want to learn how to operate during residency, consider a program in the midwest without a lot of fellows.
The skills issue you identify with some big-name programs is a real thing for sure, though.
Glad to ask her any engineering- or programmer-minded questions that HN folks might have about what robotic surgery is like. (I'll collect any that are posted here, turn a list of them into a batch for her, and transcribe her answers.)
One thing that I notice that the author of this article leaves out is that though trainees are often "watching" a surgery rather than controlling it via the second console, this is a much better form of "watching" than most surgical trainees are typically accustomed. This is because both consoles attached to the robot get the immersive PoV of the primary surgeon. This should be compared to the alternatives, "'straight-stick' laparoscopy" and "open surgery", wherein the view of the surgery for trainees is usually quite limited.
FWIW, my wife trained "both ways" (robotic and 'straight-stick') and believes there are trade-offs -- it depends on the patient condition and what one is trying to accomplish.
The article's author, who is a roboticist rather than a surgeon, paints a picture where robotic surgery does not have a clear advantage over straight-stick surgery due to a lack of training: "In fact, a recent survey of 50 randomized control trials that compared robotic surgery to conventional and laparoscopic surgeries found that outcomes were comparable, and robotic surgeries were actually a bit slower. From my perspective, focusing on education, it’s something of a miracle that outcomes aren’t worse, given that residents are going to their first jobs without the necessary experience. "
To learn from an alternative perspective, what might be an example of a patient condition or objective where robotic surgery may have a meaningful advantage over conventional surgery?
Stereotactic surgery in Neurosurgery.
I read somewhere that computer+radiologist perform the planning of beams and the gamma knive does all the work
I think it'd be pretty hard to do a true apples-to-apples comparison. You'd want to find traditional surgeries that were complex enough that robotic surgery would be indicated, yet for some reason they went ahead with traditional surgery anyway. Almost by definition this would push you more toward emergent surgeries which have worse outcomes overall given their acute nature. You could probably find areas where transfer to a facility with a robot would take too long but you're bringing in a lot of other confounding variables (comparing robotic surgeries at a well funded academic institute with lots of residents and fellows to a small poorly staffed hospital in the sticks, for example).
Kind of like the difference between a kebel space program and an ultra realistic physics and material simulator.
I'd be shocked if there wasn't at least a few "games" to practice dexterity and perform device diagnostics.
1. Computerized i.e. Eyesi Surgical Simulator
2. Practice surgery with real equipment on synthetic eyes designed to replicate human tissue
3. Practice surgery with real equipment on human cadaver / pig cadaver eyes
Many ophthalmology residency programs use a combination of these for training.
[0] https://eyewiki.aao.org/Cataract_surgery_training_around_the...
Other manufacturers also have them
I am interested in the trade offs & what it is not a good fit for.
I realize that is a broad “question”. But any insight is appreciated
Also… any words of wisdom for someone about to enter med school?
For a 5 hour surgery, the fellow got to drive the robot for about 90 minutes. He spent the rest of the time watching.
The resident made incisions to introduce the robotic instruments and then closed at the end. This took about 15 minutes at the start of the case and and another 15 at the end. She spent the rest of the time standing there and watching.
I wasn't even allowed to scrub in - not enough space with the robot docked. I had to stand in the corner of the room for 5 hours watching the surgery on a monitor. And of course the circulating RN wouldn't let me stand in a place with a decent view.
I would have had a better learning experience watching a YouTube video of a surgery. What a colossal waste of time for all trainees involved.
This same limitation applies to simulators though, so this application isn't an answer to the parent comments question.
Here is one example paper: https://pubmed.ncbi.nlm.nih.gov/29023350/
On the other hand, simulating say skin/muscle/blood or anything that closely resembles human body is near impossible. Without that, a simulator is pretty much useless and it'll probably easier to train the surgeons on real robot + some animal like pig
To run a high-fidelity simulator of human body that is useful for surgeons, you need a LOT more. And I doubt it can be data-driven. Data-driven simulators for things like autonomous cars are just coming up, and these are way simple as the agent (the autonomous car) doesn't directly change the environment when it's driving around (as in, you don't have to simulate the car colliding into a traffic pole and then breaking it, etc.)
To simulate a human body, you need to be able to capture the material properties of different layers, some of which are fluids, and then also the interaction between them and how different organs react to a surgical operation. It's a very hard problem.
Why do all that when you have animal corpses readily available? There's no need to create a problem that doesn't exist.
a) thousands of hours is far far far too little data. This is a total ballpark estimate, with only knowledge of the ML and basically zero knowledge of the surgery side, but I would expect three to six orders of magnitude greater, i.e. millions to billions of hours necessary to train a machine learning model to do something like that, to a standard.
b) the big problem is not the procedures themselves, but edge cases and things going a little bit wrong.
c) you are fine with tiny flukes in your generated images, but you won't be very happy with an ML model whose tiny flukes lead to internal bleeding.
d) unfortunately (with contemporary models) we can't easily explore latent space, which might possibly contain regions corresponding to catastrophic robot arm movements. the chance isn't that high, but it's not a chance most'd be willing to take at this point.
In the case of robotic surgery simulator, you are using the controls to control the arm, but to interact with what? If you just want to move the arm around and maybe interact with some rigid objects sure that's easy. Would that add any training value to the surgeon? Probably not. You can get value only when the simulator includes a simulation of something the surgeon would have to face eventually - organic mass of the human body. Simulating that is hard, and I doubt anyone would invest much into it when you can train surgeons on alternative physical objects like pigs.
I'm working for a small company that is trying to bridge the gap and make something good that can run on the consumer VR/AR hardware that's coming out in the next year or three. Lots of interesting problems to solve.
https://www.intuitive.com/en-us/products-and-services/da-vin...
In my experience in a related field, simulators are about 2% as useful as advertised. The cousin thread explains how difficult building a flesh simulator is, so I wouldn't expect surgical experience on a simulator to be very useful.
The author wrote: "The paper I published in 2019 summarized my findings, which were dismaying. The small subset of trainees who succeeded in learning the skills of robotic surgery did so for one of three reasons: They specialized in robotics at the expense of everything else, they spent any spare minutes doing simulator programs and watching YouTube videos, or they ended up in situations where they performed surgeries with little supervision, struggling with procedures that were at the edge of their capabilities. I call all these practices “shadow learning,” as they all bucked the norms of medical education to some extent. I’ll explain each tactic in more detail.
"Residents who engaged in “premature specialization” would begin, often in medical school and sometimes earlier, to give short shrift to other subjects or their personal lives so they could get robotics experience. Often, they sought out research projects or found mentors who would give them access. Losing out on generalist education about medicine or surgery may have repercussions for trainees. Most obviously, there are situations where surgeons must turn off the robots and open up the patient for a hands-on approach. [...] My data strongly suggest that residents who prematurely specialize in robotics will not be adequately prepared to handle such situations."
The author also listed examples of accessible simulators, notably one that uses virtual reality: "In the past five years, there has been an explosion of apps and programs that enable digital rehearsal for surgical training (including both robotic techniques and others). Some, like Level EX and Orthobullets, offer quick games to learn anatomy or basic surgical moves. Others take an immersive approach, leveraging recent developments in virtual reality like the Oculus headset. One such VR system is Osso VR, which offers a curriculum of clinically accurate procedures that a trainee can practice in any location with a headset and Wi-Fi."
An additional aspect of simulation is calibration and use of phantoms [1]. These are materials of known characteristics approximating human anatomical densities. I suppose for robotic surgery this would be used for both the imaging and the surgical tech.
0. https://radiationoncology.weillcornell.org/clinical-services...
Surgeons can take a few practice simulations in the Sim, but it's just that doing so ties up the robot from doing real cases at that time also.
So, pretty cheap, it sounds like? How much is the hourly rate of surgeons?
A surgeon makes on average $115 an hour in California, $280k a year. So the console plus simulator backpack costs a surgeon or two's yearly salary.
https://www.ziprecruiter.com/Salaries/Surgeon-Salary--in-Cal....
I’m aware you need to be steady. I’m aware it can take a great deal of time and focus and endurance. But how hard is it to figure out a surgery, and execute it?
My daughter had brain surgery and we found the actual medical paper describing how to perform the procedure. It’s basically 6 sentences long. Cut here, make an incision, use a tool there. All while being sure not to accidentally sever an infant’s spine and make them a quadriplegic. The actual instructions were simple enough that I could understand perfectly well how to do the procedure based on the document. However, I’m sure if I actually attempted the surgery I’d be a nervous wreck. I’d guess confidence is probably another part. But maybe a doctor will chime in.
I just tried to find the paper but am not sure where we dug it up or I’d just post it here.
And that's all without getting into things like how much of a grace period you have between the first cut and the last fastener, which you don't have with a living organism.
To answer your question, basic surgury isn't (difficult). Good medicine is. The more complex the issue, the better medicine you need.
A common analogy used in neurosurgery training: "Imagine a wooden plank on the driveway and walk its length -- no problem. Suspend that same board ten stories in the air and try again." The hard part is not the "figuring out" or "execution" but knowing the irreversibility and making the correct decision. Your patient expects you to be correct 10 times out of 10, yet you know that's not possible. Squaring our fallibility with the irreversibility of our missteps is the hard part, and what keeps surgeons up at night. The fly struggles in the web.
Fascinating. I definitely assumed that the robotic surgeries had better outcomes.
I wonder how much of this kind of thing is contributing to higher costs in US healthcare.
So it adds the cost of one extra surgeon, for the same outcomes, but slower?
Here's a list of advantages. [1]
The task is also not necessarily closed at the start, i.e., target of surgery is established during the procedure and might evolve.
So, I'd take the other side of that bet for surgery as a whole.
1k longbowmen beat 1k musket bros, but that’s not the comparison that really mattered.
Before addressing anything further, robotic surgery is probably a misnomer, a better classification would be robotic assisted laparoscopic surgery. Once in place and spatial / positional orientation is obtained, the robot remains a tool directly controlled by the surgeon, no automation of the actual surgery is involved.
1: Regarding the actual commentary in the article:
Surgical trainees have transiently suffered in the still (early) adoption of this technology as the Attending surgeons themselves are often recently trained in robotic assisted surgery and lack confidence in letting trainees take full control. In the hands of an experienced attending surgeon, the trainee experience is comparable with any other surgery. Most academic centers should have two consoles, one for the resident and one for the attending, and control is easily handed off.
As is appropriate, robotic training is being increasingly incorporated into surgical training, with some programs being more advanced than others. There are a few classes (I.e graduation years) of trainees that have / will be left out of this due to the relatively recent and ongoing adoption. Overall though this is a transient issue that is being actively resolved.
2) Is surgery hard?
While in many way surgery is similar to mechanical repair / construction, the human body is much less discrete and predictable than most mechanical objects. While some surgeries are straightforward and can be learned quickly (I.e with 30-100 cases), there is an enormous variation in complexity and risk even with a particular surgery. For example, laparoscopic appendectomy is a common surgery that is considered to be “easy”. However there is a lot of subtlety in that assessment. First appendicitis can range in severity, with severe cases lacking in identifiable anatomy and often requiring a procedure of fundamentally higher complexity. How would you replace a clutch if you can’t actually see the clutch, are not sure where it is, and it is surrounded but a wide range of other critical components that would be irreparably damaged if they are touched in the wrong way. In addition, a lot of the learning is determining how hard you can safely pull or push without inadvertently hurting something or causing substantial bleeding, which is a learned skill. Finally, surgery is an extension of medicine, so you also have to learn how to determine a diagnosis, whether or not a surgery is indicated, what specific surgery is indicated, and how to take care of your patient post operatively to minimize complications.
All of this usually takes many years of hands on experience. Reading about something (and there is a lot to read) doesn’t mean you know how to safely and appropriately manage an issue.
3) What benefits are there to robotic assisted laparoscopy compared to traditional laparoscopy
The robotic arms add a fully rotating “wrist” joint near the tip of the instrument which adds multiple degrees of freedom to the standard straight sticks of laparoscopy (which only has rotation of the instrument tip). This adds for much more flexibility in tight spaces, such as the pelvis, or in areas where rigidity limits mobility of the instruments (the chest). Related to this, it improves surgeon ergonomics in many cases. It’s use is also being explored to allow for much more complex cases than have been possible with traditional laparoscopy due to awkward working angles, such as massive ventral hernia repairs. In addition it has a larger dual camera (for stereoscopic 3d) and comes with a more complex co2 insufflation system which both insufflates and drains air, greatly improving visualization (though this can theoretically be used with standard laparoscopy).
In terms of outcomes, for most cases there probably won’t be a difference, but a lot of the benefit is likely in intangible things like surgeon ergonomics, improved visibility, and enabling some cases that are simply too difficult or awkward to do safely with traditional laparoscopy.