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Background Effective visualization of the operative field is vital to surgical safety and education. However, additional metrics for visualization are needed to complement other common measures of surgeon proficiency, such as time or errors. Unlike other surgical modalities, robot-assisted minimally invasive surgery (RAMIS) enables data-driven feedback to trainees through measurement of camera adjustments. The purpose of this study was to validate and quantify the importance of novel camera metrics during RAMIS. Methods New ( n  = 18), intermediate ( n  = 8), and experienced ( n  = 13) surgeons completed 25 virtual reality simulation exercises on the da Vinci Surgical System. Three camera metrics were computed for all exercises and compared to conventional efficiency measures. Results Both camera metrics and efficiency metrics showed construct validity ( p  < 0.05) across most exercises (camera movement frequency 23/25, camera movement duration 22/25, camera movement interval 19/25, overall score 24/25, completion time 25/25). Camera metrics differentiated new and experienced surgeons across all tasks as well as efficiency metrics. Finally, camera metrics significantly ( p  < 0.05) correlated with completion time (camera movement frequency 21/25, camera movement duration 21/25, camera movement interval 20/25) and overall score (camera movement frequency 20/25, camera movement duration 19/25, camera movement interval 20/25) for most exercises. Conclusions We demonstrate construct validity of novel camera metrics and correlation between camera metrics and efficiency metrics across many simulation exercises. We believe camera metrics could be used to improve RAMIS proficiency-based curricula.

Classic studies in human sensorimotor control use simplified tasks to uncover fundamental control strategies employed by the nervous system. Such simple tasks are critical for isolating specific features of motor, sensory, or cognitive processes, and for inferring causality between these features and observed behavioral changes. However, it remains unclear how these theories translate to complex sensorimotor tasks or to natural behaviors. Part of the difficulty in performing such experiments has been the lack of appropriate tools for measuring complex motor skills in real-world contexts. Robot-assisted surgery (RAS) provides an opportunity to overcome these challenges by enabling unobtrusive measurements of user behavior. In addition, a continuum of tasks with varying complexity-from simple tasks such as those in classic studies to highly complex tasks such as a surgical procedure-can be studied using RAS platforms. Finally, RAS includes a diverse participant population of inexperienced users all the way to expert surgeons. In this perspective, we illustrate how the characteristics of RAS systems make them compelling platforms to extend many theories in human neuroscience, as well as, to develop new theories altogether.

Purpose Surgical skill evaluation that relies on subjective scoring of surgical videos can be time-consuming and inconsistent across raters. We demonstrate differentiated opportunities for objective evaluation to improve surgeon training and performance. Methods Subjective evaluation was performed using the Global evaluative assessment of robotic skills (GEARS) from both expert and crowd raters; whereas, objective evaluation used objective performance indicators (OPIs) derived from da Vinci surgical systems. Classifiers were trained for each evaluation method to distinguish between surgical expertise levels. This study includes one clinical task from a case series of robotic-assisted sleeve gastrectomy procedures performed by a single surgeon, and two training tasks performed by novice and expert surgeons, i.e., surgeons with no experience in robotic-assisted surgery (RAS) and those with more than 500 RAS procedures. Results When comparing expert and novice skill levels, OPI-based classifier showed significantly higher accuracy than GEARS-based classifier on the more complex dissection task (OPI 0.93 ± 0.08 vs. GEARS 0.67 ± 0.18; 95% CI, 0.16–0.37; p  = 0.02), but no significant difference was shown on the simpler suturing task. For the single-surgeon case series, both classifiers performed well when differentiating between early and late group cases with smaller group sizes and larger intervals between groups (OPI 0.9 ± 0.08; GEARS 0.87 ± 0.12; 95% CI, 0.02–0.04; p  = 0.67). When increasing the group size to include more cases, thereby having smaller intervals between groups, OPIs demonstrated significantly higher accuracy (OPI 0.97 ± 0.06; GEARS 0.76 ± 0.07; 95% CI, 0.12–0.28; p  = 0.004) in differentiating between the early/late cases. Conclusions Objective methods for skill evaluation in RAS outperform subjective methods when (1) differentiating expertise in a technically challenging training task, and (2) identifying more granular differences along early versus late phases of a surgeon learning curve within a clinical task. Objective methods offer an opportunity for more accessible and scalable skill evaluation in RAS.

The basic hypothesis of producing a range of behaviors using a small set of motor commands has been proposed in various forms to explain motor behaviors ranging from basic reflexes to complex voluntary movements. Yet many fundamental questions regarding this long-standing hypothesis remain unanswered. Indeed, given the prominent nonlinearities and high dimensionality inherent in the control of biological limbs, the basic feasibility of a low-dimensional controller and an underlying principle for its creation has remained elusive. We propose a principle for the design of such a controller, that it endeavors to control the natural dynamics of the limb, taking into account the nature of the task being performed. Using this principle, we obtained a low-dimensional model of the hindlimb and a set of muscle synergies to command it. We demonstrate that this set of synergies was capable of producing effective control, establishing the viability of this muscle synergy hypothesis. Finally, by combining the low-dimensional model and the muscle synergies we were able to build a relatively simple controller whose overall performance was close to that of the system's full-dimensional nonlinear controller. Taken together, the results of this study establish that a low-dimensional controller is capable of simplifying control without degrading performance.

Purpose In this study, we examine three-dimensional (3D) proctoring tools (i.e., semitransparent ghost tools overlaid on the surgeon’s field of view) on realistic surgical tasks. Additionally, we develop novel, quantitative measures of whether proctors exploit the additional capabilities offered by ghost tools. Methods Seven proctor–trainee pairs completed realistic surgical tasks such as tissue dissection and suturing in a live porcine model using 3D ghost tools on the da Vinci Xi Surgical System. The usability and effectiveness of 3D ghost tools were evaluated using objective measures of proctor performance based on proctor hand movements and button presses, as well as post-study questionnaires. Results Proctors exploited the capabilities of ghost tools, such as 3D hand movement ( p  < 0.001), wristedness ( p  < 0.001), finger pinch gestures ( p  < 0.001), and bimanual hand motions ( p  < 0.001). The median ghost tool excursion distances across proctors in the x -, y -, and z -directions were 57.6, 31.9, and 50.7, respectively. Proctors and trainees consistently evaluated the ghost tools as effective across multiple categories of mentoring. Trainees found ghost tools more helpful than proctors across all categories ( p  < 0.05). Conclusions Proctors exploit the augmented capabilities of 3D ghost tools during clinical-like training scenarios. Additionally, both proctors and trainees evaluated ghost tools as effective mentoring tools, thereby confirming previous studies on simple, inanimate tasks. Based on this preliminary work, advanced mentoring technologies, such as 3D ghost tools, stand to improve current telementoring and training technologies in robot-assisted minimally invasive surgery.

Background Validated training exercises are essential tools for surgeons as they develop technical skills to use robot-assisted minimally invasive surgical systems. The purpose of this study was to show face, content, and construct validity of four, inanimate training exercises using the da Vinci ® Si surgical system configured with Single - Site ™ instrumentation. Methods New ( N  = 21) and experienced ( N  = 6) surgeons participated in the study. New surgeons (11 Gynecology [GYN] and 10 General Surgery [GEN]) had not completed any da Vinci Single - Site cases but may have completed multiport cases using the da Vinci system. They participated in this study prior to attending a certification course focused on da Vinci Single - Site instrumentation. Experienced surgeons (5 GYN and 1 GEN) had completed at least 25 da Vinci Single - Site cases. The surgeons completed four inanimate training exercises and then rated them with a questionnaire. Raw metrics and overall normalized scores were computed using both video recordings and kinematic data collected from the surgical system. Results The experienced surgeons significantly outperformed new surgeons for many raw metrics and the overall normalized scores derived from video review ( p  < 0.05). Only one exercise did not achieve a significant difference between new and experienced surgeons ( p  = 0.08) when calculating an overall normalized score using both video and advanced metrics derived from kinematic data. Both new and experienced surgeons rated the training exercises as appearing, to train and measure technical skills used during da Vinci Single - Site surgery and actually testing the technical skills used during da Vinci Single - Site surgery. Conclusions In summary, the four training exercises showed face, content, and construct validity. Improved overall scores could be developed using additional metrics not included in this study. The results suggest that the training exercises could be used in an overall training curriculum aimed at developing proficiency in technical skills for surgeons new to da Vinci Single - Site instrumentation.

Background As more surgeons choose to complete procedures robotically, validated training tools are needed so that they can acquire and maintain the technical skills required to proficiently use robotic systems. The purpose of this study was to show construct validity of nine new inanimate training exercises for robot-assisted surgery. The inanimate training exercises were designed to span several core technical skills required to use a robotic system. Methods New ( n  = 30) and experienced ( n  = 11) robotic surgeons participated in the study. New robotic surgeons had not yet completed their first robotic surgery case and participated in this study before attending their robotic certification course. Experienced robotic surgeons had completed more than 200 robotic surgery cases. The raw scores from the exercises were reported so that other research groups could easily define custom proficiency levels. Example normalized scores that could be used in proficiency-based curricula were computed. These normalized scores balanced efficiency (completion time) and accuracy (exercise-specific errors) to measure performance. Finally, the setup was standardized using a custom docking model, which enabled consistent and repeatable completion of the inanimate exercises across surgeons. Results For all nine exercises, experienced robotic surgeons completed the exercises significantly faster than new robotic surgeons ( p  < 0.01). Similarly, experienced robotic surgeons achieved higher normalized scores than new robotic surgeons for all nine exercises ( p  < 0.01). Finally, consistent robot setup was achieved using the custom docking model based on an analysis of the robot kinematic data. Conclusions In summary, all nine inanimate exercises showed construct validity. The results suggest that the inanimate exercises along with the custom docking model can be used as part of proficiency-based curricula to improve robotic surgeon training.

Experienced surgeons commonly mentor trainees as they move through their initial learning curves. During robot-assisted minimally invasive surgery, several tools exist to facilitate proctored cases, such as two-dimensional telestration and a dual surgeon console. The purpose of this study was to evaluate the utility and efficiency of three, novel proctoring tools for robot-assisted minimally invasive surgery, and to compare them to existing proctoring tools. Twenty-six proctor-trainee pairs completed validated, dry-lab training exercises using standard two-dimensional telestration and three, new three-dimensional proctoring tools called ghost tools. During each exercise, proctors mentored trainees by correcting trainee technical errors. Proctors and trainees completed post-study questionnaires to compare the effectiveness of the proctoring tools. Proctors and trainees consistently rated the ghost tools as effective proctoring tools. Both proctors and trainees preferred 3DInstruments and 3DHands over standard two-dimensional telestration (proctors p  < 0.001 and p  = 0.03, respectively, and trainees p  < 0.001 and p  = 0.002, respectively). In addition, proctors preferred three-dimensional vision of the operative field (used with ghost tools) over two-dimensional vision ( p  < 0.001). Total mentoring time and number of instructions provided by the proctor were comparable between all proctoring tools ( p  > 0.05). In summary, ghost tools and three-dimensional vision were preferred over standard two-dimensional telestration and two-dimensional vision, respectively, by both proctors and trainees. Proctoring tools—such as ghost tools—have the potential to improve surgeon training by enabling new interactions between a proctor and trainee.

BackgroundSurgical training requires clinical knowledge and technical skills to operate safely and optimize clinical outcomes. Technical skills are hard to measure. The Intuitive Data Recorder (IDR), (Sunnyvale, CA) allows for the measurement of technical skills using objective performance indicators (OPIs) from kinematic event data. Our goal was to determine whether OPIs improve with surgeon experience and whether they are correlated with clinical outcomes for robotic inguinal hernia repair (RIHR).MethodsThe IDR was used to record RIHRs from six surgeons. Data were obtained from 98 inguinal hernia repairs from February 2022 to February 2023. Patients were called on postoperative days 5–10 and asked to take the Carolina Comfort Scale (CCS) survey to evaluate acute clinical outcomes. A Pearson test was run to determine correlations between OPIs from the IDR with a surgeon’s yearly RIHR experience and with CCS scores. Linear regression was then run for correlated OPIs.ResultsMultiple OPIs were correlated with surgeon experience. Specifically, for the task of peritoneal flap exploration, we found that 23 OPIs were significantly correlated with surgeons’ 1-year RIHR case number. Total angular motion distance of the left arm instrument had a correlation of − 0.238 (95% CI − 0.417, − 0.042) for RIHR yearly case number. Total angular motion distance of right arm instrument was also negatively correlated with RIHR in 1 year with a correlation of − 0.242 (95% CI − 0.420, − 0.046). For clinical outcomes, wrist articulation of the surgeon’s console positively correlated with acute sensation scores from the CCS with a correlation of 0.453 (95% CI 0.013, 0.746).ConclusionsThis study defines multiple OPIs that correlate with surgeon experience and with outcomes. Using this knowledge, surgical simulation platforms can be designed to teach patterns to surgical trainees that are associated with increased surgical experience and with improved postoperative outcomes.

Validated training exercises are essential tools for surgeons as they develop technical skills to use robot-assisted minimally invasive surgical systems. The purpose of this study was to show face, content, and construct validity of four, inanimate training exercises using the da Vinci ^sup ^ Si surgical system configured with Single-Site ^sup (TM)^ instrumentation. New (N = 21) and experienced (N = 6) surgeons participated in the study. New surgeons (11 Gynecology [GYN] and 10 General Surgery [GEN]) had not completed any da Vinci Single-Site cases but may have completed multiport cases using the da Vinci system. They participated in this study prior to attending a certification course focused on da Vinci Single-Site instrumentation. Experienced surgeons (5 GYN and 1 GEN) had completed at least 25 da Vinci Single-Site cases. The surgeons completed four inanimate training exercises and then rated them with a questionnaire. Raw metrics and overall normalized scores were computed using both video recordings and kinematic data collected from the surgical system. The experienced surgeons significantly outperformed new surgeons for many raw metrics and the overall normalized scores derived from video review (p < 0.05). Only one exercise did not achieve a significant difference between new and experienced surgeons (p = 0.08) when calculating an overall normalized score using both video and advanced metrics derived from kinematic data. Both new and experienced surgeons rated the training exercises as appearing, to train and measure technical skills used during da Vinci Single-Site surgery and actually testing the technical skills used during da Vinci Single-Site surgery. In summary, the four training exercises showed face, content, and construct validity. Improved overall scores could be developed using additional metrics not included in this study. The results suggest that the training exercises could be used in an overall training curriculum aimed at developing proficiency in technical skills for surgeons new to da Vinci Single-Site instrumentation.