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Robotic surgery turns surgical trainees into spectators

spectrum.ieee.org

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Re: Robotic surgery turns surgical trainees into spectators

#41
post #31

Earlier quoted context omitted.

> 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.

Aren't these non-intrusive and done using gamma knives? I read somewhere that computer+radiologist perform the planning of beams and the gamma knive does all the work

You still have biopsies, SEEGs and anything else that requires deep brain invasive action.

Re: Robotic surgery turns surgical trainees into spectators

#42

Earlier quoted context omitted.

I think we should solve autonomous driving before jumping multiple steps to autonomous surgery. There are many low hanging fruit in the world of automation; automated surgery is not one of them.

Autonomous surgery is probably easier to solve than driving, because the patient is lying still. Though you'd still need at least a nurse observing and a surgeon standing by. But you could have only one surgeon as backup for multiple robots in the same hospital.

A surgery is a closed task. Driving is an open ended task interacting many actors and novel challenges. It’s probably slow enough that it can visually confirm assumptions with a human operator if need be.I would bet on the autonomous surgeon over the autonomous driver any day.

Re: Robotic surgery turns surgical trainees into spectators

#43

Earlier quoted context omitted.

> The cost of the da Vinci robot was obtained from Intuitive Surgical. This analysis utilized the $1.5 million da Vinci-S robot. The cost of the robot was amortized over 5 years; thus, the robot costs $300,000 per year and the service contract is $112,000 per year. So it adds the cost of one extra surgeon, for the same outcomes, but slower? Here's a list of advantages. [1] [1] https://www.ncbi.nlm.nih.gov/pmc/article…

So I suspect we're in a stage similar to where early muskets were vs bows. Barely better, possible even worse. But we're on a path that let's us unlock many advancements. i.e. autonomous surgery.

Guns were pretty much immediately better. They were easy to use, cheap to reload, and you could shoot through armor.

Re: Robotic surgery turns surgical trainees into spectators

#44
post #2

I’m a bit shocked that simulators aren’t made readily accessible to surgeons. I thought that would be the biggest advantage of robotic surgery - a surgeon could prep with a few practice surgeries on the sim, while being taken through a few “sometimes this is what goes wrong, here is how you recognize/recover”-scenarios.

It'll be interesting to see the growth of simulation in other fields similar to that used in radiation oncology [0]. The trick about human bodies is that they aren't all the same and they don't say the same. Once the robot can perform sufficiently similarly in simulation as in real life, then a high risk and cost intervention like surgery will be simulated before performance.

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...

1. https://www.nist.gov/physics/what-are-imaging-phantoms

Re: Robotic surgery turns surgical trainees into spectators

#45

Earlier quoted context omitted.

Autonomous surgery is probably easier to solve than driving, because the patient is lying still. Though you'd still need at least a nurse observing and a surgeon standing by. But you could have only one surgeon as backup for multiple robots in the same hospital.

A surgery is a closed task. Driving is an open ended task interacting many actors and novel challenges. It’s probably slow enough that it can visually confirm assumptions with a human operator if need be.I would bet on the autonomous surgeon over the autonomous driver any day.

Human anatomy is actually surprisingly variable and there is, of course, trauma - so novel challenges.

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.

Re: Robotic surgery turns surgical trainees into spectators

#46
post #40

Earlier quoted context omitted.

It is nearly impossible to accurately simulate a “software body“.

Why? Couldn’t one model the various tissues and bones, fluids, surface tensions, resistance to cutting etc?

Very very many variables... For example, burnt tissue, crushed tissue, injection trauma, infected tissue plus variable anatomy.

Re: Robotic surgery turns surgical trainees into spectators

#47

Earlier quoted context omitted.

So I suspect we're in a stage similar to where early muskets were vs bows. Barely better, possible even worse. But we're on a path that let's us unlock many advancements. i.e. autonomous surgery.

Guns were pretty much immediately better. They were easy to use, cheap to reload, and you could shoot through armor.

I'm not sure this is true. Reloading muskets took a long time, no? You had to fumble with pouring the powder, tamping it, putting in the round, possibly also a sabot. "Reloading" a bow takes a second.

Re: Robotic surgery turns surgical trainees into spectators

#48

Surgeon here who does the majority of my “major case” work robotically. Author of this article has a coastal-centric point of view. My residency was apprenticeship model and I graduated very confident in my capabilities to perform robotic surgery “skin-to-skin”. The phenomenon he references about trainees no longer being able to start a surgery without the “attending” surgeon present is not related to robotics. It is…

[deleted]

Re: Robotic surgery turns surgical trainees into spectators

#49
I am currently a senior surgical trainee at a major American academic medical center (1 year to go out of 7). Thought I can provide some insight on some of the primary questions I see in the comments:

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.

Re: Robotic surgery turns surgical trainees into spectators

#50
There is long term advantage to do robotic surgery in the creation of a large learning dataset. All the inputs to the surgeon - video, audio, bio metrics - are digitized, and all the surgeon outputs like movements and actions and even the peripheral actions like dosage changes or orders to nurses, it's all digitized. If all the inputs and outputs can be digitized,we can also expect the creation of outputs to be automated. Why not?
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