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Robotic surgery turns surgical trainees into spectators

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31–40 of 90 posts

Re: Robotic surgery turns surgical trainees into spectators

#31

Earlier quoted context omitted.

I'm curious to learn more about the main advantages of the da Vinci machines in certain contexts, over 'straight-stick' surgery. 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 conventio…

> 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

Re: Robotic surgery turns surgical trainees into spectators

#32
post #19

I'm a programmer and my wife is a robotic surgeon who did many, many operations with these da Vinci machines (and also trained with them in residency). Her focus is on what's known as "MIGS", described here: https://en.wikipedia.org/wiki/Robot-assisted_surgery#Gynecol... 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…

Is there someway for the trainees to do simulations on these machines? You'd think if they can simulate landing the space shuttle, you could simulate doing a surgery.

In cataract surgery there are three main kinds of simulation I'm aware of.

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...

Re: Robotic surgery turns surgical trainees into spectators

#33
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 due to CMS or liability (lawyers) or hospital policy regulations (lawyers). Same reason medical students are pushed away from direct patient care until they graduate and become residents.

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.

Re: Robotic surgery turns surgical trainees into spectators

#34
post #16

Question: is surgery hard? 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?

I think it depends on the surgery. Farmers neuter their own pigs and cattle all the time which is a type of surgery. 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 instructi…

I imagine the trained surgeon knows what to do when anything goes wrong following those 6 simple instructions, and from thence flows confidence.

Re: Robotic surgery turns surgical trainees into spectators

#35
post #16

Question: is surgery hard? 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?

I think it depends on the surgery. Farmers neuter their own pigs and cattle all the time which is a type of surgery. 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 instructi…

I think a lot of it is the knowledge of the rest of the body and the ability to adapt when something doesn't go exactly according to plan.

Re: Robotic surgery turns surgical trainees into spectators

#36
post #16

Question: is surgery hard? 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?

I think it depends on the surgery. Farmers neuter their own pigs and cattle all the time which is a type of surgery. 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 instructi…

My fiance does a lot of abdominal surgeries, including robotic. There are a handful that are "difficult" in the traditional sense - lots of complicated steps, indications and contraindications for different methods to complete the same task, etc - but by-and-large most of them are following a set of prescribed steps. For her, because the surgeries are abdominal, a lot of the difficulty comes in when dealing with patients of larger weight and/or who have had lots of previous procedures. A surgery that takes 45 minutes on a 110-pound 17 year old with no major medical history can easily take 4 hours or more for a 400-pound woman with multiple c-sections and multiple other surgeries. Scar tissue distorts the anatomy, it's just physically more difficult to move past outer layers, etc.

Re: Robotic surgery turns surgical trainees into spectators

#37

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.

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.

Re: Robotic surgery turns surgical trainees into spectators

#38
post #30
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.

What makes you think they're not readily accessible? They are. Part of the issue is time. If you're a surgeon, one individual surgery is but a small part of your day. There really isn't any spare time to "prep" for a surgery other than reading the specific of that individual case.

The submitted article also discusses how a limiting factor is time rather than availability of simulators.

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."

Re: Robotic surgery turns surgical trainees into spectators

#39

I'm a programmer and my wife is a robotic surgeon who did many, many operations with these da Vinci machines (and also trained with them in residency). Her focus is on what's known as "MIGS", described here: https://en.wikipedia.org/wiki/Robot-assisted_surgery#Gynecol... 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…

I spoke to a radiologist in a regional hospital in a rural area. I believe they were in talks among themselves at the hospital to buy one of the da Vinci machines. This physician’s contention was that new surgeons operating mostly through these robots aren’t necessarily effective to react to a bleeder during a procedure. He was no doubt skeptical of the surgeons he was seeing operating with these things. Curious what your wife thinks.

Also… any words of wisdom for someone about to enter med school?

Re: Robotic surgery turns surgical trainees into spectators

#40
post #20

Earlier quoted context omitted.

it would control a software arm operating on a software body, just like a flight sim controls a software plane.

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?
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