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t’s not the way his father learned surgery, at least the first time around, but resident David McClusky III (left) believes his experiences in Emory’s virtual surgical environment made him better, and certainly more comfortable, when he finally operated on a real patient. “Because I already knew what I needed to be doing with my hands, and how it looked and felt to do the procedures, I was able to concentrate more on the patient, rather than strictly on whether I was doing something right,” he says.
     McClusky’s dad, a general surgeon in Twin Falls, Idaho, was an early adopter of the minimally invasive surgery (MIS) that is driving surgical training. Patients and payers alike have embraced new procedures that reduce pain, scarring, and hospital stays, but for surgeons such as the elder McClusky, MIS turned what they knew upside down.
     “Yes, it took Dad a little longer to learn than me,” says the son, “precisely because he was already such an experienced surgeon.”
     In MIS procedures, a thumb-sized, high-resolution video camera and long, narrow surgical instruments are inserted and manipulated through small “keyhole” incisions. Surgeons must mentally translate two-dimensional tissue images on a video screen to three-dimensional images seen in an actual surgical field. They then must overcome the fulcrum effect, the visual-sensory mismatch caused when the hand moves down but the instrument on the screen moves up. Furthermore, the powerful tactile feedback of direct hand contact with tissue is replaced by weaker feedback from the instruments, which are attached to 18-inch levers.
     “Surgeons used to have to learn from other surgeon’s mistakes,” says McClusky. “Now you can learn from your own.”

Minimally invasive surgery is only a part of the revolution that began in the 1990s, says Emory surgeon Dan Smith, director of the Emory Simulation, Training and Robotics (ESTAR) program. More and more procedures are being done laparoscopically, endoscopically, or via surgical robotic systems, the newest advance. Surgeons use these remote-controlled devices, connected to computers, to operate through the tiniest of incisions while monitoring and adjusting their instruments to account for heartbeat, breathing, and other physiologic movements.
     When used safely, Smith says, these systems deliver “equalizing technologies” for better and safer care of patients, extending the range of difficult procedures that skilled surgeons can perform with less risk and greater comfort for the patient. However, the new technology and procedures aren’t intuitive, he says. They “challenge the way human beings naturally interact with the physical world and thus have enormous implications for the practitioner and patient, especially for the practitioners’ first few patients undergoing a new procedure.”
     Emory established ESTAR in 2001, in part because the tools of surgery had changed so radically in recent years. But other factors came into play as well. Two years earlier, the Institute of Medicine published “To Err Is Human: Building a Safer Health System,” highlighting the issue of medical and surgical errors and ways to circumvent them using lessons learned in other professions. More recently, residency training time was reduced to 80 hours per week under new federal guidelines, necessitating increased efficiency. And Emory’s medical school is now in midst of a curriculum redesign, with ESTAR as a key component.
     The program designs curricula for surgical training using the newest MIS technologies. Now increasingly used by Emory’s own students, residents, and faculty, the learning modules have wide applicability to other institutions as well. ESTAR now offers six to 10 continuing education programs annually, with more on the way, and clinicians and educators from other institutions arrive regularly on campus to learn how to add virtual reality, simulation, and robotics to their training programs. Dissemination of this knowledge is likely to increase in importance as the American College of Surgeons and the American Board of Surgery undertake development of new national training standards.
     ESTAR enhances rather than replaces current methods of education and training, says Smith, citing cholecystectomy as an example. Young surgeons still get their information on anatomy and physiology of the gallbladder in traditional ways. They still learn traditional open-incision cholecystectomy—necessary in clinical situations like inflammation and bleeding—by taking incremental responsibility in real-life procedures. However, more and more, they are acquiring and honing their basic skills, beginning with suturing, in the simulation lab. When it comes to laparoscopic procedures, they increasingly turn to the ESTAR lab. There they progress through a carefully sequenced series of experiences, learning to move spheres and cubes, manipulating clips on duct-like tubes, and, finally, performing the entire operation on a haptic simulator. This simulator includes both a video monitor and actual tactile feedback as the trainee cuts away the virtual gallbladder, manipulates it into a little sack, and withdraws it through the small incision.

That’s what Smith wants to find out. The ESTAR program conducts research on how surgeons learn and on the effectiveness of the new training tools. Numerous studies have shown that training on a simulator makes surgeons better at operating simulators. ESTAR researchers measure which simulators reduce the learning curve and improve skills in the operating room and how. For example, urologist Kenneth Ogan is now teaching 12 Emory urology residents to use an aptly named “uro-mentor” to treat kidney stones and tumors in a minimally invasive fashion. In the study, residents will either train on the uro-mentor or learn skills through traditional means. Following training, the residents will be assessed on actual cases in the operating room. The hope is that this virtual reality simulator will provide residents with necessary skills prior to entering the operating room, which will result in fewer errors and improved patient safety.
     Smith considers ESTAR a “simulation and robotics playground.” General and subspecialty surgeons, interventional radiologists, anesthesiologists, emergency medicine physicians, and nursing faculty all turn to the program for help in designing training modules specific to their own needs. Now tucked away in an Emory University Hospital annex, the playground will get new digs when a new medical school building opens, complete with a large simulation laboratory where students can operate and recreate other patient situations using actors and electronic models.

Current guidelines for deciding when a surgeon is adequately trained now depend on his or her completion of a certain number of procedures, a one-size-fits-all approach. Simulation provides a more precise, individualized, step-by-step assessment of proficiency, and many predict readiness will eventually be measured this way. How many times does a surgeon need to remove an electronic gallbladder before being ready to operate on a real patient? As many as it takes, says Smith, just as novice or experienced pilots learning to maneuver a new plane may crash and burn over and over before they leave the simulator for the real cockpit. The flight simulation analogy is used frequently in discussions of simulation training for clinicians, and for good reason. A decade ago, Smith was present at the birth of simulation training in surgery––or at least its adoption from the airline industry. He was part of the team of physicians, engineers, and behavioral scientists who studied flight simulators for pilots, and then developed one of the first simulators for laparoscopic surgery.
     The combination of simulators, the Internet, and robotics has enormous potential to provide remote proctoring, assessment, and surgical support anywhere in the world, says Smith. He is discussing such possibilities with medical centers in Shanghai and Beijing. But first he wants to spend time, robotically that is, in Idaho. In July, several Emory surgical residents began a rotation in the elder McClusky’s Twin Falls community hospital. While the residents operated alongside community surgeons, Emory surgical faculty monitored their work, able to see what was happening as precisely and at the same instant as did the surgeons in the operating room. They then remotely offered critiques and suggestions. After fine-tuning this pilot, Smith hopes to incorporate it into continuing education programs, robotically going home with doctors while they continue to practice and then perform their first real procedures.
     Young David McClusky, like his father, will welcome them there in the OR. “Everyone has to learn,” he says, “but some things you simply don’t want to have to learn first on your patients.”
     And for that he can thank the robots.
Sylvia Wrobel, former associate vice president of Health Sciences Communications at Emory, writes about science and medicine.


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