Virtual Reality Robotic Surgery Warm-Up Improves Task Performance in a Dry Laboratory Environment: A Prospective Randomized Controlled Study

Abstract

Background Pre-operative simulation “warm-up” has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. Study Design In a two-center randomized trial, fifty-one residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot. Once successfully achieving performance benchmarks, surgeons were randomized to either receive a 3-5 minute VR simulator warm-up or read a leisure book for 10 minutes prior to performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical and cognitive errors. Results Task time (-29.29sec, p=0.001, 95%CI-47.03,-11.56), path length (-79.87mm, p=0.014, 95%CI -144.48,-15.25), and cognitive errors were reduced in the warm-up group compared to the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32, p=0.020, 95%CI 0.06,0.59) were reduced after the dissimilar VR task. When surgeons were stratified by prior robotic and laparoscopic clinical experience, the more experienced surgeons(n=17) demonstrated significant improvements from warm-up in task time (-53.5sec, p=0.001, 95%CI -83.9,-23.0) and economy of motion (0.63mm/sec, p=0.007, 95%CI 0.18,1.09), whereas improvement in these metrics was not statistically significantly appreciated in the less experienced cohort(n=34). Conclusions We observed a significant performance improvement and error reduction rate among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing) suggesting the generalizability of the warm-up.

A systematic examination of preoperative surgery warm-up routines

“…Two studies [22,25] reported a priori power calculations, but one of these studies [22] calculated that a substantially larger number of participants would be required than were actually recruited-thus indicating a lack of statistical power in this study. Relatedly, the sample sizes across all studies was generally modest, with only one RCT or cross-over study [25] reporting more than 20 participants per group. The included case studies could not be objectively assessed by the methods used to review the RCTs and cross-over studies, but each demonstrated methodological shortcomings, as discussed below.…”

“…Only one study [25] was judged to be at low risk of bias: Table 1, 2. Five studies [22,23,25,26,29] were found to be at low risk of randomisation bias, with explicit detailing of the methods of randomisation and allocation concealment employed.…”

“…Only one study [25] was judged to be at low risk of bias: Table 1, 2. Five studies [22,23,25,26,29] were found to be at low risk of randomisation bias, with explicit detailing of the methods of randomisation and allocation concealment employed. Two studies [22,25] reported a priori power calculations, but one of these studies [22] calculated that a substantially larger number of participants would be required than were actually recruited-thus indicating a lack of statistical power in this study.…”

“…Seven of the included studies [22, 23, 27Ð30, 34] reported this outcome metric -defined as a summary of objective assessment parameters by an expert examiner. Nine global rating scales [22,23,25, 35Ð41] were employed in the seven studies, with all but two studies reporting a different global rating scale. In a majority of studies, validated global rating assessments were used.…”

“…Five of the included studies [24,25,27,31,33] reported `pureÕ performance timedefined as the time taken to perform an assessed task. Those articles that reported duration as part of a global rating scale were not included as such studies have been discussed above.…”