Assessment of virtual reality for key-hole surgery and robo-surgery for key-hole gallbladder removal

Oxford 20 January 2009Using a robotic assistant to remove a patient's gallbladder by key-hole surgery - laparoscopic cholecystectomy - is as safe as working with a human assistant, a Cochrane Review has concluded. Comparisons between robot- and human-assisted surgery showed that there were no differences in terms of morbidity, the need to switch to open surgery, total operating time, or length of stay in hospital. In addition, trainee surgeons who add virtual reality (VR) training to standard "apprenticeship" training in key-hole surgery learn more quickly, work with greater accuracy and have less errors than those with no VR training, and perform as well as those who use additional video training.

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The finding of this Cochrane Systematic Review is important because training surgeons is time-consuming and costly, and surgeons have to develop new skills while working within the hour-limits set by European legislation.

More and more abdominal surgery is now performed using laparoscopes - instruments introduced into the patient's body through small incisions in the skin. This means that surgeons experienced in conventional surgery need to train with the new equipment, as well as newly qualified doctors who are at the beginning of their surgical careers.

The Royal College of Surgeons runs training courses that let a surgeon see what a procedure involves. With the arrival of desktop computing that has high graphic capability, software developers have built programmes that enable the trainee to interact with the images. "This greater level of involvement gives the possibility that surgeons will be able to develop skills more rapidly", stated Kurinchi Gurusamy, who works at the University Department of Surgery at the Royal Free Hospital, London.

To assess the impact of VR training, Kurinchi Gurusamy and colleagues searched for published research studies that compared VR training with other methods of training. They then undertook a detailed analysis of all the randomised trials that addressed this issue. There were 23 trials in total involving a total of 612 participants. The data clearly demonstrated the benefits of VR training.

"If we are going to meet the requirements of the European Working Time Directive, which effectively decreases the time available for training surgeons, as well as the Department of Health's modernising medical careers initiative, we need to develop highly efficient means of teaching new surgical skills. Virtual reality techniques may fulfill that need", stated Kurinchi Gurusamy.

Between 10 and 15 percent of the adult western population develop gallstones, placing a huge demand on health services. In the USA alone, more than 500.000 people have their gall bladder removed each year. The preferred way of doing this is now to use keyhole surgery that involves a surgeon and an assistant. In key-hole surgery, the surgeon sees inside the patient via a long camera introduced through a 1 cm abdominal cut. The camera guides the surgeon in using the surgical instruments introduced through other small cuts - ranging from 0,5 to 1 cm. The assistant's job is to move the camera, which acts as the surgeon's eyes.

A range of robots can now perform this task: this study looked at trials involving 'Endoassist', 'Aesop', 'Passist' and 'Zeus'. To assess how well robots were performing, a team of researchers considered data from five randomised trials that included a total of 453 patients. The results showed a marginal - though not statistical - decrease in the numbers of gallbladders that burst during robot-assisted surgery, but overall there was no appreciable difference.

"We need more trials that see whether the success rates using robotic assistants increase once surgeons have more experience using them", stated lead researcher Kurinchi Gurusamy. One of the aims behind using robots is that it could enable a surgeon to perform an emergency operation without having to wait for a human assistant to become available. This could have distinct advantages in countries where there are limits to the numbers of hours assistants are allowed to work.

Current data suggest that we are not yet at that point. "Robotic assistants seem to be an exciting possibility, but we are not yet at the stage that they should be used as replacements for human assistants", stated Kurinchi Gurusamy.


Source: Wiley-Blackwell

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