Robotic surgery turns surgical trainees into spectators(spectrum.ieee.org)
spectrum.ieee.org
Robotic surgery turns surgical trainees into spectators
https://spectrum.ieee.org/robotic-surgery
89 comments
I don’t think it’s so much “coastal” as “big-name (and big) programs”. Wife is an attending at a one-a-year program here in the northeast, and the residents definitely get _way_ more operating experience then they do at, say, Michigan.
The skills issue you identify with some big-name programs is a real thing for sure, though.
The skills issue you identify with some big-name programs is a real thing for sure, though.
How long were her shifts as a resident? I remember reading an article about laws seeking to limit resident hours about a decade ago but I'm not of the opinion that anything regarding hours has really changed since the days of William Halsted.
They’ve been pretty successful about capping individual shift length (to a day and change, granted), the real killer is the total hours per week, which can’t really go down without either the government funding more residency slots or hospitals hiring a bunch of PAs to take over some of the workload, but why would they in a privatized system when the residents are paid for and can’t really leave?
How many hours a week? How much of it is actual medical work vs being on standby?
They’re capped at 80 hours per week, more or less. Most residents go over, regularly. But a single report of a work hours violations is a pretty serious deal for a residency program, so that alone means things are better than they used to be. On the other hand, programs tend to use everything from coercion to collective punishment to prevent these reports from being filed. In practice, this seems to work out as residents tolerating a certain amount of extra hours, as a matter of culture (this varies by institution and by specialty), but it doesn’t seem to be as bad as the old days. Just my limited perspective as a partner to a surgical resident.
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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 are posted here, turn a list of them into a batch for her, and transcribe her answers.)
One thing that I notice that the author of this article leaves out is that though trainees are often "watching" a surgery rather than controlling it via the second console, this is a much better form of "watching" than most surgical trainees are typically accustomed. This is because both consoles attached to the robot get the immersive PoV of the primary surgeon. This should be compared to the alternatives, "'straight-stick' laparoscopy" and "open surgery", wherein the view of the surgery for trainees is usually quite limited.
FWIW, my wife trained "both ways" (robotic and 'straight-stick') and believes there are trade-offs -- it depends on the patient condition and what one is trying to accomplish.
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 are posted here, turn a list of them into a batch for her, and transcribe her answers.)
One thing that I notice that the author of this article leaves out is that though trainees are often "watching" a surgery rather than controlling it via the second console, this is a much better form of "watching" than most surgical trainees are typically accustomed. This is because both consoles attached to the robot get the immersive PoV of the primary surgeon. This should be compared to the alternatives, "'straight-stick' laparoscopy" and "open surgery", wherein the view of the surgery for trainees is usually quite limited.
FWIW, my wife trained "both ways" (robotic and 'straight-stick') and believes there are trade-offs -- it depends on the patient condition and what one is trying to accomplish.
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 conventional and laparoscopic surgeries found that outcomes were comparable, and robotic surgeries were actually a bit slower. From my perspective, focusing on education, it’s something of a miracle that outcomes aren’t worse, given that residents are going to their first jobs without the necessary experience. "
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?
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 conventional and laparoscopic surgeries found that outcomes were comparable, and robotic surgeries were actually a bit slower. From my perspective, focusing on education, it’s something of a miracle that outcomes aren’t worse, given that residents are going to their first jobs without the necessary experience. "
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?
> 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.
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
I read somewhere that computer+radiologist perform the planning of beams and the gamma knive does all the work
Another example is robotic-assisted pedicle screw insertion in patients with challenging spinal deformities
Radiation oncologist*, this is far outside my (radiologist) scope!
You still have biopsies, SEEGs and anything else that requires deep brain invasive action.
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.
Yes, they have simulators that bolt on : https://www.intuitive.com/en-us/products-and-services/da-vin...
Other manufacturers also have them
Other manufacturers also have them
I'd actually think a surgery simulator is more difficult than a space one.
Kind of like the difference between a kebel space program and an ultra realistic physics and material simulator.
I'd be shocked if there wasn't at least a few "games" to practice dexterity and perform device diagnostics.
Kind of like the difference between a kebel space program and an ultra realistic physics and material simulator.
I'd be shocked if there wasn't at least a few "games" to practice dexterity and perform device diagnostics.
Eg: Suture Practice Kit (physical, not digital) https://a.co/d/g7Ecn72
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...
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...
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?
Also… any words of wisdom for someone about to enter med school?
how would your wife respond to the claim in the article that the outcomes between robotic and traditional surgeries appear the same?
Not the GP but my fiance is also an OB and is also qualified on robotic surgeries. Robotic candidates are typically more difficult cases than more traditional surgeries, so even an equal prevalence of positive outcomes would indicate that robotic surgeries are worth the additional training/time/expense/etc.
I think it'd be pretty hard to do a true apples-to-apples comparison. You'd want to find traditional surgeries that were complex enough that robotic surgery would be indicated, yet for some reason they went ahead with traditional surgery anyway. Almost by definition this would push you more toward emergent surgeries which have worse outcomes overall given their acute nature. You could probably find areas where transfer to a facility with a robot would take too long but you're bringing in a lot of other confounding variables (comparing robotic surgeries at a well funded academic institute with lots of residents and fellows to a small poorly staffed hospital in the sticks, for example).
I think it'd be pretty hard to do a true apples-to-apples comparison. You'd want to find traditional surgeries that were complex enough that robotic surgery would be indicated, yet for some reason they went ahead with traditional surgery anyway. Almost by definition this would push you more toward emergent surgeries which have worse outcomes overall given their acute nature. You could probably find areas where transfer to a facility with a robot would take too long but you're bringing in a lot of other confounding variables (comparing robotic surgeries at a well funded academic institute with lots of residents and fellows to a small poorly staffed hospital in the sticks, for example).
> and believes there are trade-offs -- it depends on the patient condition and what one is trying to accomplish.
I am interested in the trade offs & what it is not a good fit for.
I realize that is a broad “question”. But any insight is appreciated
I am interested in the trade offs & what it is not a good fit for.
I realize that is a broad “question”. But any insight is appreciated
When I rotated through surgical oncology as a 3rd year medical student, a lot of the cases were robotic.
For a 5 hour surgery, the fellow got to drive the robot for about 90 minutes. He spent the rest of the time watching.
The resident made incisions to introduce the robotic instruments and then closed at the end. This took about 15 minutes at the start of the case and and another 15 at the end. She spent the rest of the time standing there and watching.
I wasn't even allowed to scrub in - not enough space with the robot docked. I had to stand in the corner of the room for 5 hours watching the surgery on a monitor. And of course the circulating RN wouldn't let me stand in a place with a decent view.
I would have had a better learning experience watching a YouTube video of a surgery. What a colossal waste of time for all trainees involved.
For a 5 hour surgery, the fellow got to drive the robot for about 90 minutes. He spent the rest of the time watching.
The resident made incisions to introduce the robotic instruments and then closed at the end. This took about 15 minutes at the start of the case and and another 15 at the end. She spent the rest of the time standing there and watching.
I wasn't even allowed to scrub in - not enough space with the robot docked. I had to stand in the corner of the room for 5 hours watching the surgery on a monitor. And of course the circulating RN wouldn't let me stand in a place with a decent view.
I would have had a better learning experience watching a YouTube video of a surgery. What a colossal waste of time for all trainees involved.
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's easy to simulate the robotic manipulators - the dynamics are well known and they are rigid objects.
On the other hand, simulating say skin/muscle/blood or anything that closely resembles human body is near impossible. Without that, a simulator is pretty much useless and it'll probably easier to train the surgeons on real robot + some animal like pig
On the other hand, simulating say skin/muscle/blood or anything that closely resembles human body is near impossible. Without that, a simulator is pretty much useless and it'll probably easier to train the surgeons on real robot + some animal like pig
Not impossible, there are some good new algorithms for soft tissue deformation that aren't CPU killers like even a few years ago. Most of the surgical sim software out now is either so basic that it isn't good for much beyond cursory anatomical review, or it requires some major hardware installed in a permanent space with limited use-cases that nobody ever bothers to use because at the end of a resident shift they just want to go home and sleep.
I'm working for a small company that is trying to bridge the gap and make something good that can run on the consumer VR/AR hardware that's coming out in the next year or three. Lots of interesting problems to solve.
I'm working for a small company that is trying to bridge the gap and make something good that can run on the consumer VR/AR hardware that's coming out in the next year or three. Lots of interesting problems to solve.
It's a solved problem
https://www.intuitive.com/en-us/products-and-services/da-vin...
https://www.intuitive.com/en-us/products-and-services/da-vin...
Do you believe the marketing of this company?
In my experience in a related field, simulators are about 2% as useful as advertised. The cousin thread explains how difficult building a flesh simulator is, so I wouldn't expect surgical experience on a simulator to be very useful.
In my experience in a related field, simulators are about 2% as useful as advertised. The cousin thread explains how difficult building a flesh simulator is, so I wouldn't expect surgical experience on a simulator to be very useful.
I've used it, it's pretty good.
I’m not even thinking of anything as grandiose as a full simulation of the human, it could be as simple as mimicking the movements from a previous surgery using an overlay of the simulated robot arms.
Is a physical object even required? Why can't it be like a flight sim and just be controls and some screens?
What do you mean? In a flight simulator you have your controls controlling a plane (right body, dynamics are well known) in the sky (simple environment, dynamics are reasonably well known, even with different atmospheric conditions like wind). The output is visualized on the screens as a rendering of the scene.
In the case of robotic surgery simulator, you are using the controls to control the arm, but to interact with what? If you just want to move the arm around and maybe interact with some rigid objects sure that's easy. Would that add any training value to the surgeon? Probably not. You can get value only when the simulator includes a simulation of something the surgeon would have to face eventually - organic mass of the human body. Simulating that is hard, and I doubt anyone would invest much into it when you can train surgeons on alternative physical objects like pigs.
In the case of robotic surgery simulator, you are using the controls to control the arm, but to interact with what? If you just want to move the arm around and maybe interact with some rigid objects sure that's easy. Would that add any training value to the surgeon? Probably not. You can get value only when the simulator includes a simulation of something the surgeon would have to face eventually - organic mass of the human body. Simulating that is hard, and I doubt anyone would invest much into it when you can train surgeons on alternative physical objects like pigs.
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?
Yes, you can produce a model incorporating nonlinear elasticity, viscosity, plasticity, frictional contact, subfailure damage, and fracture / cutting. Repeat for each tissue involved. Some of those methods are well-developed, others are not. Damage and failure in particular is poorly developed, and simulating deformable body contacts can be tricky. Then you have to estimate parameters for all of that, validate that the model produces realistic outcomes, and get it to run in real time.
You can ignore most of the complexity and make approximations, like treating everything as an isotropic linear elastic material, setting cutting resistance to a fixed value per tissue, treating the scalpel like a lightsaber, and accepting that contact will be imperfectly enforced (surfaces may interpenetrate). A crude simulation can still be good enough to be useful as a learning tool though, but it tends to work more like a video game than a true physics-based simulation. We'll still eventually get the kind of accurate simulation you're asking for, probably.
I was specifically constraining the discussion to robotic surgery. Do all these variables apply in that case?
Not sure how to interpret the question. Using a robot vs. a person doesn't change anything about the physics of how tissue responds to perturbation. You can of course simplify the simulator and correspondingly limit its use to specific learning objectives, probably novice-level. To return to the thread's starting point—we understand flight well enough to make general-purpose flight simulators, we don't understand tissue well enough to make general-purpose surgical simulators. You can still make simple interactive training tools to help someone rehearse the motions of a procedure, but I wouldn't call such a tool a simulator.
Very very many variables... For example, burnt tissue, crushed tissue, injection trauma, infected tissue plus variable anatomy.
But don't we now have thousands of hours of real-use? Surely in the age of Dall-e, a system to use that as input to ape if not fully simulate the surgical environment is within reach.
While DALL-E might seem like something out of the world, what it outputs at the end of the day is pretty basic: a 2D image.
To run a high-fidelity simulator of human body that is useful for surgeons, you need a LOT more. And I doubt it can be data-driven. Data-driven simulators for things like autonomous cars are just coming up, and these are way simple as the agent (the autonomous car) doesn't directly change the environment when it's driving around (as in, you don't have to simulate the car colliding into a traffic pole and then breaking it, etc.)
To simulate a human body, you need to be able to capture the material properties of different layers, some of which are fluids, and then also the interaction between them and how different organs react to a surgical operation. It's a very hard problem.
Why do all that when you have animal corpses readily available? There's no need to create a problem that doesn't exist.
To run a high-fidelity simulator of human body that is useful for surgeons, you need a LOT more. And I doubt it can be data-driven. Data-driven simulators for things like autonomous cars are just coming up, and these are way simple as the agent (the autonomous car) doesn't directly change the environment when it's driving around (as in, you don't have to simulate the car colliding into a traffic pole and then breaking it, etc.)
To simulate a human body, you need to be able to capture the material properties of different layers, some of which are fluids, and then also the interaction between them and how different organs react to a surgical operation. It's a very hard problem.
Why do all that when you have animal corpses readily available? There's no need to create a problem that doesn't exist.
Content note: surgery gore
a) thousands of hours is far far far too little data. This is a total ballpark estimate, with only knowledge of the ML and basically zero knowledge of the surgery side, but I would expect three to six orders of magnitude greater, i.e. millions to billions of hours necessary to train a machine learning model to do something like that, to a standard.
b) the big problem is not the procedures themselves, but edge cases and things going a little bit wrong.
c) you are fine with tiny flukes in your generated images, but you won't be very happy with an ML model whose tiny flukes lead to internal bleeding.
d) unfortunately (with contemporary models) we can't easily explore latent space, which might possibly contain regions corresponding to catastrophic robot arm movements. the chance isn't that high, but it's not a chance most'd be willing to take at this point.
a) thousands of hours is far far far too little data. This is a total ballpark estimate, with only knowledge of the ML and basically zero knowledge of the surgery side, but I would expect three to six orders of magnitude greater, i.e. millions to billions of hours necessary to train a machine learning model to do something like that, to a standard.
b) the big problem is not the procedures themselves, but edge cases and things going a little bit wrong.
c) you are fine with tiny flukes in your generated images, but you won't be very happy with an ML model whose tiny flukes lead to internal bleeding.
d) unfortunately (with contemporary models) we can't easily explore latent space, which might possibly contain regions corresponding to catastrophic robot arm movements. the chance isn't that high, but it's not a chance most'd be willing to take at this point.
I think this overestimates what Dall-E is actually doing, and underestimates the complexity of the task.
It's because the interface console itself is a big part of the cost and complexity of the thing. The simulator requires the console and input manipulators to use, so they can't train on it while it's being used for surgury. Hospitals could buy a second console to use exclusively with the simulator but that's a multi hundred thousand dollar piece of equipment.
Surgeons can take a few practice simulations in the Sim, but it's just that doing so ties up the robot from doing real cases at that time also.
Surgeons can take a few practice simulations in the Sim, but it's just that doing so ties up the robot from doing real cases at that time also.
"multi hundred thousand dollar piece of equipment"
So, pretty cheap, it sounds like? How much is the hourly rate of surgeons?
So, pretty cheap, it sounds like? How much is the hourly rate of surgeons?
Not really.
A surgeon makes on average $115 an hour in California, $280k a year. So the console plus simulator backpack costs a surgeon or two's yearly salary.
https://www.ziprecruiter.com/Salaries/Surgeon-Salary--in-Cal....
A surgeon makes on average $115 an hour in California, $280k a year. So the console plus simulator backpack costs a surgeon or two's yearly salary.
https://www.ziprecruiter.com/Salaries/Surgeon-Salary--in-Cal....
Only if they're spending 2500hours a year in the OR.
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
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
The thing about simulation in radiation oncology is its more focused on simulation of the physics of the beam delivery, and not so much on simulation of the tissue or human body portion of the equation. This is more the latter.
When I saw the keywords in these posts it reminded me of a job I interviewed for. This was in 1991 and the state of the art was to plot iso-dose contours on top of X-ray images, presumably using facts about the beam and the tissues at hand. The plan was to evolve from there to 3D images, possibly rendering these planing data in arbitrary orientations in real time. The link provided above discusses tattooing the patient for future reference and other things, using a machine that was 'similar' to the beam machine but without the beam itself. So it is good to see that planning has moved on in 30 years.
Yeah, what you describe is common now on systems like cyberknife. etc.
I don't know for sure, but I suspect cadavers are cheap enough and much "higher fidelity" than any sim could ever be.
Yes and no, for example, they have no blood circulation anymore, thus one of the potentially fatal risks of any surgery - bleeding - can't be "trained" there.
It can, they can plumb things up with pumps to simulate whatever.
This same limitation applies to simulators though, so this application isn't an answer to the parent comments question.
This same limitation applies to simulators though, so this application isn't an answer to the parent comments question.
I would think pumping blood through a cadaver is a quick way to get a visit from a handful of agencies.
There are lots of hoops to jump through to get to use cadavers for one's work, but the act of pumping blood itself isn't particularly of concern to any agencies.
Here is one example paper: https://pubmed.ncbi.nlm.nih.gov/29023350/
Here is one example paper: https://pubmed.ncbi.nlm.nih.gov/29023350/
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."
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."
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’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 instructions were simple enough that I could understand perfectly well how to do the procedure based on the document. However, I’m sure if I actually attempted the surgery I’d be a nervous wreck. I’d guess confidence is probably another part. But maybe a doctor will chime in.
I just tried to find the paper but am not sure where we dug it up or I’d just post it here.
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 instructions were simple enough that I could understand perfectly well how to do the procedure based on the document. However, I’m sure if I actually attempted the surgery I’d be a nervous wreck. I’d guess confidence is probably another part. But maybe a doctor will chime in.
I just tried to find the paper but am not sure where we dug it up or I’d just post it here.
barber chirurgeons
I imagine the trained surgeon knows what to do when anything goes wrong following those 6 simple instructions, and from thence flows confidence.
Exactly. Wife is a neurosurgeon, and somewhere towards the end of her sixth year of residency, she had the gradual realization that she could handle anything that might happen in the course of an even semi-normal case. That fluency has continued to build since then, of course.
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.
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.
Any beginning woodworker quickly learns how much of the job is not just making a straight cut but juggling a whole ton of shit you didn't think about.
And that's all without getting into things like how much of a grace period you have between the first cut and the last fastener, which you don't have with a living organism.
And that's all without getting into things like how much of a grace period you have between the first cut and the last fastener, which you don't have with a living organism.
The difficulty of a task transcends mere mechanics.
A common analogy used in neurosurgery training: "Imagine a wooden plank on the driveway and walk its length -- no problem. Suspend that same board ten stories in the air and try again." The hard part is not the "figuring out" or "execution" but knowing the irreversibility and making the correct decision. Your patient expects you to be correct 10 times out of 10, yet you know that's not possible. Squaring our fallibility with the irreversibility of our missteps is the hard part, and what keeps surgeons up at night. The fly struggles in the web.
A common analogy used in neurosurgery training: "Imagine a wooden plank on the driveway and walk its length -- no problem. Suspend that same board ten stories in the air and try again." The hard part is not the "figuring out" or "execution" but knowing the irreversibility and making the correct decision. Your patient expects you to be correct 10 times out of 10, yet you know that's not possible. Squaring our fallibility with the irreversibility of our missteps is the hard part, and what keeps surgeons up at night. The fly struggles in the web.
There are a lot of difficult non-obvieous things to watch for and know. It's like an old cardiac surgeon told me, he can walk into a room and know from across the room if the patient has high blood pressure, is this, is that, just by their coloring etc. It's the same way watching the experienced surgeons do their work, they know so much about a patient just by looking around inside, this means that, etc. Wisdom.
To answer your question, basic surgury isn't (difficult). Good medicine is. The more complex the issue, the better medicine you need.
To answer your question, basic surgury isn't (difficult). Good medicine is. The more complex the issue, the better medicine you need.
I can't speak to how hard surgery is to perform but I will say, from talking to surgeons, it sounds like deciding when to operate (and to what extent) is more difficult than actually performing the surgery in a lot of circumstances.
> Many people assume that patient outcomes must be better with robotic surgery. It’s not obvious that’s true. In fact, a recent survey of 50 randomized control trials that compared robotic surgery to conventional and laparoscopic surgeries found that outcomes were comparable, and robotic surgeries were actually a bit slower.
Fascinating. I definitely assumed that the robotic surgeries had better outcomes.
I wonder how much of this kind of thing is contributing to higher costs in US healthcare.
Fascinating. I definitely assumed that the robotic surgeries had better outcomes.
I wonder how much of this kind of thing is contributing to higher costs in US healthcare.
I wonder if they’re more expensive though?
> 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/articles/PMC3016020
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/articles/PMC3016020
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.
Bows could shoot faster and further but you would tire out. You also had to be a trained archer vs a random nobody with a gun. Becoming an archer was hard, and arrows were a lot more expensive.
1k longbowmen beat 1k musket bros, but that’s not the comparison that really mattered.
1k longbowmen beat 1k musket bros, but that’s not the comparison that really mattered.
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.
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.
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.
It's a big marketing driver for centers.
That was the connection I was thinking it probably had with higher care costs. Expensive, shiny things that don't actually improve outcomes is a good way to bring people through the doors. Like my dentist's LIDAR scanner.
Or is there a bias that harder cases end up on robots, so they even “equal outcomes” is a big win for that cohort?
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?
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.
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.
Ergonomics may seem not a big deal in that list of improvements, however it can make or break surgery technique and a surgeon's career. Many professions that rely on manual dexterity lose practitioners due to long-term inappropriate ergonomics leading to physical damage/pain.
Hopefully soon it will turn the surgeons into spectators as well.
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.