We are entering a new era in health care, where innovative technologies are frequently developed and introduced to health care workers. One of the most groundbreaking developments has been the use of robots to assist surgeons with complicated procedures. However, optimal training of physicians is crucial to ensure this technology is utilized in a safe and effective manner. Since robot-assisted surgeries can place human lives at stake, no one can argue that simulation is one of the safest most ethical training methods.
One of the leaders in robotic surgery simulation training is a Seattle-based company called Mimic Technologies, which is the primary vendor for Intuitive Surgical Simulation Training. Mimic has several simulation products on the market, including the da Vinci Skills Simulator (a simulator co-developed between Mimic and Intuitive and sold by Intuitive that connects a high powered simulation computer directly to the da Vinci console to allow for simulation directly on the console) and dV-Trainer (a stand-alone robotic simulator developed and sold by Mimic). Mimic recently introduced FlexVR, the first portable, flexible and storable simulation system for robot-assisted surgery simulation training. We at Medgadget had the pleasure of meeting with Dr. Jeff Berkley, Mimic’s CEO and founder, during the MIS WEEK in San Francisco to learn more about FlexVR.
Kenan Raddawi, MD, Medgadget: Mimic recently introduced a new simulation device called FlexVR. Can you tell us what FlexVR is and the idea behind this new device?
Mimic, Dr. Jeff Berkley: Let’s start with the issue of training in robotics. If you take laparoscopic surgery training, you can grab a couple laparoscopic instruments, get a shoebox and a ham hock and practice suturing. However, if your surgical device is a robot, it is a little different! It is not very often a hospital can afford a $1.8 million robot just for the purpose of training, so access is very much a challenge. Typically, training on the da Vinci robot takes place in the operating room, usually overnight or on the weekends, when the robot is not being used for surgery. This method limits training materials. Hospitals may have dry labs for practice, but if the robot is being used clinically, usually it cannot be used with animals in a wet lab. Unless you are fortunate enough to have an institution that has a dedicated wet lab system, which is rare, you need to travel somewhere to practice in a wet lab.
The learning process for robot-assisted surgery is very challenging. We at Mimic wanted to take the training outside of the operating room. We started with the da Vinci Skills Simulator, which was a big step, and then, we introduced the dV-Trainer. In the last couple years we learned that access is very important. Therefore, the Mimic team thought if we can create a system that is even more accessible than the da Vinci Skills Simulator and the dV-Trainer, we have everything. Another advantage of coming up with a portable simulation system is that most Simulation Training Centers, and almost every hospital, are short on space. It is definitely a major advantage to have a simulator that can be used during robotic training and folded up and stacked away when not in use. We felt if you have this, we can take access to an entirely new level, and that was the main thinking behind the FlexVR.
Medgadget: Can you give us more details about FlexVR?
Dr. Berkley: FlexVR is a portable simulation unit, which you can actually take home. It looks almost like a large laptop, and it weighs around 40 pounds. The armrest unfolds and hooks to the table. FlexVR has an open 3D screen with an active display shutter glasses. This screen actually looks very similar to the screens we will see on some of the new robotic systems coming out, opposed to the immersive screen on da Vinci. One of the reasons we called the system FlexVR is that we wanted a flexible system with superior adaptability to the rapidly evolving technologies in surgical robotics.
Medgadget: Who are the main target users for FlexVR?
Dr. Berkley: They are users new to robot-assisted surgery, who have typically not used a robot before. FlexVR is a lower cost entry product. It doesn’t have the fidelity of a surgeon console or a dV-Trainer, but it is close. FlexVR is designed for the new user who needs to know how to use the robot, perform basic skills, and/or wants to train for a certain procedure. The idea is that once you have trained on the FlexVR system, you would move on to use the real robot or the dV-Trainer for advanced training. Then, you would proceed to the operating room to do a wet lab. Hopefully, at this point, you are trained to a certain standard so that when you get to your first surgery, you preform on a very high level. There are definitely studies that showed with enough training, you could enter the operating room and perform your first case on an expert level. You don’t need 70 to 200 cases to become proficient in robotic surgery.
Medgadget: What are some of the compromises that Mimic made in order to build FlexVR?
Dr. Berkley: The biggest expense in a simulation interface is haptic feedback. One of the nice things about the da Vinci Skills Simulator and dV-Trainer is that you have a neutralizing force where you don’t hold your hands up in the air. This will give you significantly more accuracy and less fatigue. With the FlexVR, we have free-floating grips, so we took force feedback, which is extremely expensive, and we substituted it with tactile feedback (vibration). Therefore, if you are training on the FlexVR and you are outside of the workspace of a real robot, you are going to feel a vibration. If you try to do the crossovers, you are going to feel the vibration. We use tactile feedback to give people a warning, and hopefully, the vibration irritates you enough that it makes the user correct his/her behavior. The use of tactile feedback versus force feedback significantly reduces the cost of the device and is one of the reasons we have this new product that sells around the $30K-level instead of the $100K-level. This becomes very important when considering how simulators get purchased. At the $100K-level, it is considered capital expenditure. We would need to go to a committee, where people are more interested in devices like CT and MRI machines that generate clear revenue. As opposed to training devices like ours, which can lead to significant savings over time, most people like to make money versus save money. By keeping the price of our product low enough, a committee isn’t necessary and it changes how the device can be purchased.
Medgadget: I recently visited Mimic headquarters in Seattle, and I had the opportunity to trial all of Mimic’s simulation systems, including the FlexVR. I noticed that Mimic utilizes the same software throughout all of its various training devices. The software was spot-on in teaching how to perform manual dexterity with the robot. However, when it came to learning a procedure, Mimic opted to use videos of real surgeries, with limited interaction available to the trainee, instead of building a fully immersive virtual reality that trains users on the entire procedure. Could you tell us why you took this route and are there any plans to offer complete virtual reality surgeries in the future?
Dr. Berkley: I did my PhD in continuous mechanical-based modeling of soft tissue. I would love to be able to tell you that we can model soft tissue perfectly like the human body, but unfortunately, we can’t. We can simulate a single task with a few structures, like cuff closure or anastomosis, but when it comes to representing multiple deformable bodies, that is just not something we, or anybody else, has solved. Now remember, we are talking about surgery simulation, which is an $800 million industry. We are not working with large movie or video game budgets, and we have a much tougher problem to solve. We at Mimic use virtual reality for the complex tasks and an augmented reality for cognitive and hand-eye motor learning. We wanted to make sure that users will be able to look at each step of the procedure, but we didn’t feel that we have to invest the amount of time and money to recreate it in virtual reality, as there is limited gain for that. The problem with basic skill training verses complete virtual reality training is once you go to the procedure, you have really raised the bar in complexity of modeling. If you take five surgeons and ask them how to perform a certain procedure, they are never going to agree. It’s possible that they would disagree on 30 percent of the procedure. If we decided to spend a year plus creating a procedure using virtual reality, and we did it based on a particular surgeon’s approach, we have limited our audience to one procedure because not everybody performs that procedure. We have also limited ourselves to a subgroup in that discipline since certain users want to learn the surgery using surgeon A’s approach and not surgeon B’s approach. I can tell you that the interaction is going to be much more detailed as time goes on, but in our mind, our approach of using recordings of actual surgeries is much more economical and practical.
Medgadget: Why didn’t you use a personal computer to perform what FlexVR does – where a user connects the pedals and controllers to a personal computer? Do you think Mimic stopped a step short by not offering such a training device instead of FlexVR?
Dr. Berkley: We couldn’t get the accuracy and fidelity that we have right now with FlexVR using the standard gaming components that are available in the field. We felt that FlexVR is the device that would have the minimum fidelity we needed, and we would be able to represent the hardware of the robot a little bit better than what a personal computer would offer. We would love to make FlexVR smaller, but here is one of the problems. When it comes to 3D displays, a good projection of 3D images is a function of how big the display is. With smaller screens, you would not be able to obtain good-quality 3D image projection, and it is not going to be nearly as rich as the 3D environment on the actual robot. There was a certain size that we had to use. We still tried to make the FlexVR small enough that you can check it onto a commercial flight.
Link: Mimic Technologies…