9 ms·

Robotic surgery turns surgical trainees into spectators

82 points by samizdis 4y ago

catgary 4y ago
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.
- elromulous 4y ago
  I don't know for sure, but I suspect cadavers are cheap enough and much "higher fidelity" than any sim could ever be.
  - inglor_cz 4y ago
    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.
    - iancmceachern 4y ago
      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.
      - ranger_danger 4y ago
        I would think pumping blood through a cadaver is a quick way to get a visit from a handful of agencies.
        iancmceachern 4y ago
        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/ https://pubmed.ncbi.nlm.nih.gov/29023350/
- quantumduck 4y ago
  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
  - musingsole 4y ago
    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.
    - quantumduck 4y ago
      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.
    - ska 4y ago
      I think this overestimates what Dall-E is actually doing, and underestimates the complexity of the task.
    - hansword 4y ago
      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.
- pc86 4y ago
  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.
  - foldedcornice 4y ago
    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."
- adolph 4y ago
  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-and-technologies/external-beam-radiation-therapy/simulation https://radiationoncology.weillcornell.org/clinical-services... 1. https://www.nist.gov/physics/what-are-imaging-phantoms https://www.nist.gov/physics/what-are-imaging-phantoms
  - iancmceachern 4y ago
    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.
    - cardiffspaceman 4y ago
      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.
      - iancmceachern 4y ago
        Yeah, what you describe is common now on systems like cyberknife. etc.
- iancmceachern 4y ago
  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.
  - actionfromafar 4y ago
    "multi hundred thousand dollar piece of equipment" So, pretty cheap, it sounds like? How much is the hourly rate of surgeons?
    - iancmceachern 4y ago
      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-California#:~:text=How%20much%20does%20a%20Surgeon,%2Fweek%20or%20%2419%2C899%2Fmonth https://www.ziprecruiter.com/Salaries/Surgeon-Salary--in-Cal....
      - Scoundreller 4y ago
        Only if they're spending 2500hours a year in the OR.
pixelmonkey 4y ago
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#Gynecology 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.
- foldedcornice 4y ago
  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?
  - DoingIsLearning 4y ago
    > 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.
arcticbull 4y ago
> 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.
- oneoff786 4y ago
  I wonder if they’re more expensive though?
  - arcticbull 4y ago
    > 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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016020
    - elromulous 4y ago
      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.
      - sarpeedo 4y ago
        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.
oneoff786 4y ago
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?
- wincy 4y ago
  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.
  - 0des 4y ago
    barber chirurgeons
  - galdosdi 4y ago
    I imagine the trained surgeon knows what to do when anything goes wrong following those 6 simple instructions, and from thence flows confidence.
    - stephencanon 4y ago
      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.
  - usrn 4y ago
    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.
senortumnus 4y ago
Surgeon here who does the majority of my “major case” work robotically. Author of this article has a coastal-centric point of view. My residency was apprenticeship model and I graduated very confident in my capabilities to perform robotic surgery “skin-to-skin”. The phenomenon he references about trainees no longer being able to start a surgery without the “attending” surgeon present is not related to robotics. It is due to CMS or liability (lawyers) or hospital policy regulations (lawyers). Same reason medical students are pushed away from direct patient care until they graduate and become residents. 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.
- deleted 4y ago
  [deleted]
- stephencanon 4y ago
  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.
  - Dracophoenix 4y ago
    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.
    - stephencanon 4y ago
      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?
soontobesurgeon 4y ago
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.
lven 4y ago
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?
Calavar 4y ago
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.
petermcneeley 4y ago
Hopefully soon it will turn the surgeons into spectators as well.

82 points by samizdis 4y ago

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.

elromulous 4y ago
I don't know for sure, but I suspect cadavers are cheap enough and much "higher fidelity" than any sim could ever be.
- inglor_cz 4y ago
  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.
  - iancmceachern 4y ago
    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.
    - ranger_danger 4y ago
      I would think pumping blood through a cadaver is a quick way to get a visit from a handful of agencies.
      - iancmceachern 4y ago
        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/ https://pubmed.ncbi.nlm.nih.gov/29023350/
quantumduck 4y ago
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
- musingsole 4y ago
  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.
  - quantumduck 4y ago
    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.
  - ska 4y ago
    I think this overestimates what Dall-E is actually doing, and underestimates the complexity of the task.
  - hansword 4y ago
    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.
pc86 4y ago
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.
- foldedcornice 4y ago
  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."
adolph 4y ago
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-and-technologies/external-beam-radiation-therapy/simulation https://radiationoncology.weillcornell.org/clinical-services... 1. https://www.nist.gov/physics/what-are-imaging-phantoms https://www.nist.gov/physics/what-are-imaging-phantoms
- iancmceachern 4y ago
  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.
  - cardiffspaceman 4y ago
    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.
    - iancmceachern 4y ago
      Yeah, what you describe is common now on systems like cyberknife. etc.
iancmceachern 4y ago
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.
- actionfromafar 4y ago
  "multi hundred thousand dollar piece of equipment" So, pretty cheap, it sounds like? How much is the hourly rate of surgeons?
  - iancmceachern 4y ago
    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-California#:~:text=How%20much%20does%20a%20Surgeon,%2Fweek%20or%20%2419%2C899%2Fmonth https://www.ziprecruiter.com/Salaries/Surgeon-Salary--in-Cal....
    - Scoundreller 4y ago
      Only if they're spending 2500hours a year in the OR.

pixelmonkey 4y ago

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#Gynecology 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.

foldedcornice 4y ago
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?
- DoingIsLearning 4y ago
  > 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.

arcticbull 4y ago

> 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.

oneoff786 4y ago
I wonder if they’re more expensive though?
- arcticbull 4y ago
  > 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 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016020
  - elromulous 4y ago
    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.
    - sarpeedo 4y ago
      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.

oneoff786 4y ago

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?

wincy 4y ago
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.
- 0des 4y ago
  barber chirurgeons
- galdosdi 4y ago
  I imagine the trained surgeon knows what to do when anything goes wrong following those 6 simple instructions, and from thence flows confidence.
  - stephencanon 4y ago
    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.
- usrn 4y ago
  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.

senortumnus 4y ago

Surgeon here who does the majority of my “major case” work robotically. Author of this article has a coastal-centric point of view. My residency was apprenticeship model and I graduated very confident in my capabilities to perform robotic surgery “skin-to-skin”. The phenomenon he references about trainees no longer being able to start a surgery without the “attending” surgeon present is not related to robotics. It is due to CMS or liability (lawyers) or hospital policy regulations (lawyers). Same reason medical students are pushed away from direct patient care until they graduate and become residents. 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.

deleted 4y ago
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stephencanon 4y ago
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.
- Dracophoenix 4y ago
  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.
  - stephencanon 4y ago
    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?

soontobesurgeon 4y ago

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.

lven 4y ago

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?

Calavar 4y ago

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.

petermcneeley 4y ago

Hopefully soon it will turn the surgeons into spectators as well.