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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

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.

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.