Enhancing robotic head and neck surgical skills using stimulated simulation

使用刺激仿真提高机器人头颈外科手术技能 摘要 我们建议刺激模拟作为加速基于模拟器的训练的下一个范例， 使用非侵入性脑刺激的经口机器人手术（TORS）。TORS是一种微创 这项技术在耳鼻咽喉头颈外科领域迅速被采用， 咽喉部的良性和恶性肿瘤以及治疗阻塞性睡眠呼吸暂停。作为一个相对 新的和复杂的程序，外科医生正在学习执行TORS后，他们的居住，主要是在一个 奖学金年。然而，TORS有一个陡峭的学习曲线，至少需要20-35个病例， 达到基本的熟练程度。没有结构化的课程或有效的模拟平台，大多数新手 外科医生目前在对活体患者进行手术时达到20-35例的基准。因此，积极 余量（即，肿瘤没有完全切除）， 是高容量设施的两倍。商用机器人任务训练器和虚拟现实模拟器 外科手术有四个主要缺陷：（i）他们没有准备学员在密闭空间中操作， 口咽部，并且不提供TORS所必需的程序特定技能，例如组织操作， 牵引，或使用电烙器解剖;（ii）它们依赖于平台-训练基本的机器人技能， da芬奇平台（Intuitive Surgical，桑尼维尔，CA），尽管目前有两个平台已被FDA批准用于 TORS，第三个正在等待批准，（iii）它们成本高昂，仅限于最富裕的中心使用 （iv）除了暴力重复练习之外，它们没有提供任何机制来加速技能的获得。 为了解决这些限制，我们将设计，开发和验证第一个虚拟经口机器人， 手术（VTORS）模拟器，用于培训TORS手术并使用经颅直流电 刺激（tDCS），一种安全有效、成熟、市售的可穿戴非侵入性脑 一种刺激技术，使用非常低的直流电（<4 mA）施加到头皮，以调节皮质 兴奋性，以加速手术技能的获得。我们组建了一支高度跨学科的团队， 研究人员完成该项目的两个目标：（SA 1）设计，开发和验证高分辨率， 超低成本、多功能、独立于平台的虚拟经口机器人手术（VTORS）模拟器， TORS舌根切除术;（SA 2）经颅直流电训练效果验证 刺激（tDCS）（即，刺激的模拟）与假刺激相比。 基于现成的虚拟现实（VR）和tDCS技术的最新发展， 仿真软件源码，有潜力成为模拟仿真培训的首选 范例-同时提高技能和加速技能获得-对于复杂的心理技能， 包括手术、航空、驾驶、体育和音乐。

Enhancing robotic head and neck surgical skills using stimulated simulation Abstract We propose stimulated simulation as the next paradigm for accelerating simulator-based training of transoral robotic surgery (TORS) using noninvasive brain stimulation. TORS is a minimally invasive technology that is seeing rapid adoption in the field of otolaryngology - head and neck surgery to resect benign and malignant tumors of the pharynx and larynx as well as treat obstructive sleep apnea. As a relatively novel and complex procedure, surgeons are learning to perform TORS after their residency, mostly during a fellowship year. However, TORS has a steep learning curve, with a minimum of 20-35 cases needed to achieve basic proficiency. Without a structured curriculum or effective simulation platform, most novice surgeons currently reach the 20-35 case benchmark while operating on live patients. Consequently, positive margin (i.e., the tumor is not entirely removed) rates for oropharyngeal cancers in low-volume centers are twice that in high-volume facilities. Commercially available task trainers and virtual reality simulators for robotic surgery have four major deficiencies: (i) they do not prepare trainees to operate in the confined space of the oropharynx and do not provide the procedure-specific skills necessary for TORS, such as tissue manipulation, retraction, or dissection using electrocautery; (ii) they are platform-dependent – training basic robotic skills for the da Vinci platform (Intuitive Surgical, Sunnyvale, CA), though two platforms are currently FDA approved for TORS, and a third one is waiting for approval, (iii) they are costly, limiting their use to the most affluent centers and (iv) they offer no mechanism to accelerate skill acquisition beyond brute-force repeated practice. To address these limitations, we will design, develop, and validate the first Virtual Transoral Robotic Surgical (VTORS) simulator for training TORS procedures and use transcranial direct current stimulation (tDCS), a safe and effective, well-established, commercially available, wearable noninvasive brain stimulation technique that uses very low direct current (<4mA) applied to the scalp to modulate cortical excitability, to accelerate the surgical skill acquisition. We have assembled a highly interdisciplinary team of researchers to accomplish the two aims of the project: (SA1) Design, develop and validate a high-resolution, ultra-low-cost, versatile, and platform-independent Virtual Transoral Robotic Surgical (VTORS) simulator for TORS tongue base resection; and (SA2) Demonstrate the training efficiency with transcranial direct current stimulation (tDCS) (i.e., stimulated simulation) compared with sham stimulation. Based on the latest developments in off-the-shelf virtual reality (VR) and tDCS technology and open- source simulation software, stimulated simulation has the potential to become the preferred training paradigm – simultaneously improving skills and accelerating skill acquisition - for complex psychomotor skills, including surgery, aviation, driving, sports, and music.