Raphael Thys
When medical student Alyssa Murillo stepped into surgery, she was met with something most wouldn’t expect to find in an operating room: a towering surgical robot. She wasn’t there to observe the kind of surgeries she was used to seeing; instead she was getting an in-depth view inside the patient’s body through the robot’s video console.
“It was incredible,” says Murillo, who is now a forth-year general surgery resident at the University of California, San Francisco. “You have a full 3D view, which is different from any other minimally invasive surgery technique.”
The robot Murillo is referring to is the Da Vinci Surgical System. Created by Intuitive, the Da Vinci is an almost 8-foot robot with four surgical arms. With an extremely small incision, “straws” are placed into the surgical site. The robotic arms hold a camera and small instruments that can be brought in and out of the patient through the straws. The surgeon uses a console to move the robot almost like a “crane operator.” The robot translates the surgeon’s every move while allowing for wrist control, which is not the case in traditional laparoscopic surgery.
This is in contrast to the misconception that the robot performs the surgery on its own. Instead, the robot is simply a tool the surgeon uses. While the lead surgeon controls the arms from a console, another medical professional serves as a bedside assistant, setting up, inserting, and removing instruments from the patient. The camera that is inserted through one of the “straws” allows the surgeon to have a left and a right view when looking through the console, enabling a clear 3D picture.
Since the Da Vinci’s FDA approval in 2000, there have been waves of skepticism about accepting the surgical robot as commonplace in medical procedures that were traditionally done using other techniques. Despite scrutiny, the use of robotic surgery has skyrocketed in recent years. A 2020 study in the Journal of the American Medical Association concluded that “the use of robotic surgery increased from 1.8 percent in 2012 to 15.1 percent in 2018.” For some procedures, specifically in urological and gynecological surgeries, that growth is magnified.
The robot isn’t the only change in the surgical field. Medical education is rapidly evolving too. The next generation of surgeons are learning in ways far different from those before them.
Alisa Coker, the director of robotic surgery education at Johns Hopkins, calls herself a “robotic surgeon.” She specializes in hernias, bariatric surgery, and foregut surgery, and she conducts roughly 98 percent of her surgeries with the Da Vinci.
“Some residency programs didn’t see the benefit of teaching their surgery residents robotics,” says Coker. “But over the last six years, residents started demanding to be taught robotics … They were asking that we prepare a curriculum to teach them.”
So that’s exactly what she did.
Now her intern class (the first year of residency) does a “boot camp” in which they get acquainted with robotic surgery, and they get other touch points throughout their curriculum. First, students use robotic simulators, in which they complete games and tasks that teach them the skills they need for robotic surgery. Coker uses an app to track her students’ simulator use. She can see who has completed which tasks and can also assign specific tasks to students if she thinks they could benefit from extra sessions.
The simulators are “a little more like video games,” says Murillo, who wonders if someone who has played video games their whole life could have an advantage when it comes to working on the robot.
That’s a question that has actually been studied. A 2023 study in the Journal of Robotic Surgery found that “the video game experience improves basic robotic surgery abilities,” specifically when looking at robotic surgical tasks like camera targeting, energy switching, and vertical defect suturing. Others argue that while some skills from video games might be applicable, the hand-eye coordination that you need to operate a surgical robot is different from that developed playing video games.
Asher Mandel, an associate researcher in the Department of Urology at Mount Sinai, puts it this way, “Does playing baseball help you play soccer?” In other words, while some skills from video games may help in robotic surgery, they are still very different.
While playing video games might not translate directly to robotic surgery, extensive research into the best ways to gain expertise is underway.
Murillo is spending a dedicated research year trying to answer this question. In a study funded by UCSF and Intuitive, she plans to identify the measures that can differentiate a novice robot user from a proficient one. Once she finds those measures, she will also investigate how to teach students those specific skills through new curricula.
While there is currently no single standardized curriculum for using the surgical robot, students generally practice on simulators, work as bedside assists for around 10 cases, and then transition to working on the console with the help of an attending surgeon. In the past, there has been an emphasis on the amount of time spent using simulators. But Murillo explains, “what people are starting to realize is that maybe time is not the best measure of proficiency in robotic surgery. We are looking for other factors that we can teach to make someone truly proficient on the robot.”
Additionally, experts are questioning the pros and cons of teaching using a surgical robot. Challenges include involving medical students when their main role is watching from the console, “almost like watching YouTube videos or something,” said Murillo. Issues surrounding the high cost of the robot and access to simulators are also limiting factors.
Still, there can actually be educational benefits to teaching with robotic surgery.
“Robotic surgery has actually made [education] more equal because for the first time the student can see exactly what the surgeon sees,” says Johannes Kratz, the director of minimally invasive and robotic thoracic surgery at the University of California, San Francisco. Otherwise, students may be watching from the opposite side of the patient or from an uncomfortable angle. The console allows students to have the same view as the lead surgeon.
Ashutosh Tewari, the chair of urology and director of the robotic surgery institute at Mount Sinai, echoed these sentiments. “Students can learn better because they can finally see,” says Tewari.
Tewari was involved in the first robotic prostatectomy (with his mentor, the professor Mani Menon) in 1999 and has since completed over 9000 robotic radical prostatectomy surgeries. This is a minimally invasive procedure in which the surgeon removes the prostate to treat prostate cancer. Tewari explains that exposure to robotic surgery starts from day one for students in his residency program and says he even wants to bring this kind of 3D modeling to anatomy labs for first-year medical students.
“It goes beyond the robots, it’s all the technology,” Tewari says about some of the projects his team is working on to enhance surgical education. Some of those projects include using augmented reality to potentially overlay patient imaging from a Magnetic Resonance Imaging, or MRI, onto the surgical field, and using AI to help medical students identify structures in the body.
Some companies, like OssoVR, want to create virtual reality glasses that can place students in a virtual operating room for training or practice—without the high risk of operating on an actual patient.
Robotic surgery itself will also continue to advance. With some of the original Intuitive patents having recently expired, new surgical robots beyond Intuitive’s Da Vinci will soon hit the market. This will likely reduce costs, which will improve access.
“There are certainly discrepancies in educational opportunities,” says Coker, the Johns Hopkins surgeon. She has already heard from other program directors who want to teach their students robotic surgery safely but may not have access to pricey simulators, which can set medical schools or hospitals back anywhere from half a million dollars to over $2 million.
Students may need to master different robotic systems if hospitals choose to switch their tools. Just as today’s medical educational landscape looks markedly different than that of 20 years ago, tomorrow’s could have endless technological possibilities.
As Coker said, “The newer generation of people growing up are more proficient with technology overall, and part of it is an eagerness to accept it.”