Simulation training with haptic feedback of instrument vibrations reduces resident workload during live robot-assisted sleeve gastrectomy

Abstract

Background: New surgeons experience heavy workload during robot-assisted surgery partially because they must use vision to compensate for the lack of haptic feedback. We hypothesize that providing realistic haptic feedback during dry-lab simulation training may accelerate learning and reduce workload during subsequent surgery on patients.

Methods: We conducted a single-blinded study with 12 general surgery residents (third and seventh post-graduate year, PGY) randomized into haptic and control groups. Participants performed five simulated bariatric surgeries on a custom inanimate simulator followed by live robot-assisted sleeve gastrectomies (RASGs) using da Vinci robots. The haptic group received naturalistic haptic feedback of instrument vibrations during their first four simulated procedures. Participants completed pre-/post-procedure STAI and post-procedure NASA-TLX questionnaires in both simulation and the operating room (OR).

Results: Higher PGY level (simulation: p < 0.001, OR p = 0.004), shorter operative time (simulation: p < 0.001, OR p = 0.003), and lower pre-procedure STAI (simulation: p = 0.003, OR p < 0.001) were significantly associated with lower self-reported overall workload in both operative settings; PGY-7 s reported about 10% lower workload than PGY-3 s. The haptic group had significantly lower overall covariate-adjusted NASA-TLX during the fourth (p = 0.03) and fifth (p = 0.04) simulated procedures and across all OR procedures (p = 0.047), though not for only the first three OR procedures. Haptic feedback reduced physical demand (simulation: p < 0.001, OR p = 0.001) and increased perceived performance (simulation: p = 0.031, OR p < 0.001) in both settings.

Conclusion: Haptic feedback of instrument vibrations provided during robotic surgical simulation reduces trainee workload during both simulation and live OR cases. The implications of workload reduction and its potential effects on patient safety warrant further investigation.

Keywords: Haptic feedback; NASA-TLX; Naturalistic vibrotactile feedback; Robotic surgery; Subjective workload assessment; Surgical simulation.

Fig. 1

Simulator and robotic bariatric procedures. a Custom abdominal simulator used for the simulated procedures, and sample video frames from the b simulated and c live OR robot-assisted sleeve gastrectomy (RASG) procedures

Fig. 2

Study flowchart. After participants were randomized to either the haptic group or the control group, they performed five high-fidelity procedure-specific simulations: two trials of robot-assisted gastric banding (RAGB) and three trials of robot-assisted sleeve gastrectomy (RASG). Starting the following day, participants performed live RASG’s on patients for the duration of their gastrointestinal surgery rotation

Fig. 3

Multiple linear regression for NASA-TLX_overall Correlation between predicted and actual NASA-TLX_overall from a simulated and b live OR bariatric surgical procedures, with R as the correlation coefficient

Fig. 4

The effect of haptic feedback on NASA-TLX_overall and its subscales during simulation procedures. The thick black line shows the median, the box shows the inter-quartile range (IQR), the thin lines show the range up to 1.5 times the IQR, and dots show outliers. (a) NASA-TLX_overall for the five simulated procedures (n = 60). The differences between the haptic group and the control group are significant for the fourth and fifth procedures. Significance remained after Bonferroni-Holm correction. (b) Analysis of the six NASA-TLX subscales showed significant differences between the groups in physical demand, performance, and effort. For these analyses, NASA-TLX_overall and its subscales scores were adjusted for PGY level and sleep

Fig. 5

The effect of haptic feedback on NASA-TLX_overall and its subscales in the live OR setting. The thick black line shows the median, the box shows the inter-quartile range (IQR), the thin lines show the range up to 1.5 times the IQR, and dots show outliers. NASA-TLX_overall showed a lower workload for the haptic group across 76 live RASG cases (Haptic: n = 45, Control: n = 31) and b no difference in the first three RASG live procedures (n = 36). c Analysis of the NASA-TLX workload subscales showed a significantly lower mental demand, lower physical demand, and better perceived performance in the haptic group. Here, the NASA-TLX_overall and its subscales were adjusted for PGY level