Camran Nezhat, MD reports on his efforts to encourage simulation to become even more realistic, to influence surgical curriculum and to impact training protocols.

We now know that the limiting factor for performing minimally invasive surgery is surgical skill and experience, as well as the availability of proper instrumentation.

In my career-long search for the best quality for patients, I have been absolutely committed to minimally invasive surgery with and without robot assistance. It has been proven that better results are afforded through this minimally invasive, modern technology. But such complex surgical methods require in-depth training, otherwise surgeons will do harm not only to their patients but also slow the progress of medicine.

It is no longer accepted to say that skilled surgeons attain their expertise through years of observation and experience. We can and must encourage the best, most efficient training possible for the benefit of our patients. So it is essential to train surgeons with the most modern simulation technology, independently validating the method and quality of the procedure through our academic centers. There is no substitute for such training in terms of overall patient recovery and for minimizing post-operative risks and adverse consequences for patients.

The Study

For the past two years we have been studying the methods of simulation training in order to determine which is easiest to learn and best for the surgeon. We are currently comparing simulation training between traditional laparoscopy  and Mimic Technology’s for robotic-assisted- software for the da Vinci Robot. Mimic’s training technology has been independently validated by academic medical centers throughout the country, and for this reason their technology is an important part of the study. We are evaluating the best, least-invasive ways of surgically managing intraabdominal pathologyI in order to help surgeons avoid the more traditional open surgery.

Our study is made up of a group of postgraduate trainees at Stanford University Medical Center. In order to evaluate the benefits, the tasks we’ve chosen include suturing, knot tying, and moving of the objects from one location to another on the dV Trainer, a robotic surgery simulator. These particular exercises are to be completed before the more formal training, and then we continue to evaluate the time the trainees take to complete the tasks.  This takes place periodically to measure the improvement in different individuals.

Why the Study

In my field, about 60 percent of hysterectomies are performed through open surgery, resulting in more risk and pain to women. I am deeply concerned that most surgeons use a large incision to gain access to the uterus and other pelvic organs. The hope is that through better quality training more surgeons will adopt more up-to-date methods of caring for their patients. Determining which methods are easier to teach and learn will help us reach that goal.

We must continue to conduct research to demonstrate the effectiveness of simulation training and how it can affect patient outcomes. An analysis of previous studies finds that the use of technology-enhanced simulation training in health professions education, in comparison with no intervention, is associated with significant effects for outcomes of knowledge, skills, and behaviors and more moderate effects for patient-related outcomes, according to an article in the September 7, 2011 issue of The Journal of the American Medcial Association.

Determining an Easier Path to Training

There are advantages to training surgery with and without robot assistance. When looking at outcomes for both laparoscopic with and without robot assistance surgery in the past, we see that they have been similar; however, robotic assistance offers the surgeon three-dimensional images, helpful instruments, and an opportunity to be seated during surgery. Traditional laparoscopic is more established, and that familiarity can be an advantage, even at the training stage.

As reported by the Mayo Clinic, both are preferable to the traditional open incision because there is less blood loss, shorter hospital stays and fewer post-operative complications. One of the aspects of this study that is so important is how simulators enable surgeons to become proficient in a much shorter time. It is not enough to allow surgeons to become proficient with learning only during postgraduate courses. We need better protocols so that surgeons go into surgery with an acceptable level of skill from day one. Our study is important in demonstrating how simulators enable surgeons to become proficient in a much shorter time.

Additionally, we are looking at whether the training techniques have a significant effect for patients. Anything that helps us preserve the uterus and other vital organs in a way that is much less invasive to women is the way to go.

Training surgeons with the most up-to-date technology prevents complications during surgery and relieves patients of having to undergo more complicated procedures in the future to repair problems from previous surgeries.

The Importance of Teaching Simulation

There are simply not enough surgeons in the United States and worldwide that are trained to perform advanced minimally invasive surgery with and without robot assistance. If you want to be great at anything, and surgeons should be at their craft, you have to practice frequently. Obviously this practice cannot occur on humans; we need simulators for them.

The shortcomings in available training technology have introduced an opportunity for skilled medical device manufacturers who have sophisticated experience, such as Mimic Technologies, to develop simulators that train surgeons on performing minimally invasive surgery. We need to do a much better job explaining or teaching the importance of simulation. As I have told many, in the same way that pilots, before they start flying, must log in thousands of miles of flying in simulators—we should be going in the same direction for surgery.


The Advantages: Current Technology

Some simulators can recreate the same consistency, to some degree, of tissues, vessels, and breathing. Every year, we train hundreds of surgeons to become minimally invasive or robotic surgeons. Now, instead of sending them to the animal lab, they can practice on a simulator. That has been the purpose of the study. We are working with Mimic Technologies directly to encourage simulation to become even more realistic, to influence surgical curriculum and to impact training protocols.

Studies have proven that good quality simulators can divulge whether surgeons are an expert or new surgeon. We have figured out that training on the simulator translates to improved skill on the robot itself. However, most of these findings involve studies that are conducted with a “dry lab”, but our study takes it further by measuring actual patient outcomes and how simulation training curriculum affects those outcomes.

Dr. Camran Nezhat with his fellows Erica Balassiano, Jillian Main and Diana Aldape. Image Credits: Maia Dignlassan
Dr. Camran Nezhat with his fellows Erica Balassiano, Jillian Main and Diana Aldape. Image Credits: Maia Dignlassan

Challenges: Investment

The challenges in training surgeons to use robotic-assisted surgical technology involve the time, the cost, and the available resources. For each surgery, instruments total close to $2,000. Add the cost of bringing in a team to set up the robot, a proctor for observation, physical models, and then the price of sacrificing surgery time to train with the robot and you have a significant investment. These costs are added to the cost of the robot for $1.6 million and a simulator for less than $100,000.

However, this investment is well worth the cost. As reported by many hospitals, surgeons report they like the fact that they are allowed a three-dimensional view, as opposed to traditional laparoscopy, where the view is two-dimensional. This gives them more detail and more ability to manipulate the view, which is important to some surgeons. The robot removes the sometimes confusing, counterintuitive motion of traditional laparoscopy, where the endpoints move in the opposite direction of the surgeon's hands. To some, the robotic instruments are more flexible because they operate like the human wrist. Performing while sitting is another advantage of robotic surgery.

There are subjective views about technical difficulty. For many surgeons, it could make sense to embrace robotic assisted surgery once trained. For others who are already traditional laparoscopic surgeons, they should become great laparoscopic surgeons, by investing in further training.

But the most important aspect is that minimally-invasive surgeries, with and without robot assistance, offer better outcomes. When patients leave the hospital sooner, and with less pain, then we have succeeded. When they are able to return to work more quickly and resume their lives with their families--  that is what counts.

There has been tremendous growth in the use of simulation for robotic assisted surgery. This is evident in the fact that we are seeing many more hospitals building simulation centers. With many improved outcomes for patients, there is no doubt this trend will continue.


Our study will produce short- and long-term results and could last for years. Our hope is that it has a significant effect on the use of simulation technology. If it shows the strengths of laparoscopic and robotics with and without robot assistance, administrators might be willing to invest more in a laparoscopic simulator. In any case it is going to have an impact on the way that people train surgeons, and that will help build a foundation, so that training can be applied consistently throughout hospitals and in academic centers around the world—that is our overall goal.

About the Author

Camran Nezhat, MD, is the internationally renown minimally invasive surgeon at Stanford University Medical Center in Palo Alto, California. Nezhat is widely recognized as a pioneer in the field and recognized as “The Father of video assisted laparoscopic surgery”.


1Hospital and Health Networks; Boston Business Journal; San Francisco Business Times;