LAUSR

I read with great interest the article by Sessa et al., entitled “Face and content validity of XperienceTM Team Trainer: bed-side assistant training simulator for robotic surgery”, published recently by Updates in Surgery [1]. The number of robot-assisted surgery (RAS) procedures performed with da Vinci Surgical System by Intuitive Surgical (Sunnyvale, CA, USA) has increased exponentially over the years, exceeding 750,000 procedures in 2016 [2]. For an efficient and safe use of the da Vinci robot, surgeons need specific technical skills, different from open surgery. These are bimanual wristed manipulation, camera control, master clutching, use of fourth robotic arm, activation of energy sources, depth perception, and awareness of force [3]. Unlike open surgery and laparoscopy, RAS does not allow surgeons to feel interaction between tissue and instruments. To avoid potential damages to tissue, surgeons rely on visual cues [3]. Since the use of an actual da Vinci robot for training purposes is extremely costly (about $500/h), virtual simulators for RAS may represent an affordable solution from an economic point of view [4]. Currently, there are five virtual simulators for RAS commercially available: Surgical Education Platform (SEP) by SimSurgery (Oslo, Norway), Robotic Surgical System (RoSS) by Simulated Surgical Systems (San Jose, CA, USA), dV-Trainer by Mimic (Seattle, WA, USA), da Vinci Skills Simulator (dVSS) by Intuitive Surgical, and the recently introduced RobotiX Mentor by 3D Systems, Simbionix Products (Cleveland, OH, USA) [5]. These simulators enable novices in RAS to acquire the needed technical skills by executing a wide array of exercises, ranging from simple to advanced tasks (suture and knot tying), up to simulated procedures (partial nephrectomy, inguinal hernia repair, hysterectomy, and prostatectomy), enabled by virtual reality (for RobotiX Mentor) and augmented reality (for dV-Trainer). In RAS, surgeons have no direct access to patient, contrary to open surgery. They interact with the surgical team only through audio communication. Therefore, an appropriate level of team training, where bedside assistant is involved, is essential for a successful procedure. For this reason, Mimic and Simbionix launched simulators, which can be coupled optionally to their flagship simulator for RAS, for team training between primary surgeon and assistants. I had the privilege to try Experience Team Trainer (XTT) by Mimic just after its commercial release and was positively impressed. It enables interaction with virtual environment through two manual laparoscopic interfaces. It can be used as standalone training tool for the assistant or coupled with dV-Trainer as a complete platform for coordination with the surgeon. The study by Sessa et al. is the first assessing face and content validity of XTT including only subjects with experience as bedside assistants in RAS (beginners with less than 50 cases and experts with more than 50), contrary to the one by Xu et al. including also subjects without such an experience [1, 6]. Additionally, it is the first study assessing XTT as standalone training tool for laparoscopy [1]. Authors also used NASA Task Load Index to assess mental, physical, and temporal workloads of participants. XTT has demonstrated face validity as both laparoscopic and team training simulator. The good results in terms of content validity suggest that XTT is a useful team training platform. In the questionnaire on content validity, experts were also asked to rank importance of metrics used by the simulator to assess performances. Readers, especially novices in RAS, should interpret this ranking with caution. Although experts rated instruments out of view as the least important metric, this parameter is crucial as surgeons must view surgical tools during procedures to avoid touching tissue, with an ultimate goal to exclude the unexpected and * Andrea Moglia [email protected]