Article published online: 2022-05-01

Robotically Assisted Microsurgery: Development

of Basic Skills Course
Topic

Philippe André Liverneaux1, Sarah Hendriks1, Jesse C Selber2, Sijo J Parekattil3

1
Department of Hand Surgery, Strasbourg University Hospital, Illkirch, France; 2Plastic Surgery, Anderson Cancer Center, The University of
Texas, Houston, TX; 3Robotic Surgery and Urology, Winter Haven Hospital and University of Florida, Florida, FL, USA

Robotically assisted microsurgery or telemicrosurgery is a new technique using robotic telemanip­ Correspondence:
Philippe André Liverneaux
ulators. This allows for the addition of optical magnification (which defines conventional micro­ Department of Hand Surgery,
surgery) to robotic instrument arms to allow the microsurgeon to perform complex microsur­gical Strasbourg University Hospital, 10 av
procedures. There are several possible applications for this platform in various microsurgical Baumann, F-67403 Illkirch, France
Tel: +33-688894779
disciplines. Since 2009, basic skills training courses have been organized by the Robotic Assisted Fax: +33-388552363
Microsurgical and Endoscopic Society. These basic courses are performed on training models E-mail: philippe.liverneaux@
in five levels of increasing complexity. This paper reviews the current state of the art in roboti­ chru-strasbourg.fr
cally asisted microsurgical training.
Supported by RAMSES: The
Robotic Assisted Microsurgical and
Endoscopic Society (http://www.
roboticmicrosurgeons.org/publications/).

No potential conflict of interest relevant

Keywords Robotics / Microsurgery / Computer simulation / Training to this article was reported.

Received: 2 Feb 2013 • Revised: 15 Feb 2013 • Accepted: 18 Feb 2013

pISSN: 2234-6163 • eISSN: 2234-6171 • http://dx.doi.org/10.5999/aps.2013.40.4.320 • Arch Plast Surg 2013;40:320-326

INTRODUCTION roboticmicrosurgeons.org), have reported their experiences in

various disciplines such as urology, plastic surgery, Ear, Nose,
Developed in the 1960s, microsurgery is a surgical technique Throat (ENT) surgery, ophthalmology, neurosurgery, hand
using optical magnification that allows the microsurgeon to surgery, and peripheral nerve surgery [3]. RAMSES not only
perform delicate movements which are difficult or impossible aims to promote microsurgery with robotic manipulators, but
using the naked eye. Over the last few years, microsurgery has also aims to develop a new concept: endoscopic microsurgery.
seen two major technical advances: supermicrosurgery [1] and It combines the properties of microsurgery, endoscopic surgery,
telemicrosurgery [2]. The latter, telemicrosurgery or robotically and telesurgery. This would not only allow magnification of
assisted microsurgery can be defined as the technique of micro- the view of the operating field, but also enable microsurgeon to
surgery that uses robotic telemanipulators to scale down surgical scale down the gestures or movements of the operator’s hands,
gestures or movements. The da Vinci robot (Intuitive Surgical while taking a minimally invasive approach.
Inc., Sunnyvale, CA, USA) is the only medical robot currently While telemicrosurgery is still in its infancy, RAMSES has orga-
available on the market for robotically assisted microsurgery. nized telemicrosurgery classes since 2009. The purpose of this
Several international groups, including the Robotic Assisted paper is to describe the models used for training, evaluation
Microsurgical and Endoscopic Society (RAMSES, http://www. methods, and the organization and proceedings of basic and

Copyright © 2013 The Korean Society of Plastic and Reconstructive Surgeons

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-aps.org

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advanced telemicrosurgery training. surgery. The optical magnification of the operating field is ob-
tained by the optical and digital magnification of the stereoscop-
THE DA VINCI ROBOT ic camera. The suppression of physiological tremor improves
the quality of surgical movements. The scaling down of surgical
The only surgical telemanipulator currently available on the movements improves accuracy by reducing the surgeon’s move-
market is the da Vinci robot (Intuitive Surgical Inc.). It consists of ments by a factor of 3 (position “fine”) or 5 (position “extra-fine”).
three components: a mobile instrument cart with four articulated The ergonomic design of the surgeons’ console is very useful
arms, an imaging cart, and a console for the surgeon to control the in microsurgery because it improves the comfort of the surgi-
robotic arms (Fig. 1). The mobile cart contains four articulated cal movements by simplifying the motion. The possibility of
robotic arms, three of which carry surgical instruments and a minimally invasive surgery allows the microsurgeon to work in
fourth arm that manipulates the digital stereoscopic camera to unique operative fields with minimal cutaneous incisions.
visualize the surgical field. Each of these arms has multiple joints Robotic telemanipulators have often been criticized for not
providing three-dimensional movement of the surgical instru- having tactile feedback. In reality, it has been clearly demonstrated
ments and optics. The surgical tools have articulation that pro­vides that force or tactile feedback is not absolutely necessary in mi-
intracorporeal range of movement to 360°, called “EndoWrist” crosurgery: first, because the range of motion in the microsurgi-
technology. The tools available vary: dissecting forceps, scissors, cal field is minimal, and second, because the perception of a 9/0
scalpel, spreaders, etc. The fourth arm, which controls the op- and 10/0 nylon yarn voltage is at the limit of human physiology
tics, has a stereoscopic, high definition, endoscopic camera. The [4]. Successful microsurgery with suture-assisted microsurgical
stereoscopic camera lens comprises a video imaging column robots has already been reported [5]. In addition, a new robotic
similar to that used in conventional laparoscopy or arthroscopy platform, the Amadeus telemanipulator (Titan), that will be
and two light sources and dual stereoscopic cameras for three- available soon, will be equipped with tactile feedback. It is not
dimensional vision with progressive magnification up to 12 to difficult to imagine that, in the future, there will be a robot able
15 times. The surgeons’ console is equipped with an optical to replicate microsurgical maneuvers with tactile feedback force,
viewing system, two telemanipulation handles, and five pedals. possibly enabling endoscopic supermicrosurgery [1].
The optical viewing system, called the stereo viewer, offers a
three-dimensional view of the operating field and displays text TRAINING MODELS
messages and icons that reflect the status of the system in real
time. The two telemanipulation handles allow remote manipula- Among the models currently available in conventional mi-
tion of the four articulated robotic arms. In its latest version, the crosurgery, there are nonliving non-biological models (latex,
da Vinci SI, the robot is equipped with 2 surgeon consoles to silicone, Gore-Tex, PracticeRat), nonliving biological models
allow for the simultaneous use with two operators: the primary (artery of the chicken wing, pig’s feet, placenta) and living mod-
robotic surgeon and a surgical assistant. In this mode, the 3 ro- els (mouse, rat, rabbit) [6,7]. The ideal model would meet the
botic arms can be utilized at the same time by the two operators. following specifications: inexpensive, easily available, similar
Five properties of the da Vinci robot are essential in telemicro- to the biological tissue, without ethical issues [8]. No model
perfectly fulfills all these specifications and full education in tele-
Fig. 1. Da Vinci Robot microsurgery must have several levels of increasing complexity,
The robot da Vinci SI contains three parts (from right to left): a mobile the ability to address technical challenges, and applicability to
cart with four articulated arms, an imaging cart, and a console for varying microsurgical procedures.
the surgeon to control the robot arm (reprinted with permission from
Intuitive Surgical, Sunnyvale, CA, USA). The first level is to become familiar with the robot and master
the basic skills of telemicrosurgery. This can be done either by
means of an analog simulator such as plastic rings (Fig. 2) or
by means of a virtual simulator. Several simulators are available
on the market: Mimic, Ross [9], dV-Trainer [10], and da Vinci
skills simulator [11]. The virtual simulators assess students’ per­
formances in terms of time to complete the exercise, gesture
accuracy, missed targets, instrument collision, drops, etc. This is
one reason why virtual simulators allow for highly efficient self-
teaching (Fig. 3).

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Fig. 2. Robot set-up Fig. 4. Earthworm model

Installation of a robot da Vinci SI for level 1 training. Plastic rings Preparation of one worm for level 2 training. A terminoterminal
must be manipulated and moved from one display stand to the other. telemicrosurgical anatomosis is realized with a 10/0 nylon thread.
No measure of performance is possible with this model, except the
time of realization of the task.

Fig. 5. Chicken artery model

Fig. 3. Simulator set-up Preparation of a femoral artery of a chicken leg for level 2 training. A
terminoterminal telemicrosurgical anatomosis is realized with a 10/0
Installation of the da Vinci skills simulator for level 1 training. Several nylon thread.
tasks of increasing difficulty can be developed, including vascular
sutures. Precise measures of performance allow for self-education.

is less attractive than the worm because of its higher cost and the
The second level is to use telemicrosurgical sutures on inex- greater difficulty of its preparation.
pensive models that pose no ethical dilemma in terms of animal The third level is to perform telemicrosurgical sutures on living
testing. We use calibrated earthworms (Lombricus rubellus) models. The rat model for instance, must be used in accordance
with an average length of 60 mm and a mean outer diameter of with current legislation on animal experimentation. The telemi-
3 mm (Fig. 4). Each worm is anaesthetized by soaking in a 1% crosurgeon, as well as the microsurgeon, must learn to perfectly
xylocaine solution until a significant slowdown in locomotor master the vascular sutures: venous and arterial (Fig. 6) [14]
activity is observed. Each end of the worm is then cut with a and the nerve suture techniques (Fig. 7) [15].
scalpel followed by gentle finger pressure applied from one end The fourth level is to perform more complex telemicrosurgical
to the other in order to completely eviscerate the worm. One maneuvers. A thawed fresh human cadaver is an ideal model on
obtains a hollow tube, the lumen, which replicates the lumen of which to learn to manipulate nerve regrowth scaffolds (Fig. 8),
a vessel of an average internal diameter of 2 mm. A frank cut in and to make pedicled flaps (Fig. 9) [16] and free flaps [17]. Re-
the middle of the model produces two segments of equal length implantations on living animals can also be performed [18].
ready to be anastomosed [12]. After anastomosis, the perme- The fifth and final level is reserved for endoscopic telemicro-
ability and tightness of the model can be tested by injecting sa- surgery. It consists of telemicrosurgical manuevers through min-
line solution through one end [13]. It is also possible to use the imally invasive incisions. Reconstructive surgery of the brachial
femoral vessels of chicken thighs (Fig. 5). However, this model plexus [19] or the removal of large flaps of the latissimus dorsi

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Fig. 6. Rat artery model Fig. 8. Cadaver nerve model

Preparation of an artery of the tail of a rat for level 3 training. A Preparation of a fresh human cadaver forearm for level 4 training.
terminoterminal telemicrosurgical anatomosis is realized with a 10/0 A graft of a nerve median is realized with a nerve guide with a 7/0
nylon thread. nylon thread.

Fig. 7. Rat nerve model Fig. 9. Cadaver flap model

Preparation of a rat sciatic nerve for level 3 training. A terminoterminal Preparation of a fresh human cadaver hand for level 4 training. The
telemicrosurgical anatomosis is realized with a 10/0 nylon thread. pedicle of the first dorsal interosseous space is isolated before raising
a kite flap.

muscle or of the rectus abdominis muscle [20] are particularly

suited to endoscopic telemicrosurgery. and applied it to a cohort of microsurgical trainees, demonstrat-
ing acceptable inter-rater reliability and a reproducible learning
METHODS OF ASSESSMENT curve [25].
Robotic microsurgical skill combines many of the same prin­
Despite advances in surgical training, microsurgical training is ciples and specific skill techniques as conventional microsurgery,
still based on an apprenticeship model. Considering the com- but has the additional skill set that is unique to the use of the
plexity of microsurgery and the consequences of failure, the lack surgical robot. In order to capture this blend of skills for robotic
of a standardized, quantitative system to evaluate surgeons’ skill, microsurgery, we combined a validated robotic surgical rating
provide feedback, and measure training endpoints raises major system [26,27] with the SAMS, to create the Structured Assess-
quality control issues. ment of Robotic Microsurgical Skill (SARMS) (Table 1). This
The Structured Assessment of Microsurgical Skills (SAMS) is evaluation system combines two separately validated skills assess-
a model designed to assess technical skills during microsurgery ment systems into a single evaluation system that encompasses
that was formulated from other assessment tools such as the both robotic skills and microsurgical skills. The SARMS is in
Imperial College Surgical Assessment Device (ICSAD) and the the process of being validated by testing inter- and intra-rater
Observed Structured Assessment of Technical Skills (OSATS) reliability in a laboratory model. This is the first evaluation sys-
[21-24]. In a recent study, we validated the SAMS instrument tem of its kind and will serve as a guide to robotic microsurgical

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Table 1. Structured Assessment of Robotic Microsurgery Skills (SARMS)

Skills 1 3 5
Micro skills
Dexterity
Bimanual dexterity Lack of use of non-dominant hand Occasionally awkward use of non-dominant Fluid movements with both hands working
hand together
Tissue handling Frequently unnecessary force with tissue Careful but occasional inadvertent tissue Consistently appropriate with minimal tissue
damage damage damage
Visuo-spatial ability
Micro suture placement Frequently lost suture and uneven placement Occasionally uneven suture placement Consistently, delicately and evenly spaced
sutures
Knot technique Unsecure knots Occasional awkward knot tying and improper Consistently, delicately and evenly placed
tension sutures
Operative flow
Motion Many unnecessary or repetitive moves Efficient but some unnecessary moves Economy of movement and maximum
efficiency
Speed Excessive time at each step due to poor Efficient time but some unnecessary or Excellent speed and superior dexterity without
dexterity repetitive moves awkward moves

Robotic skills
Camera movement Unable to maintain focus or suitable view Occasionally out of focus and inappropriately Continually in focus and appropriate view
view
Depth perception Frequent inability to judge object distance Occasional empty grasp Consistently able to judge spatial relations
Wrist articulation Little or awkward wrist movement Occasionally inappropriate wrist movement or Continually using full range of endowrist
angles motion
Cutting Erratic suture length or uncoordinated cutting Occasionally long/short suture and occasional Smooth cutting motion with consistent suture
effort discoordinated cutting motion length
Fourth arm transition Inability to change from needle driver to Occasionally awkward changes from needle Consistent and fluid transition from needle
scissors without prompting driver to scissors driver to scissors
Communication Always delayed requests for instrument Occasional inability to recognize out of Consistent and timely requests for appropriate
reposition position instrument instruments
Atraumatic needle handling Consistent bending/breakage of needle Occasional bending/breakage of needle Consistently undamaged needle
Atraumatic tissue handling Consistent inappropriate grasping/crushing or Occasional inappropriate grasping/crushing or Consistently gentle handling of tissue
over spreading of tissue over spreading of tissue

Overall 1 2 3 4 5
Overall performance Poor Borderline Satisfactory Good Excellent
Indicative skill Novice Advanced beginner Competent Proficient Expert

credentialing, as well as training endpoints for a robotic micro- ferent specialties: urology, plastic surgery, hand surgery, ortho-
surgical curriculum. This will also serve as a research tool to help pedics, ophthalmology, and neurosurgery. Up to the present,
determine the learning curve for robotic microsurgical skills. 42 surgeons from 11 countries have attended the basic courses
In addition to the SARMS, a demographic survey (Table 2) (Japan, Singapore, Brazil, USA, Belgium, France, Netherlands,
will be distributed in order to determine if years of training, level Spain, Switzerland, Turkey, and Kuwait). Two to three expert
of training, gender, handedness, or previous experience with members of RAMSES supervise the participants. Each class
robotic, microsurgical, or laparascopic training, or video games lasts a full day. In the morning, seminars are given by engineers
has any effect on robotic microsurgical skill acquisition. of the Intuitive Surgical Company and by RAMSES experts.
The program includes the history of medical robotics, descrip-
ORGANIZATION OF BASIC COURSE tion of the robots, presentation of the telemicrosurgical models,
SKILL and current clinical applications. The morning session ends at
the laboratory, with a demonstration of the setup of the da Vinci
Since 2009, RAMSES has organized foundation telemicrosur- robot by an engineer from the company Intuitive Surgical. The
gery courses, twice a year, at the IRCAD facility, Strasbourg, afternoon is devoted to a practical workshop. For a configura-
Europe. A basic course program will open soon in Florida, USA. tion of six participants, participants are divided into 3 groups
Each course welcomes a maximum of 6 participants from dif- of 2 people; 1 group of level 1 on the simulator and 2 groups of

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ROBOTIC­ASSISTED MICROVASCULAR ANASTOMOSIS SURVEY
Table 2. Robotic-Assisted Microvascular Anastomosis Survey

Name: No:

Please complete the following questionnaire by checking the appropriate box.

Gender Female Male

Age

25-30 31-35 36-40 41-45 46-50 >50

Hand dominance:

Right-handed Left-handed Ambidextrous

Level of training:
Resident Clinical Fellow Research Fellow Junior Faculty Senior Faculty

Competent
Advanced

Proficient
beginner
Novice

Expert
How much experience do you have with the following?

1. Microsurgery experience

2. Robotic experience

3. Laparoscopic experience

4. Video game experience

Number of robotic simulator hours completed?

None <5 hr 6-10 hr >10 hr

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