The Value of Robotics for Surgery Training

© 2019 Mimic Technologies, Inc. All rights reserved. www.MimicSimulation.com© 2019 Mimic Technologies, Inc. All rights reserved. www.MimicSimulation.com
The Value of Robotics Simulation for
Surgical Training
Jeff Berkley, PhD
CEO, President & Founder
Mimic Technologies Inc SKIP INTRO
© 2019 Mimic Technologies, Inc. All rights reserved. www.MimicSimulation.com

According to the federal Agency for Healthcare Research and Quality (AHRQ),
patient safety has been declining leading to over 250,000 deaths a year at a cost of
approximately $30 billion*
As a result of the Affordable Care Act, medicine is transforming from a “Pay per Service” to a “Pay for
Performance” industry
Our Medical System is Broken!
• “To Err is Human – To Delay is Deadly…Ten years later, a million lives lost, billions of dollars
wasted”, Consumers Union, SafePatientProject.org, May 2009
• BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2139 (Published 03 May 2016)
Equivalent
to seven
jumbo jets
crashing
every
week

Epidemiology of Surgical Errors
Primitive Causes of Surgical Errors
8.85
10.27
11.58
2010 2014 2018
Incidence of Surgical Errors
(Million Cases)
Procedural
Incompetence
41.81%
Lack of Adequate
Preoperative
Planning
19.56%
Indecorous Work
Process
13.45%
Poor Peer
Communication
12.18% Meager
Negligence
9.24%
Fatigue
2.23%
Usage of Alcohol
during Procedure
1.53%
CAGR:
3.19%
Surgical Errors
BIS Research, “Robotics Simulators: An Emerging Frontier in the Era of Healthcare Robotics”, July 2019
Addressable
with training

Why Robotics?
Robot assisted surgery increases the applied dexterity and accuracy of the surgeon
because of the following advantages:
• The surgeon’s hand motion is scaled so large movements results in small instrument motion
• Hand tremor can be filtered out
• The surgeon controls his or her own camera
• The surgeon can switch control between multiple instruments
• High definition 3D visualization enables better depth perception
• The da Vinci robot has been clinically shown to be equivalent or superior to open or laparoscopic surgery in
Urology, Gynecology and is developing in General Surgery
Conducting surgery through a robot is analogous to shrinking the surgeon and placing them inside the body

Challenges for Healthcare Systems
Multiple Hospitals
Many Robots
Central Robotics Committee but Decentralized Local Committees
Need for improved Risk Management
Need for improved Efficiency in the OR
Comprehensive Credentialing & Privileging
SOLUTION
Comprehensive Robotics Program built on
Proficiency, Data & Simulation

New Concerns with Credentialing
Surgeons are being sued for lack of
informed consent regarding their skill
and experience level
Medicolegal Review of Liability Risks for Gynecologists
Stemming from Lack of Training in Robot-Assisted Surgery
Yu L. Lee, Gokhan S. Kilic, MD, John Y. Phelps, MD, JD, LLM.
JMIG, 2011; 18(4), 512-515.
Hospitals are now being sued for negligence
regarding credentialing policies

Recent Landmark Robotic Case
Bremerton WA
Taylor v. Intuitive
“…responsibility for training, credentialing,
and privileging surgeons to use new
technologies belongs to physicians and
the hospitals where they work.”

Traditional Surgical Credentialing
Take a course
Get proctored
Good until you retire

Traditional Surgical Credentialing
Problems with Traditional Credentialing
One Time Event
doesn’t address skills degradation with no ongoing
maintenance of certification or proficiency
Doesn’t Anticipate Changes in technology
Review of privileges usually
Only Triggered by Traditional
Morbid Events, not by deviations from normal

IMPACT OF
TECHNOLOGY
on Aviation Safety

Impact of Technology on Aviation Safety
A Statistical Analysis of Commercial Aviation Accidents 1958-2016, Airbus

What the Aviation Industry Can Teach Us
Aviation Industry
Initial Pilots License
Upgrade Certification
Demonstrate Competency
Annual Currency Required
Annual Recertification
Medical Industry
Initial Surgical Privilege
New Procedure Training
None
None
None

Who Would Benefit From Better Training?
Uniquely positioned to
set the standard for
robotic surgery
simulation across
most robotic platforms
Surgeons
Hospitals
Med Device Industry
Nearly every surgeon who
uses the da Vinci robot
has trained with Mimic’s
virtual reality platform
Mimic’s advanced
analytics help executives
assess surgeon risk &
efficiency before they
enter the OR Medical device companies
use Mimic’s simulation to
optimize robot design and
deliver exceptional
training
 With +1M robotic
surgeries conducted
last year, there is a
tremendous opportunity
to reduce costs through
simulation training and
evaluation
 Partnered to deliver
simulation with nearly
every company
launching a minimally
invasive surgical (“MIS”)
robot
 Mimic is ready to expand
its product and services
offering as new surgical
robot companies enter
the market
 Robotic surgery will
replace most manual
surgery and Mimic has
significantly enabled
adoption
 Extensive data
collection and analytics
allow surgeons to
compare themselves to
surgeons in “rest-of-
world”

It Takes A Team

Laparoscopic skills development
for the surgical assist
Mimic Simulation Platforms
S U R G E O N T R A I N I N G T E A M T R A I N I N G
Innovation, through leadership in robotic simulation
On demand, stand-alone simulation
training for da Vinci Xi®, da Vinci Si®,
and da Vinci S®
Portable simulation training
for da Vinci Xi®, da Vinci Si®,
and da Vinci S®
www.MimicSimulation.com

Mimic Simulation Software
High fidelity virtual reality training
for learning robot control, advanced surgical
skills, first assistant skills and team collaboration.
Procedure-specific augmented reality training
where expert surgeons lead you through
interactive video of real surgical cases.

 120+ laparoscopic and team
training exercises included with
Mimic’s dV-Trainer® and FlexVR™
(compared to 35+ on the ISI
‘backpack’)
 Over 4.3 million training sessions
since 2007 launch of dV-Trainer®
 Regular software updates continue
to deliver new and novel content to
keep trainees engaged and
entertained
High fidelity simulation engine
that runs dV-Trainer®, FlexVR™, and
XTT™
BAC K

 Features world-class surgeons and
educators and live surgery footage
to mentor trainees in VR and AR
through procedure specific learning
 Features real 3D video footage with
embedded virtual content to enable
an interactive experience
 Develop decision-making skills and
procedure knowledge
Scoring system, sophisticated
admin tools and cloud back up for
proficiency assessment and
curriculum customization.
BAC K

Immersive VR Training for the Entire Team
Operating room setup
Patient positioning
Robot draping and prep
Trocar placement
Robot positioning and docking
Emergency procedures

Internal Video Review
Optimize follow-up curriculum training based on video review of initial surgeries
Customize Curriculum
(Leverage Machine Learning)
Conduct Internal
GEARS Review
Record Video
of Surgery

Robot vs. Simulator
0
50
100
150
200
250
300
350
DVSS dVT Hopsital Flex VR
TIME TO COMPLETE COMPARISON
75% 25% Median
+60%
+33%
0
50
100
150
200
250
300
350
DVSS dVT Hospital Flex VR
TIME TO COMPLETE COMPARISON
75% 25% Median
+ 2%
-6%
When no feet involved in the exercise
difference in performance noticeable
When feet involved in the exercise
difference in performance variable decreases

Utilization Comparison
Mimic Team Trainer Total Sessions (Dec 2016 – Jan 2017) : 1351
XTT Team Training Sessions (Dec 2016- Jan 2017) : 450
ISI Skills Simulator Total Sessions (2014-2016): 209

Benefits of Stand-alone
 Access to training anytime
 Training does not sacrifice valuable
OR and robot time
 Allows for independent training
without supervision and observation
 Surgeons and teams are trained to
proficiency before robot even installed
 Better program management with data
access and cloud-based analytics
 Utilizes low cost capital for training
 Greater efficiency in multi robot
systems through a common
training platform

Distributed Simulation Hospital Program
Unify training, testing, and monitoring across ALL
system hospitals utilizing the Mimic MScore Portal™

TRAINING HUB
dV-Trainer® XTT™
TRAINING & PRIVILEGING
Training Hub sets standards and
provides premium training.
Leverages Mimic’s simulation
platforms such as dV-Trainer®,
XTT™ and the real robot.

TRAINING HUB
dV-Trainer® XTT™
SATELLITE SATELLITE SATELLITE SATELLITE
MOBILITY OF FlexVR™
Transfer FlexVR between
satellite locations as needed
TRAINING & TESTING
Satellite hospitals train and test surgeons
with portable FlexVR™ Systems.

TRAINING HUB
dV-Trainer® XTT™
Surgeons seeking advanced training
or in need of remediation are sent to
the Training Hub
SATELLITE SATELLITE SATELLITE SATELLITE
TRAINING & TESTING
Satellite hospitals train and test surgeons
with portable FlexVR™ Systems.

Visibility into your data
anytime, anywhere
Superior analysis tailored
specifically to your needs
Simulation Assessment Platforms
Custom Reporting
Proficiency-based scoring is the
core of our simulation platform

Performance Analytics and Reports
 Easy admin tools to setup and manage users
and curricula
 Proficiency-based scoring that is derived from
experienced surgeon data
 Data backed up in the cloud with MScore Portal™
for managing users, implementing programs,
generating reports, etc.
 Advanced analytics and comparisons to rest-of-world
Scoring system and sophisticated admin tools
for dV-Trainer®, FlexVR™, and XTT™

Custom Reporting and Program Management
 Mimic builds customized training curriculums and
helps hospital systems manage their programs.
 Focus is on training, privileging and credentialing
through objective simulation data.
 Mimic distills data down to dashboards that can
be absorbed by stakeholders at a glance.
 Mimic facilitates the continuance of robotics
simulation programs despite the turnover over
program managers and stakeholders.
Mimic brings 18 years of experience in robotics
training to help customers understand best
practices for utilizing simulation.

Quality and Efficiency Example
Example data from Beaumont Hospital
-5 -4 -3 -2 -1 0 1 2 3 4 5 -5 -4 -3 -2 -1 0 1 2 3 4 5
Includes time to complete task, economy of motion, and master workspace range
MORE EFFICIENT
use of the device
SHORTER
OR time
MEASURES
commitment to
learning process
METRICS
for surgical
case privilege
METRICS
for skill
degradation
=
Increased
Quality &
Efficiency
Established
Benchmark
Training Based on Dreyfus Model

-5 -4 -3 -2 -1 0 1 2 3 4 5-5 -4 -3 -2 -1 0 1 2 3 4 5
LEADS TO
fewer mistakes
& complications
MEASURES
commitment
to program
METRICS
for surgical
case privilege
METRICS
for skill
degradation
Risk and Safety Example
Example data from Beaumont Hospital
Includes instrument collisions, dropped objects, moving instruments when out of view, excessive force, and missed targets
=
Increased
Safety &
Decreased
Risk
Training
Standards
S T A R T
F I N I S H
Training Based on Dreyfus Model

Predictive Analytics
Mimic uses machine learning and advanced statistic to identify top performers and anticipate curriculum durations
Distribution of hypothetical hours to competency in all exercises of curriculums at STAN (Nancy, France)
and the Nicholson Center (Florida)
22% competent
in
over 20 hours
22% competent in
over 20 hours
“Distribution of Innate
Psychomotor Skills
Recognized as Important
for Surgical
Specialization in
Unconditioned Medical
Undergraduates”, Moglia,
et al., Surgical
Endoscopy, 2018
Innate Ability Curve
37% competent in
under 10 hours STAN Curricula
Nicholson Center Curricula
BAC K

Hysterectomy Cost Models
Activity Cost
Top
25%
Cost
per case
Bottom
25%
Cost
per case
Delta
per case
OR Times $50/minute 90 mins $4,500 140 mins $7,000 $2,500
Complications
$20,000/
complication
1% $200 4% $800 $600
LOS $500/day 1 day $500 1.8 days $900 $400
Re-
Admissions
$20,000/
re-admission
1% $200 3% $600 $400
Total $5,400 $9,300 $3,900
Delta = $3,900 per case
Data/study from CAVA Robotics, Dr. Rick Low et al, 2015.
Data from 250 surgeons, 200,000 robotic cases, 36
institutions
A hospital group doing 4,500
cases per year using 20 robots,
with the lowest performing 50
surgeons doing approximately
225 cases a year:
Potential Savings
from training bottom performing
50 surgeons and teams:
Data/study from Loftus Health Healthcare
Consulting, 2015)
INCREASED HOSPITAL EFFICIENCY =
REDUCED CASE TIME IN THE OR
$926K/year

Culligan Study – Morristown Protocol
Culligan, et al, FPMRS, Jan/Feb 2014
EXPERT SURGEONS STUDY GROUP CONTROL
Number 5 14 4
Demographics N/A Same (49.1) Same (53.5)
Average simulation hours Some 20 (9.7 to 38.2) 0
No of cases Average 142/year 0 Enough to be
granted privileges
Mean Hyst operative times 20.2 minutes 21.7 minutes 30.9 minutes
EBL 25ml 25.4ml 31.25ml
Goals score 50 34.7 31.1
Completing this protocol IN THE STUDY GROUP of robotic
simulator skills translated to EXPERT-LEVEL SURGICAL TIMES
during live human surgery. As such, we have established
predictive validity of this protocol.”
BAC K

Skills Degradation Prevention
Mimic develops a plan for a
SKILLS MAINTENANCE CURRICULUM
Required integration of surgical specialty benchmarks
Skills Maintenance and Remediation
Core robotic psychomotor skills begin to
degrade significantly in 2–4 weeks
Particularly true for surgeons new to robotics
Efficiency – Accuracy – Safety
FOCUS ON
Guseila LM, Saranathan A, Jenison EL, Gil KM, Elias JJ (2013) Training to maintain surgical skills during periods of robotic surgery inactivity. Int J Med Robot; doi:10.1002/rcs.1562.
Jenison EL, Gil KM, Lendvay TS, Guy MS (2012) Robotic surgical skills; Acquisition, maintenance, and degradation. J Soc Laparoendoscopic Surgeons 16:218-228.

Pre and Post Exercises were performed
Both Surgeons 1 & 2 attended MIS/Mimic Courses
Skills Degradation Study
0
200
400
600
800
1000
1200
1400
Energy Switching 1 Peg Board 1 Ring & Rail 1 Energy Switching 1 Peg Board 1 Ring & Rail 1
Aug-15 15-Oct
Skills Degradation
Surgeon 1
Performance remained consistent
• Performed 5 Robotic Procedures
• Practiced on a simulator
Surgeon 2
Performance declined significantly
• Performed 0 Robotic Procedures
• Did not practice on a simulator

What we did in Tacoma
2005: Acquired robot
2007: Decision to form Robotics Committee
2008: Formal robotics committee for system
 Multi-disciplinary
 Independent
 Medical Director position
‒ Under COO
‒ Peer Review Authority
 Gives advice to other Medical Staff Departments

Annual Recertification: ALL
Pass 2 Consecutive
Peg Board 2 90%
Energy Dissection 2 90%
Ring Walk 2 90%
Suture Sponge 2 90%
Simulator

C&P at MultiCare Health Systems
Robotic Credentialing: Basic,
Advanced simulation requirements
(pass 5 with 2 consecutive passes)
Annual Certification: Minimum 12
cases per year, all surgeons pass 2
consecutive Sim exercises
 Program adopted in 2008
 All robotics surgeons required to pass annual
simulation test to prove proficiency
 Failure to complete at least 12 cases per year
results required simulation training and testing
 62 surgeons credentialed (all specialties),
35 currently have privileges at all 4 hospitals
 5 surgeons have relinquished privileges
‒ Could not pass simulation due to physical
conditions not otherwise apparent
 5 low volume surgeons have maintained
privileges by passing simulation training and
testing requirements
Multi-Care:
Only Health Care System in the
Pacific Northwest that has NOT
had a robotic surgery lawsuit.

The Evolving Role of Simulation
 Training
‒ Basic: Psychomotor skills
‒ Advanced: Procedures
‒ Team: Bedside assist
Current Uses of Simulation
 Credentialing, privileging
and remediation
 Surgical Warm-up
Gaining Momentum

Complication-Simulation Training
Basic Management
 Vascular injuries
 Bowel and urinary tract injuries
Advanced Management
 Worsening complication
scenario
Procedure-specific
Complications
 Major vessel injury and repair
with pelvic lymph node
dissection

 MScore™ portal cloud links simulators to
central admin for review
‒ Data Analytics available to all program
directors as well as surgeons/students
‒ Link to simulation performance
to clinical outcomes
‒ Compare performance and outcomes on
different robotic systems
‒ Reduce insurance rates for high utilization
and proven simulation performance
 Remote surgical planning
 Virtual Reality for OR setup and docking
Connected, Smart Simulation

 Surgical Planning
‒ Practice complex procedures on
actual patients based on imaging
input into simulator
‒ Practice simulated procedures new to
surgeon with Augmented Reality
 Practice on different robots prior to
actual surgeries if you use more
than one system
 Machine learning: Identify skills
necessary to improve clinical
outcomes, then practice
2019 and Beyond!

Conclusions
 Robots will take over the operating room!
 Over 1 million robot assisted surgeries
 Procedures growing at 17%
 Simulation enables surgeons to learn, improve and maintain skills,
especially during periods of robotic inactivity, without training on
patients
 Need to establish a credentialing and privileging system (high stakes
testing) that relies on simulation
 Simulation will eventually enter the operating room
 Pre-operative planning
 Tele-collaboration
 Assisted surgery through augmented reality and machine learning

Join the Contest! Join our Team!
Thank you! jeff@mimicsimulation.com

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