Enhancing robotic head and neck surgical skills using stimulated simulation - Enhancing robotic head and neck surgical skills using stimulated simulation Abstract We propose stimulated simulation as the next paradigm for accelerating simulator-based training of transoral robotic surgery (TORS) using noninvasive brain stimulation. TORS is a minimally invasive technology that is seeing rapid adoption in the field of otolaryngology - head and neck surgery to resect benign and malignant tumors of the pharynx and larynx as well as treat obstructive sleep apnea. As a relatively novel and complex procedure, surgeons are learning to perform TORS after their residency, mostly during a fellowship year. However, TORS has a steep learning curve, with a minimum of 20-35 cases needed to achieve basic proficiency. Without a structured curriculum or effective simulation platform, most novice surgeons currently reach the 20-35 case benchmark while operating on live patients. Consequently, positive margin (i.e., the tumor is not entirely removed) rates for oropharyngeal cancers in low-volume centers are twice that in high-volume facilities. Commercially available task trainers and virtual reality simulators for robotic surgery have four major deficiencies: (i) they do not prepare trainees to operate in the confined space of the oropharynx and do not provide the procedure-specific skills necessary for TORS, such as tissue manipulation, retraction, or dissection using electrocautery; (ii) they are platform-dependent – training basic robotic skills for the da Vinci platform (Intuitive Surgical, Sunnyvale, CA), though two platforms are currently FDA approved for TORS, and a third one is waiting for approval, (iii) they are costly, limiting their use to the most affluent centers and (iv) they offer no mechanism to accelerate skill acquisition beyond brute-force repeated practice. To address these limitations, we will design, develop, and validate the first Virtual Transoral Robotic Surgical (VTORS) simulator for training TORS procedures and use transcranial direct current stimulation (tDCS), a safe and effective, well-established, commercially available, wearable noninvasive brain stimulation technique that uses very low direct current (<4mA) applied to the scalp to modulate cortical excitability, to accelerate the surgical skill acquisition. We have assembled a highly interdisciplinary team of researchers to accomplish the two aims of the project: (SA1) Design, develop and validate a high-resolution, ultra-low-cost, versatile, and platform-independent Virtual Transoral Robotic Surgical (VTORS) simulator for TORS tongue base resection; and (SA2) Demonstrate the training efficiency with transcranial direct current stimulation (tDCS) (i.e., stimulated simulation) compared with sham stimulation. Based on the latest developments in off-the-shelf virtual reality (VR) and tDCS technology and open- source simulation software, stimulated simulation has the potential to become the preferred training paradigm – simultaneously improving skills and accelerating skill acquisition - for complex psychomotor skills, including surgery, aviation, driving, sports, and music.
