A team of surgeons performs robot-assisted surgery on a lung cancer patient. Suddenly, blood gushes all over the operating table – the pulmonary artery was accidentally severed and the patient is massively hemorrhaging.
Fortunately, the patient is just a realistic manikin, and the surgeons are purposely creating a simulated emergency. But why?
Practice makes perfect
Robotic surgical equipment bestows upon surgeons bionic wrists and fingers that effortlessly spin 360 degrees. This equipment also simultaneously provides the surgeon with 3D high-definition views of the surgical area at magnification 10 times the size of the image a human eye sees. However, because surgeons control the robotic arms in a separate console next to the patient—and are not standing right next to the operating table—it is essential the team is prepared to seamlessly transition to an open approach should one become necessary.
Now that surgeons at UMass Memorial and UMass Chan Medical School surgeons conducting lung cancer procedures mostly using the robotic platform, the surgeons need effective protocols for low-frequency, high-stakes situations.
Realizing that proper emergency training could allay fears while improving clinical performance, assistant professor of surgery Feiran Lou, MD, and surgical resident Bryce Bludevich, MD, designed a study to develop and teach these protocols to the operating room (OR) thoracic surgeons.
The approach
Funded by an Education Grant from the Intuitive Foundation, the two-phase study had two main goals: 1) creating an effective emergency protocol to follow during intra-operative emergencies and 2) devising effective ways to disseminate the protocol to other thoracic surgeons.
Phase 1
Thoracic surgical team. Feiran Lou, MD, far left; Bryce Bludevich, MD, second from right
Two teams of surgeons conducted a simulated robotic surgery on a KindHeart Thoracic Surgical Simulator manikin (Intuitive Surgical Inc., Chapel Hill, NC) in the operating room. Inside the manikin’s chest, a balloon pumped artificial blood through a porcine lung and heart while a REALTi360 vital signs simulator (Simulate, Albany, NY) displayed the patient’s vital signs on the anesthesia machine.
Bryce Bludevich, MD, (left) with the KindHeart manikin
During the operation, the surgeons deliberately severed the pulmonary artery, prompting a massive hemorrhage and setting in motion four additional scenarios: 1) decision to convert to open procedure, 2) unstable blood flow, 3) cardiac arrest and 4) unstable ventricular tachycardia (fast heartbeat).
As the surgical team addresses the simulation scenario, a team of observers from the Simulation lab and the Patient Safety and Quality department identified vulnerabilities in the system.
After completing the simulation, the two surgical teams and the observers participated in a debriefing session and brainstormed ways to further streamline their responses. They agreed that providing more in-person training on infrequently used equipment and incorporating dedicated time for checking supply quantities and expiration dates would improve performance.
At the end of Phase 1, the surgical teams performed the simulation again in the Simulation Lab and put the finishing touches on the protocols in preparation for use in Phase 2. The results of Phase 1 of the study were presented at the ASC Annual Conference in February 2022.
Phase 2
Four different surgical team members took part in Phase 2, learning the emergency protocols either through a high-fidelity simulation conducted in the Simulation lab or via a video-based teaching session. After training, all teams successfully performed a simulated surgery in the OR, making fewer mistakes than the surgeons in Phase 1, who had received no emergency training.
“We recognize that the high-fidelity simulation is closer to a real-life scenario than the video, but that kind of training won’t always be possible. So, it is good to know the video was also effective,” says Dr. Lou.
The benefits of emergency training are far-reaching. Not only did participating surgeons make fewer errors, but the surgeons reported that the training improved their confidence in handling intra-operative emergencies. With anxieties at bay, their willingness to perform robotic surgeries should increase allowing their patients to benefit from reduced trauma, shorter recovery times and less blood loss, compared to the traditional methods.
Feiran Lou, MD, is Associate Director, Department of Surgery Research Core Specialty: Thoracic Surgery. Bryce Bludevich, MD, is a surgical resident on Academic Development Time.
