The traditional practice of imparting training of minimally invasive surgery (MIS) at medical colleges in Pakistan has been through apprenticeships. Junior doctors are placed with seniors to provide them on-the-job training, says Dr Naeem Zia, Professor of Surgery at Rawalpindi Medical College (RMC).

“Apprentices are first made to observe seniors perform surgeries. After some time, they start assisting seniors. Finally, they start carrying out surgeries by themselves under the supervision of a senior doctor,” he says.

However, nowadays junior doctors can also be trained with the help of surgical simulators which have the capability of assessing their skills and providing feedback on potential areas of improvement.

“Teaching hospitals around the world are using training simulators like LapSim, LapMentor and ProMIS but the use of these devices is expensive as their license can cost up to $50,000,” says Dr Osman Hasan, an Assistant Professor at the School of Electrical Engineering and Computer Science (SEECS) at the National University of Sciences and Technology (NUST).

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Understandably, none of the major hospitals in the public sector has yet started using any of these simulators because of the prohibitive cost of license.

Realising the importance of the device, a team headed by Dr Hasan as the principal investigator has prepared a simulator, called SmartSIM, that comes at only one-tenth the price of other major commercially available simulators. Dr Zia from RMC was one of the main doctors behind the collaboration.

This virtual reality (VR) surgical simulator for Minimally Invasive Surgery (MIS) or Laparoscopic Surgery is an outcome of joint efforts by the SEECS at NUST and the Holy Family Hospital, Rawalpindi.

Dr Hasan says the aim of this National ICT R&D funded project was to develop a cost-effective solution for training surgeons for MIS procedures.

The labour of around two years of work, the product was initially named Al-Zahrawi after the great 10-century Muslim physician and surgeon. Later the simulator was renamed SmartSIM. It was first showcased at a meeting of the Society of Surgeons in Rawalpindi and then officially launched at NUST in 2014. Since then, the team has been showcasing the product at different competitions, including the IBA Invent Entrepreneurial Challenge, TiE International Business Plan Competition, P@SHA LaunchPad and 2013 Global Innovation through Science & Technology (GIST) Tech-I Competition held in Malaysia. The simulator is also being used at training workshops held during surgical conferences across the country.

The team behind SmartSIM comprised more than 20 professionals with expertise in electrical, mechanical and software engineering as well as surgery.

Like other developing countries, Pakistan faces a dearth of human resources needed to train the future generation of surgeons who can be relied upon to deliver effective healthcare services. The use of locally produced simulators like SmartSIM promises to help fill this gap in a cost-effective manner.

Minimally Invasive Surgery or Laparoscopic Surgery

Laparoscopy or MIS is a surgical procedure in which a laparoscope (a thin lighted tube) and other surgical instruments are inserted into the human body through small incisions rather than a relatively larger incision commonly used in conventional open surgeries. The surgeons can then visualise the internal operating field on a video monitor connected to the laparoscope.

Open surgeries can result in large wounds that take longer to heal. Due to the smaller size of incisions needed, MIS leads to quicker patient recovery, less discomfort and scarring, and a lower chance of post-operative infections and complications. The operative time for the procedure might be longer but the hospitalisation time is significantly reduced. MIS procedures also enable hospital beds and facilities to be opened up quicker for other patients.

Over the past few decades, laparoscopic surgery has become important for many sub-specialties of surgery. It can now be used for gynecologic surgery, gastrointestinal surgery (including bariatric procedures for morbid obesity) and urology. Advanced procedures also include laparoscopic cholecystectomy (removal of the gallbladder), colectomy (removal of all or part of the colon), and nephrectomy (removal of the kidney). The use of this minimally invasive procedure helps in reducing the risk of post-operative morbidities such as incisional hernias in patients. The procedure is also useful for veterinarians to perform on animals.

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However, at the moment there is limited use of this surgical procedure in many specificities as compared to the numerous benefits that patients receive.

SmartSIM virtual reality simulator

Virtual reality training simulators play an important role in teaching surgeons skills such as hand-eye coordination and improving their cognitive, clinical and technical aptitudes. This hands-on practice can help improve the efficiency of surgeons at performing laparoscopic surgery.

SmartSIM simulator has been made for basic MIS training, using open-source tools and libraries, including a generic physics engine called the simulation open framework architecture (SOFA) which helps make realistic medical simulations.

The simulator consists of three parts: a mechanical interface, a controller circuit, and a software application.

The hardware interface is custom built and easy-to-fabricate. The VR simulator has a mechanical manipulator that is designed to mimic the actual laparoscopic tool, both in terms of structure and functionality. SmartSIM, like a laparoscopic instrument, is a five degrees of freedom (DoF) mechanical structure. The instrument’s point of entry into the body inhibits its free movement and acts as a pivot around which the tip can move. The surgeon is then able to carry out five possible movements: pitch, yaw, roll, depth and open/close the gripper.

The controller circuit gauges the five mechanical movements made by the instrument with the help of a microcontroller and sends them to the computer via a duplex communication protocol on the USB interface.

The software application of SmartSIM consists of the graphical user interface and runs the simulation scene based on selection from an installed list of scenarios. It also contains an intelligent and smart evaluation mechanism that analyses the competency of surgeons at performing a specific task and facilitates unsupervised and independent learning.

This story originally appeared on MIT Tech Review Pakistan and has been reproduced with permission

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