A Virtual Reality Training Program for
Improvement of Robotic Surgical Skills
*M. MUKHERJEE1, K.-C. SIU1,4, I. H. SUH1,2,4, A. KLUTMAN2, D.
OLEYNIKOV2,4, and N. STERGIOU1,3,4
1Nebraska Biomechanics Core Facility, University of Nebraska at Omaha;
2Department of Surgery, 3College of Public Health, 4Center for Advanced Surgical
Technology, University of Nebraska Medical Center,
Omaha, Nebraska, USA.
*Email: firstname.lastname@example.org web: http://biomech.unomaha.edu/
Abstract. The purpose of this study was to use a simulated virtual reality environment for
training of surgical skills and then to identify if the learning that occurred was transferable
to a real world surgical task. The virtual surgical tasks consisted of bimanual carrying,
needle passing and mesh alignment. In this ongoing study, the experimental group (n=5)
was trained by performing four blocks of the virtual surgical tasks using the da Vinci
surgical robot. Pre and post training, all subjects were tested by performing a suturing task
on a “life-like” suture pad. The control group (n=5) performed only the suturing task.
Significantly larger pre and post differences were revealed in time to task completion
(p<0.05) and total distance travelled by the dominant side instrument tip (p<0.01) in the
experimental group as compared to the control group. These differences were specific to the
suture running aspect of the surgical task. In conclusion, virtual reality surgical skills
training may produce a significant learning effect that can transfer to actual robot-assisted
Keywords: Virtual Reality, da Vinci Robotic Surgical System, Laparoscopic Training
Despite significant increases in robot-assisted surgeries, robotic surgical training
programs are not widely adopted . Virtual Reality (VR) has been used to improve
training for manual laparoscopy and to give surgeons superior performance in the
operating room . VR simulations can also provide user-friendly, attractive, easily
accessible and inexpensive environments to learn robotic surgical skills. In our past
work, we have shown that robotic surgical skill learning through VR simulations is
comparable with real world surgical skill improvement tasks [3, 4, 5]. Therefore the
next logical step was to implement the VR simulations as part of a training program
and determine the effect of learning on a common real-world surgical task – suturing.
Subjects: Ten young healthy student volunteers from the University of Nebraska
Medical Center and the University of Nebraska at Omaha participated in this ongoing
study. Subjects were randomly assigned to either the experimental (VR) group or the
Training Tasks: Subjects performed three tasks in a VR environment (Figure 1):
bimanual carrying (BC), needle passing (NP) and Mesh Alignment (MA). In the BC
task, they simultaneously picked up simulated pieces from simulated metal caps and
placed them in two other simulated metal caps. In the NP task, they passed a simulated
surgical needle through a simulated tube. In the MA task, a virtual rolled-up mesh was
opened up by the simulated arms of the robot and placed on a pre-marked virtual task
platform. The tasks have been designed to mimic training of real-life surgical skills in
terms of their cyclic nature (BC task), decision-making skills (determining location of
touch sensors to unroll the mesh in the MA task) and grasping and release skills (both
BC and NP tasks).
Testing Task: Pre and post the VR training tasks, all subjects performed three trials
of a procedure of repairing an enterotomy on a life-like suture pad (Figure 2). The
procedure consisted of using the Da Vinci Surgical System (Intuitive Surgical, CA) for
making three single knots, five running passes followed by three single knots again
between predefined locations on the suture pad.
Figure 1. The surgical tasks in the
VR simulation environment:
a) Bimanual Carrying
b) Mesh Alignment
c) Needle Passing
Experimental protocol: Subjects in the VR group performed the three tasks in four
blocks. In each block, each of the three tasks was performed five times. The order of
tasks was randomized within each block. The Webots software (Cyberbotics, Lausanne,
Switzerland) was used to build the VR environment which was driven by kinematic
data streaming in real-time from the operating console of the da Vinci robot. Subjects
in the control group performed only the pre and post test before and after a gap of 2.5
hours (the average time to complete the VR training).
Data Collection and Analysis: Kinematics of the da Vinci surgical instrument tips
was sampled at 100 Hz. Analysis of the robot data included time to task completion
and total distance travelled by the instrument tip of the dominant side.
Our results showed that after performing four blocks of simulated surgical skills
training, the VR group had a significantly larger change in time to task completion
(p<0.05) between pre and post suture running aspect of the testing task (Figure 3).
These differences were also reflected in change in the total distance travelled by the
instrument tip of the dominant side (p<0.01) between the pre and post suture running
tests on the suture pad (Figure 4). This measure was not significantly different for the
non-dominant side (p>0.05). The suture tying task was not significantly different for
either the time to task completion or the total distance travelled by the instrument tip
between the two groups.
Figure 2. Suture tying and running performance of a subject for pre-testing (left)
and post-testing (right).
Figure 3. Improvement in time to task completion between pre and post-suture
tying and running performance for the two groups.
Figure 4. Improvement in distance travelled by the dominant side instrument tip
between pre and post-suture tying and running performance for the two groups
Our results showed that simulated surgical skills training in a VR environment can
cause significant improvement in surgical skill performance on a real world surgical
task. Improvement in performance using VR simulators has been shown previously 
and validation of VR environment with real world surgical skills training has also been
shown previously [3-5]. However, this study showed that VR training of surgical skills
could transfer to real world surgical task. Differences in dominant and non-dominant
side performance in robotic surgical tasks have been shown previously . The VR
training caused significant improvement in suture running aspects of the task but not in
suture tying tasks. This could be due to the simplistic nature of the VR environment.
Our results are highly encouraging in indicating that training with simulated
surgical tasks may result in improvement of actual surgical skills. However, more
research and results from a larger sample size are needed to confirm our findings.
Moreover, further improvement of the virtual environment can enhance the learning
6. Acknowledgements Download full-text
This work was supported by the Nebraska Research Initiative, the Center for Advanced
Surgical Technology of the University of Nebraska Medical Center and the American
Heart Association (#0820136Z).
 Aggarwal R, Grantcharov T, Moorthy K, Hance J, Darzi A. (2006). A
competency-based virtual reality training curriculum for the acquisition of
laparoscopic psychomotor skill. Am. J Surgery, 191:128-133.
 Gallagher AG, Ritter EM, Champion H, Higgins G, Fried MP, Moses G,
Smith CD, Satava RM. (2005). Virtual reality simulation for the operating
room: proficiency-based training as a paradigm shift in surgical skills training.
Ann Surg. Feb;241(2):364-72.
 Katsavelis D, Siu KC, Brown-Clerk B, Lee IH, Lee YK, Oleynikov D,
Stergiou N (2008) Validated robotic laparoscopic surgical training in a virtual-
reality environment. Surg Endosc. In press.
 Brown-Clerk B, Siu KC, Katsavelis D, Lee I, Oleynikov D, Stergiou N.
(2008). Validating advanced robot-assisted laparoscopic training task in
virtual reality. Stud Health Technol Inform, 132, 45-49.
 Fiedler MJ, Chen SJ, Judkins TN, Oleynikov D, Stergiou N. (2007). Virtual
reality for robotic laparoscopic surgical training. Stud Health Technol Inform
 Lee IH, Siu KC, Katsavelis D, Oleynikov D, Stergiou N: Nonlinear Analysis
Quantifies Learning in Robot-Assisted Laparoscopic Surgery. Surgical
Endoscopy 2008; 22: S288.