Robotics is revolutionising medicine. In total hip replacement surgery (THR), the level of accuracy we can deliver from this surgical intervention has been transformed using a robotic arm, producing significant improvements in patient reported outcomes. But, highly qualified THR surgeons are not familiar with robotics technology and access to training is expensive and sporadic.

This year, the UK is expecting around 143k total hip replacement surgeries. We currently have about 1,780 active orthopaedic surgeons. About 420 of these are performing less than 50 THR surgeries a year, leaving the rest needing to perform about 100 surgeries a year to cover the remaining workload. So, with an aging population, we really are in dire need of more THR surgeons in the UK (globally, it’s a similar story). But, it currently takes 9 years and approximately £560k to train someone to be qualified to perform a THR surgery, more for robotics-assisted. The time is lengthy because it takes practice – requiring 1. repeated opportunities of non-complex patient cases, 2. an expert surgeon and novice availability at the same time and location each time, and 3. costs to prep the theatre for a ‘teaching’ surgery session. In robotic arm-assisted surgery, there’s highly expensive equipment in ‘downtime’ for the teaching – and waiting lists of patients are just getting longer (and, NHS budgets are already stretched).

Immersive simulators create high ROI training because of the ease of widespread access to training and unlimited repetition. Research demonstrates that VR or use of immersive training for surgery creates better quality learning – heightened knowledge retention and an increased confidence in self-perceived ability. But, progress of surgical grade immersive training has come unstuck with limitations of the existing technology – specifically the ability of the graphics and haptics to keep up with what’s required for a surgeon to be ‘fooled’ into believing the simulator is real enough to forget they are in a simulation. The representation of how skin behaves is difficult to simulate, and blood / liquids require intensive special effects artists who can only produce a good representation when it doesn’t allow user interaction. Haptics are nowhere near advanced enough yet to create life-like simulations for the forces used in orthopaedics. Any transfer from simulator training to real surgery – where a patient’s life is at stake – needs to be seamless; the surgeon must feel confident to perform in reality as easily as they did when ‘qualifying’ on the simulator. Flip it and essentially, surgeons need to be fooled that reality is just the same as “the game”.

Cue – Dorset Creative’s (now Iceberg Creative) insatiable technical curiosity and lateral thinking! The need for more robotics-qualified surgeons is desperate. We must use the existing technology (with its limitations) to create a product which simply works, to demonstrate it is possible already to qualify surgeons in robotics for THR. By carefully studying the surgical procedure (we sent our technologists to observe live surgeries and have scrutinised many gory videos!), Dorset Creative have created an immersive training simulator for orthopaedics which can absolutely create an illusion for the surgeon. 

In early 2019, Dorset Creative (now Iceberg Creative) noticed that in robotic assisted THR surgery, after dislocation of the joint and removal of the degenerated femoral head (which are stages no different from manual THR surgery – surgical skills that a surgeon is already expert in), the surgeon’s view is primarily focussed on either a medical imaging like CT scan data or, the anatomical landmarks of an exposed bone. Both of these visual inputs are simple to recreate in photo-realistic modelled computer graphics. The surgeon uses robotics hardware like a probe – which is easy hardware to recreate for touch authenticity – giving rise to kinaesthetic memory. Rather than concentrate on teaching surgical techniques that a surgeon is already familiar with (current immersive surgical training fails here) we concentrated on teaching only the parts of being assisted by the robot – so that we don’t distract to break the illusion with unrealism’s, but still giving a fully immersive experience.