When Dr. John Lenihan learned to fly in the Air Force, he trained many hours on a simulator.
When he learned to perform robotic surgery, he didn't train a single second on a simulator.
Looking back, that doesn't make sense to Lenihan, but at the time he had no choice. Robotic simulators didn't exist when MultiCare Health System in Tacoma bought a da Vinci Surgical System in 2005.
Today, with the number of robotic procedures growing fast, robotic surgeons can hone their skills the way pilots do with the help of simulation hardware and software developed by a Seattle company called Mimic Technologies.
"We've created a flight simulator for surgeons," said Jeff Berkley, CEO and founder.
Amid a spate of compliants about the da Vinci that highlights the need for training, Mimic's dV-Trainer and da Vinci Skill Simulator appear to be just what the doctor ordered. Mimic's domestic sales doubled and international sales tripled in 2012, Berkley said, and the company is on track to easily surpass $10 million in overall sales in 2013.
Mimic offers a vivid local example of the health care industry's capacity to sprout startups and feed the economy.
Berkley expects Mimic's work force to grow to 41 - up from 27 in 2012 - by the end of the year.
Mimic's dV-Trainer is a desktop replica of a da Vinci console. The Skill Simulator is a module that attaches to a da Vinci console. Both use virtual reality technology to provide a realistic training platform that faithfully re-creates the experience of working on patients.
Mimic introduced the dV-Trainer in 2009. Two years later, Mimic collaborated with Intuitive Surgical, California-based makers of the da Vinci robot, on the da Vinci Skill Simulator.
At last count, 1,140 hospitals are using one or both of the devices. Mimic sells the dV-Trainer for $99,200. The Skill Simulator, sold by Intuitive, goes for $85,000.
MultiCare has two dV-Trainers and three da Vinci Skill Simulators to go with its five da Vinci robots.
"I think the future is definitely bright for Mimic," said Lenihan, medical director of robotics and minimally invasive surgery at MultiCare. "There's no question this is how we're going to train (robotic) surgeons going forward."
Right now there is no industry standard for certifying surgeons to use the da Vinci. Intuitive offers some instruction, but every hospital sets its own training and proficiency requirements. MultiCare's process, Lenihan said, includes passing certain simulation exercises and taking annual "check rides" on a simulator to maintain proficiency.
Robotic surgery has boomed in the years since Intuitive rolled out the da Vinci - the only surgical robot approved for use in the U.S. by the Food and Drug Administration.
The number of robotic surgeries performed in this country soared to 367,000 in 2012 - triple the number performed in 2008, according to Intuitive.
More than 2,585 systems are installed in more than 2,025 hospitals in the U.S. and overseas, making the da Vinci the No. 1 surgical robot in the world. Recently, however, the Sunnyvale, Calif., company has been dogged by questions about costs versus benefits of the system - starting price $1.5 million - and by reports of injuries, complications and even deaths following robotic procedures.
The first of several lawsuits alleging Intuitive marketed the da Vinci to doctors without providing adequate training went to trial earlier this month in Kitsap County Superior Court. The family of a man who died from complications following robotic surgery alleges Intuitive failed to properly train the surgeon as required by state product-liability law. Intuitive has stated in court filings it has no such duty.
But bad news for the da Vinci isn't necessarily bad news for Mimic Technologies, because providing better training is part of the solution.
A surgeon must perform a procedure 50 to 200 times to become proficient with the da Vinci, Lenihan said. Once a surgeon learned the basics, operating on patients was typically the only way to improve, because practice sessions put wear and tear on the robot but don't generate revenue.
With simulators, surgeons can ascend higher up the learning curve before their first case, reducing errors and lowering costs because they can perform better and faster right from the start.
"Learning to operate the robot is tremendously challenging," Lenihan said.
A novice, he said, can take eight to 10 hours to complete a procedure that an experienced surgeon can complete in an hour or two - a costly difference that can be reduced with training on a simulator.Simulators also help surgeons maintain proficiency if they go too long between procedures.
"You lose 50 percent of your skills within two months of not using the robot," Lenihan said. "Even 15 minutes (of practice) before surgery helps."
The dV-Trainer incorporates a scoring system that assesses a surgeon's skill level. At trade shows, Mimic sponsors "Top Gun" competitions where surgeons vie for the best score.
"Surgeons are very competitive," Berkley said.
Berkley founded Mimic Technologies in 2001 while earning a doctorate in mechanical engineering at the University of Washington, where his work in the Human Interface Technology Laboratory inspired his interest in virtual reality technology as a medical training tool.
Grants from the Department of Defense, which wanted to develop a surgical robot for the battlefield, jump-started the employee-owned company.
Intuitive helped Mimic develop the dv-Trainer by sharing important information about the da Vinci's design. Mimic later licensed its platform to Intuitive for the Skills Simulator.
Mimic's only serious competition is Simulated Surgical Systems of Williamsville, N.Y., which unveiled a virtual reality simulator for the da Vinci in 2010.
Berkley expects the da Vinci to remain the only surgical robot approved for use in the U.S. for a long time. However, other systems are being developed overseas, and Mimic wants a piece of that action, as well.
"We're not looking at ourselves as a one-robot company," Berkley said. "We would like to be a common training platform across as many robotic systems as possible."
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