Virtual Reality Simulators for Robot-assisted Surgery.

In the last decade, there has been an exponential increase in the number of robot-assisted surgeries (RAS) and the annual number of robotic surgical procedures continues to grow progressively [1]. It has to be kept inmind that of all surgical fields RAS is the one that requires more specific and dedicated training owing to potential difficulties in understanding high magnification, three-dimensional vision, and the need for precise coordination between hand and eye movements because of the absence of tactile feedback. The traditional Halstedian method of ‘‘see one, do one, teach one’’ cannot and must no longer be applied [2]. New robotic training methods have been introduced to develop competence before performing live surgery [3,4]. Preclinical models are of high interest owing to the potential ability to train surgeons on a simulator rather than directly on patients. Simulators available on the market are classified as low fidelity, high fidelity, augmented reality (AR), and virtual reality (VR) [4]. Low fidelity simulators, such as the dry laparoscopic box trainer, are portable and cheap, but they are not able to reproduce a real surgical environment. High fidelity simulators include animal and cadaveric models, which provide more realistic training but are not as easily available and usable for multiple reasons (cost, veterinary assistance, anatomic variance, ethical issues). AR simulators, which have been recently introduced, provide a very realistic surgical environment, including actual surgical cases such as radical prostatectomy, narrative instructions, guided movements, audiovisual explanations, and anatomical illustrations [5]. VR simulators use a computer-derived realistic virtual operative field with tactile feedback and are considered a potential solution for learning of basic skills in RAS. Many reports, including a small randomized trial, have demonstrated that the learning curve for a novice robotic