RealSpine: realistic surgical simulation

Interview with Prof. Werner Korb, Professor for Simulation and Ergonomics in Surgical Medicine, Leipzig University of Applied Sciences


Surgeons need a great sense of touch. They first have to acquire this skill in simulation training before they can perform surgery on actual patients. Having said that, simulators are not just meant to teach the right movements; ideally, they should also provide a true-to-life experience of the surgical field – as is the case in RealSpine surgical training.
Image. Smiling man with glasses, beard and longer brown hair - Prof. Werner Korb; Copyright: HTWK Leipzig

Prof. Werner Korb; ©HTWK Leipzig

In this interview with, Prof. Werner Korb talks about realistic training using the haptic RealSpine simulation system, the importance of simulation in surgery and the roles of didactics and technology.

Prof. Korb, what exactly is the "RealSpine" surgical simulator?

Prof. Werner Korb: This system originated from the question of how human factor studies, that being studies of the effect of human beings on sophisticated operational systems, can be conducted in the operating room. We needed a simulator for this. However, it is not possible to just use virtual simulators in surgery, you also need simulators that offer haptic feedback. RealSpine is such a simulation system that includes synthetic materials, fake blood, electronic components, and software. The system allows you to perform surgeries on the spine in a realistic visual and haptic simulation.

What role do the individual components play?

Korb: The plastic components are either created directly from patient data using 3D printing or they are handmade. They generally represent soft tissue such as ligaments, muscles, fat or nerve tissue. The electronic system allows us to measure the forces during the surgery and to simulate complications such as strong bleeding. The software enables us to produce virtual X-rays without using radiation.

Image: Surgeon is working at a simulator of the human back with two instruments; Copyright: HTWK Leipzig/Rebecca Schweier

The RealSpine simulation system from Leipzig; ©HTWK Leipzig/Rebecca Schweier

What types of surgeries can be simulated?

Korb: The system includes various exchangeable cartridges, enabling us to simulate different types of surgeries. We originally started with disc surgery at the lumbar spine because it is a very common type of surgery but by now, we are also able to simulate other interventions on the spine such as dura sutures, duraplasty or lumbal spinal stenosis for example.

What instruments can physicians use on RealSpine?

Korb: Physicians can operate with any device or instrument they would otherwise also use in the operating room. One exception is coagulation instruments because in this case, the plastic reacts differently than real tissue. In a collaboration with Zeiss for example, we are currently demonstrating how well a surgical microscope can be used with the simulator.

You just mentioned haptic feedback – what can surgeons actually feel during the training?

Korb: Surgeons have the same sensations they experience during a real surgical procedure. We have evaluated this in studies where experienced surgeons used RealSpine and then rated how realistic the simulation looks and feels. Both aspects were rated based on the German grading system and averaged grades between one (English: Grade A) and two (English: Grade B). There is also a publication in the European Spine Journal on these studies.

Is this simulator only aimed at physicians-in-training?

Korb: It was essentially developed for residents. However, we have come to realize that some scenarios are also important to more experienced physicians, for instance, as it pertains to complication management and dura sutures. We have also developed several modules that are aimed at advanced physicians. This relates to spinal canal stenosis for example, where surgery is performed in very tight spaces close to neural structures.

How important are simulators today in the field of surgery?

Korb: The relationship between surgeons and the term "simulation" is an ambivalent one. Some areas use many types of simulations, for instance, the laparoscopy field where it is possible to conduct virtual simulations frequently and with great results. However, the term is partially disliked because simulations are more of a virtual nature and frequently not as realistic as previously promised. That's why instead of using the term "simulation", we prefer to refer to it as "realistic, plastic-based wet-lab training".

You introduced RealSpine in December at the AOSpine Symposium in Davos. What was the response?

Korb: In Davos, we had the chance to conduct a two-day course with 28 participants. Overall, we received very positive feedback. The participants were surprised that our technology enables these types of realistic exercises. RealSpine makes it possible to conduct these kinds of "bioskills courses" in any convention hall.

As a spin-off of the university, you founded the Real Surgical Training Technologies GmbH. Where would you like to take the development of your technology?

Korb: Using the RealSpine system, we want to develop products for surgeries on the cervical spine. Overall we can also imagine going beyond spine surgery and tapping into other surgical specialties such as surgeries in the head, hip and knee area.

It is also important for us to not just offer the technology, but also an overall concept that includes education and didactics, course supervision and support. After all, aside from technology and realistic simulation, the overall concept, evaluation forms for the participants and faculty support – a teaching staff with experienced surgeons – are essential to the success of a course. We want to promote all of this at RSTT GmbH and the University.

Image: Man with glasses and beard - Timo Roth; Copyright: B. Frommann

© B. Frommann

The interview was conducted by Timo Roth and translated from German by Elena O'Meara.