General surgery training in the era of robotic surgery: a qualitative analysis of perceptions from resident and attending surgeons

Differences in coaching in single- versus dual-console robotic cases: a mixed-methods study

BACKGROUND

A growing importance has been placed on development of trainee robotic surgical skills through simulation curricula and intraoperative experience. However, few studies have examined how console case type impacts learning outcomes. We sought to evaluate how intraoperative coaching and resident autonomy differ based on the use of a single- versus dual-console robot.

METHODS

Robotic single- and dual-console cases from February to September 2023 at a single institution were included. Faculty and trainees wore microphones to capture audio during the case. Pre/post surveys were administered, which included metrics on faculty coaching based on the Wisconsin Surgical Coaching Rubric (WiSCoR) and on trainee technical performance based on the Global Evaluative Assessment of Robotic Skills (GEARS). Statistical analysis of survey data was performed using SPSS. Audio from cases was coded by 2 researchers with a deductive approach using WiSCoR as a framework.

RESULTS

Data were collected for 7 (38.9%) single and 11 (61.1%) dual-console cases across 9 case types from 4 surgical specialties. Chi-square analysis demonstrated no significant difference in percentage of case trainee spent in the operating surgeon role based on trainee level or console case type. Independent t-tests showed no significant difference in trainee autonomy, trainee performance, or faculty coaching scores based on console case type. Trainees rated faculty highest in WiSCoR Domains 1 (sharing responsibility) and 3 (providing constructive feedback). Qualitative analysis showed that for single-console cases, Domain 4 (goal setting) was most represented (34.0% of comments), while for dual-console cases, Domain 1 was most represented (37.0% of comments).

CONCLUSIONS

Qualitative analysis highlights that despite similar survey-based faculty ratings across domains, coaching on self-reflection (Domain 2) is infrequently done, highlighting an opportunity for improvement in this area of coaching during robotic surgery.

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

OBJECTIVES

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation.

DESIGN

An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers.

SETTING

Academic medical training centers or conferences in the United States, Rwanda and Kenya.

PARTICIPANTS

10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident.

RESULTS

The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox.

CONCLUSION

The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

Comparing observed and preferred instruction in robotic surgery

BACKGROUND

The unique setup of robotic surgery challenges the traditional instructional dynamic between surgical learners and teachers. Previous studies have posited difficulties such as reliance on observational learning and ease of takeover. However, we lack understanding of how these instructional challenges manifest and are perceived by learners. Improving instruction has the potential to optimize education and performance in robotic surgery.

METHODS

In this qualitative study, we conducted robotic case observations and learner interviews focusing on instruction in robotic surgery. We deductively generated codes in a theory-informed manner after review of the instructional literature in surgery, medicine, and other fields. We applied these codes in a rigorous directed content analysis of field notes and transcripts to identify themes.

RESULTS

Thirty-eight faculty, fellows, and residents participated in 10 robotic cases and 20 semistructured interviews. Observed practices on the basis of case observations differed substantially from preferred practices on the basis of interview data. Using 37 codes, we identified 4 main themes related to instruction in robotic surgery: contextualization, individualization, autonomy, and multimodality. We contrasted observed and preferred instruction in each of these areas to generate instructional considerations that may better align preferences and practices.

CONCLUSIONS

We observed several suboptimal instructional practices that contradicted preferred ways of learning. We suggested robotic-specific instructional considerations such as using multimodality to promote active learning and to reduce ambiguity. We also provided considerations applicable to all types of surgery, such as to include rationale to promote learning consolidation and to frame operative steps to allow trainees to plan their participation.

Fellow perceptions of robotic surgery preparedness for fellowship

INTRODUCTION

Many surgical fellowship programs incorporate robotic surgery, yet not all residency programs offer robotic training for residents. Given the variability of pre-fellowship robotic exposure, the goal of this study was to explore whether standardized robotic skills assessment would be useful to fellows at the start of their training.

METHODS

In partnership with the Fellowship Council, we surveyed current fellows of accredited Thoracic, Colorectal, HPB, and Advanced GI/MIS/Bariatrics/Foregut Fellowship programs. Main outcome measurements included amount of robotic exposure during residency, fellows' robotic skills at the start of fellowship, and fellows' attitudes towards a standardized skills assessment.

RESULTS

In total, 78 fellows completed the survey. Mean percentage of cases performed robotically during fellowship was 38.1% (SD ± 32.25%). From our respondents, 46% had no robotic curriculum during residency and 86.9% felt a standardized robotic curriculum during residency would have been beneficial. When asked if they started fellowship with adequate robotic skills to operate autonomously, 31% strongly agreed, but 24.4% strongly disagreed. The majority of fellows reported their fellowship program did not conduct an assessment of their robotic skills (71.5%), or provide a specific robotic curriculum (75.6%). On the other hand, 73.3% felt a formal proficiency assessment at the start of fellowship would be helpful for individualized support and training.

CONCLUSIONS

Given the significant variability in resident exposure to robotic surgery, a standardized robotic curriculum during residency would likely be beneficial. Additionally, a robotic skills assessment at the start of fellowship could help provide a tailored training experience for fellows interested in this skillset.

Bridging the Gap: A Qualitative Assessment of General Surgery Resident Confidence and Knowledge Deficits in Managing Surgical Endocrinopathy

BACKGROUND

Most thyroid and parathyroid surgeries are performed by nonfellowship trained, low-volume surgeons with associated higher complication rates. Furthermore, the average number of endocrine procedures performed by general surgery residents is decreasing. While previous studies have documented a lack of general surgery resident confidence in performing these procedures, the specific knowledge gaps in endocrine surgery remain unexplored.

METHODS

We conducted semi-structured interviews with surgical residents (clinical PGY3-PGY5) at a high-volume academic center with an endocrine surgery fellowship to discuss their experience, knowledge, and deficits managing patients with surgical thyroid and parathyroid disease. Interviews were audio-recorded, de-identified, and transcribed verbatim. Content analysis was used to identify areas of confidence and knowledge deficits in all phases of care.

RESULTS

Overall, 14 trainees participated in the study (50% women, mean PGY: 3.8). Preoperatively, residents were confident with thyroid nodule and primary hyperparathyroidism work-up, but less comfortable with rare conditions. Residents were uncomfortable using ultrasound to identify suspicious lymph nodes or abnormal parathyroid glands. Residents perceived knowledge deficits in the multidisciplinary care and work-up of patients with advanced thyroid cancer. Intraoperatively, most residents were confident performing thyroidectomy and focused parathyroidectomy, but less comfortable performing 4-gland explorations or neck dissections. Several had concern with independently identifying and protecting the recurrent laryngeal nerve or locating parathyroid glands in the setting of negative localization. Residents noted a lack of autonomy in both thyroidectomy and parathyroidectomy. Postoperatively, residents felt confident in the acute management of patients, but identified deficits in long-term management of patients with thyroid cancer or chronic complications.

CONCLUSIONS

Despite confidence in managing "bread and butter" cervical endocrine surgery in all phases of care, residents perceive a lack of meaningful autonomy intraoperatively. Further educational endeavors may be required to ensure graduating residents are "practice ready" for straightforward cases they may encounter in practice as a general surgeon. A lack of exposure to complex endocrinopathy even at a high-volume center suggests that comprehensive endocrine surgery fellowship remains critical.

Feasibility of initiating robotic surgery during the early stages of gastrointestinal surgery education

PURPOSE

Minimally invasive surgery for gastrointestinal cancers is rapidly advancing; therefore, surgical education must be changed. This study aimed to examine the feasibility of early initiation of robotic surgery education for surgical residents.

METHODS

The ability of staff physicians and residents to handle robotic surgical instruments was assessed using the da Vinci® skills simulator (DVSS). The short-term outcomes of 32 patients with colon cancer who underwent robot-assisted colectomy (RAC) by staff physicians and residents, supervised by a dual console system, between August 2022 and March 2024 were compared.

RESULTS

The performances of four basic exercises were assessed after implementation of the DVSS. Residents required less time to complete these exercises and achieved a higher overall score than staff physicians. There were no significant differences in the short-term outcomes, operative time, blood loss, incidence of postoperative complications, and length of the postoperative hospital stay of the two surgeon groups.

CONCLUSION

Based on the evaluation involving the DVSS and RAC results, it appears feasible to begin robotic surgery training at an early stage of surgical education using a dual console system.

Behind the pattern: General surgery residsent autonomy in robotic surgery

Objective

Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT).

Methods

General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied.

Results

Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT.

Conclusions

This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.

Perceptions of theatre team members to robotic assisted surgery and the aid of technology in colorectal surgery

The implementation of robotic assisted surgery (RAS) has brought in a change to the perception and roles of theatre staff, as well as the dynamics of the operative environment and team. This study aims to identify and describe current perceptions of theatre staff in the context of RAS. 12 semi-structured interviews were conducted in a tertiary level university hospital, where RAS is utilised in selected elective settings. Interviews were conducted by an experienced research nurse to staff of the colorectal department operating theatre (nursing, surgical and anaesthetics) with some experience in operating within open, laparoscopic and RAS surgical settings. Thematic analysis on all interviews was performed, with formation of preliminary themes. Respondents all discussed advantages of all modes of operating. All respondents appreciated the benefits of minimally invasive surgery, in the reduced physiological insult to patients. However, interviewees remarked on the current perceived limitations of RAS in terms of logistics. Some voiced apprehension and anxieties about the safety if an operation needs to be converted to open. An overarching theme with participants of all levels and backgrounds was the 'Teamwork' and the concept of the [robotic] team. The physical differences of RAS changes the traditional methods of communication, with the loss of face-to-face contact and the physical 'separation' of the surgeon from the rest of the operating team impacting theatre dynamics. It is vital to understand the staff cultures, concerns and perception to the use of this relatively new technology in colorectal surgery.

Robotic surgery and work-related stress: A systematic review

Despite robot-assisted surgery (RAS) becoming increasingly common, little is known about the impact of the underlying work organization on the stress levels of members of the operating room (OR) team. To this end, assessing whether RAS may impact work-related stress, identifying associated stress factors and surveying relevant measurement methods seems critical. Using three databases (Scopus, Medline, Google Scholar), a systematic review was conducted leading to the analysis of 20 articles. Results regarding OR team stress levels and measurement methods were heterogeneous, which could be explained by differing research conditions (i.e., lab. vs. real-life). Relevant stressors such as (in)experience with RAS and quality of team communication were identified. Development of a common, more reliable methodology of stress assessment is required. Research should focus on real-life conditions in order to develop valid and actionable knowledge. Surgical teams would greatly benefit from discussing RAS-related stressors and developing team-specific strategies to handle them.

Emerging Technologies in Hand Orthopedic Surgery: Current Trends and Future Directions

Emerging technologies are changing hand surgery by improving surgical precision, minimizing tissue disruption, and expediting patient recovery. These advancements have the potential to revolutionize surgical procedures, patient outcomes, and rehabilitation processes. However, there are still challenges that need to be addressed before these technologies can be widely adopted. These challenges include the learning curve for surgeons, high costs, and ethical considerations. Future research should focus on addressing the limitations of these technologies, exploring their long-term effects, and evaluating their cost-effectiveness. To successfully implement them, a collaborative approach involving clinicians, researchers, engineers, and policymakers is necessary. This review provides an overview of current and future trends in emerging technologies for hand orthopedic surgery.

Validation of a Simulation Model for Robotic Myomectomy

STUDY OBJECTIVE

Several simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training.

DESIGN

Prospective cohort simulation study.

SETTING

Surgical simulation laboratory.

PARTICIPANTS

Twelve obstetrics and gynecology residents and 4 fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio.

INTERVENTIONS

A robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving 2 steps: fibroid enucleation and hysterotomy repair. Video-recorded performances were timed and scored by 2 blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds 3 novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility.

MEASUREMENTS AND MAIN RESULTS

Median task completion time was shorter for experts than novices (9.7 vs 24.6 min, p = .001). Experts scored higher than novices on both the GEARS scale (median 23 vs 12, p = .004) and modified GEARS scale (36 vs 20, p = .004). Experts made fewer task errors than novices (median 15.5 vs 37.5, p = .034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%).

CONCLUSION

We have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

Robotic hernia repair: the trainee "Drag" factor-a single-surgeon 9-year experience

PURPOSE

The use of robotic assisted surgery is increasing but training residents in its use may be associated with increased operative time and cost. The objective of this study is to compare the operative time of robotic incisional/ventral hernia repair (RIVHR) and robotic inguinal hernia repair (RIHR) when performed with and without a resident or fellow trainee.

METHODS

A review of prospectively collected data was performed on all patients who underwent RIVHR and RIHR by a single surgeon over a 9-year period (2014-2023). Study variables included presence of trainee (resident or fellow), procedure time, console time, and recurrent hernia. Primary outcomes include procedure time and console time.

RESULTS

A total of 402 surgeries were included for analysis. Residents assisted in 190 (47%) of the procedures, while fellows assisted in 97 (24%), and 115 (29%) were performed without a trainee. Median (IQR) console times in RIVHR assisted by fellows was 102 (72-145) minutes, compared to 90 (71-129) minutes among surgeries assisted by residents and 65 (52-82) minutes among surgeries performed without a trainee (p < 0.0001), a similar trend was observed for RIHR. The duration of hernia repair assisted by trainees was significantly longer than surgeries performed without a trainee.

CONCLUSION

Operative time for RIVHR and RIHR is significantly lower when performed without a trainee. However, RIHR assisted by residents showed a consistent decrease in operative time over the 9-year period.

Early Implementation of Robotic Training in Surgical and Surgical Subspecialty Residency

BACKGROUND

Robotic surgery has emerged as an operative tool for many elective and urgent surgical procedures. The purpose of this study was to evaluate early surgical trainees' experiences and opinions of robotic surgery.

METHODS

An introductory robotic training course consisting of online da Vinci Xi/X training and in-person, hands on training was implemented for residents and medical students across surgical subspecialties at a single institution. A voluntary survey evaluating perceptions of and interest in robotic surgery and prior robotic surgery experience, as well as a basics of robotics quiz, was distributed to participants prior to the start of the in-person session. Descriptive statistics were used to evaluate the cohort.

RESULTS

85 trainees participated in the course between 2020 and 2023, including 58 first- and second-year surgical residents (general surgery, urology, OB/GYN, and thoracic surgery) and 27 fourth-year medical students. 9.4% of participants reported any formal robotic surgery training prior to the session, with only 19% of participants reporting robotic operative experience. 52% of the participants knew of and/or had completed the da Vinci online course modules prior to the scheduled training session. Participants unanimously (100%) agreed that robotic surgery should be implemented into surgical training.

CONCLUSIONS

There is rising enthusiasm for robotic surgery, yet early exposure and training remain infrequent and inconsistent amongst medical students and new surgical residents. A standardized introduction of multi-disciplinary robotic surgery training should be incorporated into medical school and/or early residency education to ensure surgical residents receive appropriate exposure and training to achieve competency.

Identifying barriers to resident robotic console time in a general surgery residency through a targeted needs assessment

Robotic-assisted general surgery is experiencing exponential growth. Despite our institution's high volume, residents often graduate with inadequate console experience. Our aim was to identify the educational needs of residents and perceived barriers to residents' console time from both attendings and residents. Separate surveys were created and distributed to robotic surgery faculty and general surgery residents at our institution. Questions were a variety of modalities and focused on the robotic surgery experience at our institution, including barriers to resident console time from both attending surgeon and resident perspectives. Although residents' interest in robotic surgery exceeded that of open and laparoscopic surgery, confidence in their robotic skills was low compared to the other modalities. The top barriers to participating in robotic cases according to residents included minimal or no previous console time with the attending, lack of simulator time, and being required to perform bedside assistant duties. Faculty reported resident preparedness, prior robotic skill demonstration, simulator time, case complexity, and their own confidence as significant factors influencing resident console time. Using these results, we concluded that the design and implementation of a formal robotic surgery curriculum should incorporate simulation-based opportunities for residents to practice their skills, improve confidence, and increase console experience. In addition, simulation opportunities for faculty should also be considered to allow for improvement and maintenance of robotic surgical skills.

Implementation of a structured robotic colorectal curriculum for general surgery residents

There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs

INTRODUCTION

Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases.

METHODS

We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA.

RESULTS

The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT.

CONCLUSIONS

Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Active control time: an objective performance metric for trainee participation in robotic surgery

Trainee participation and progression in robotic general surgery remain poorly defined. Computer-assisted technology offers the potential to provide and track objective performance metrics. In this study, we aimed to validate the use of a novel metric-active control time (ACT)-for assessing trainee participation in robotic-assisted cases. Performance data from da Vinci Surgical Systems was retrospectively analyzed for all robotic cases involving trainees with a single minimally invasive surgeon over 10 months. The primary outcome metric was percent ACT-the amount of trainee console time spent in active system manipulations over total active time from both consoles. Kruskal-Wallis and Mann-Whitney U statistical tests were applied in analyses. A total of 123 robotic cases with 18 general surgery residents and 1 fellow were included. Of these, 56 were categorized as complex. Median %ACT was statistically different between trainee levels for all case types taken in aggregate (PGY1s 3.0% [IQR 2-14%], PGY3s 32% [IQR 27-66%], PGY4s 42% [IQR 26-52%], PGY5s 50% [IQR 28-70%], and fellow 61% [IQR 41-85%], p =  < 0.0001). When stratified by complexity, median %ACT was higher in standard versus complex cases for PGY5 (60% vs. 36%, p = 0.0002) and fellow groups (74% vs. 47%, p = 0.0045). In this study, we demonstrated an increase in %ACT with trainee level and with standard versus complex robotic cases. These findings are consistent with hypotheses, providing validity evidence for ACT as an objective measurement of trainee participation in robotic-assisted cases. Future studies will aim to define task-specific ACT to guide further robotic training and performance assessments.

Robotic Medtronic Hugo™ RAS System Is Now Reality: Introduction to a New Simulation Platform for Training Residents

The use of robotic surgery (RS) in urology has grown exponentially in the last decade, but RS training has lagged behind. The launch of new robotic platforms has paved the way for the creation of innovative robotics training systems. The aim of our study is to test the new training system from Hugo™ RAS System-Medtronic. Between July 2020 and September 2022, a total of 44 residents from urology, gynaecology and general surgery at our institution participated in advanced robotic simulation training using the Hugo™ RAS simulator. Information about sex, age, year of residency, hours spent playing video games, laparoscopic or robotic exposure and interest in robotics (90.9% declared an interest in robotics) was collected. The training program involved three robotic exercises, and the residents performed these exercises under the guidance of a robotics tutor. The residents' performance was assessed based on five parameters: timing, range of motion, panoramic view, conflict of instruments and exercise completion. Their performance was evaluated according to an objective Hugo system form and a subjective assessment by the tutor. After completing the training, the residents completed a Likert scale questionnaire to gauge their overall satisfaction. The rate of the residents' improvement in almost all parameters of the three exercises between the first and the last attempts was statistically significant (p < 0.02), indicating significant progress in the residents' robotic surgical skills during the training. The mean overall satisfaction score ± standard deviation (SD) was 9.4 ± 1.2, signifying a high level of satisfaction among the residents with the training program. In conclusion, these findings suggest that the training program utilizing the Hugo™ RAS System is effective in enhancing robotic surgical skills among residents and holds promise for the development of standardized robotics training programs in various surgical specialties.

Cost analysis of training residents in robotic-assisted surgery

INTRODUCTION

Use of robotic-assisted surgery is increasing, and resident involvement may lead to higher costs. We investigated whether senior resident involvement in noncomplex robotic cholecystectomy (RC) and inguinal hernia (RIH) would take more time and cost more when compared to non-robotic cholecystectomy (NRC) and inguinal hernia repair (NRIH).

METHODS

We extracted surgery duration and total cost of NRC, NRIH, RC, and RIH from 7/2016 to 6/2020 with senior resident (PGY4-5) involvement. We excluded complex cases as well as prisoner cases and those with new faculty and research residents. We assessed differences between robotic and non-robotic cases in surgery duration and total cost per minute, using one-way ANOVA.

RESULTS

We included 1608 cases (non-robotic 1145 vs. robotic 463). On average, RC cases with a senior resident took less time than NRC (179.4 < 185.8, p = 0.401); surgery duration of RIH cases was similar with NRIH cases. The total cost per minute of RC cases with a senior resident on average was $9.30 higher than NRC cases for each minute incurred in the operating room but did not lead to a significant change in overall cost. RIH cases, on the other hand, cost less per minute than NRIH cases (114.1 < 126.5, p = 0.399).

CONCLUSION

Training in robotic surgery is important. Noncomplex RC and RIH involving senior residents were not significantly longer nor did they incur significantly more cost than non-robotic procedures. Senior resident training in noncomplex robotic surgery can be efficient and can be included in the residency curriculum.

Comparison of Attempts Needed for Veterinary Students to Reach Proficiency in a Basic and Advanced Robotic Simulator Task

Surgical training of students is one of the most difficult aspects of veterinary medical education. Competing interests of house officers, owner's wishes, and ethical concerns have led to increasing use of inanimate models for basic surgical skills training. Robotic simulators have benefits for psychomotor training but have not been previously investigated in veterinary medicine. Understanding the necessary practice time for new training devices is important when determining their potential value. The aim of this study was to compare the number of attempts needed for veterinary students to reach proficiency in both a basic and advanced robotic simulator task, and to assess the predictive nature of performance variables. Each student performed a basic and advanced tasks on the Mimic dV-Trainer™ until proficiency was reached. Students required a median of eight attempts (95% CI = 7-8, range: 6-11) to reach proficiency for the basic task versus 22 attempts (95% CI = 20-26, range: 11-62) for the advanced task. The median time required to complete training for the basic and advanced task was 13.5 minutes (range: 8-24 minutes) and 26.5 minutes (range: 11-82 minutes) respectively. The difference in task attempts supports the training protocol and confirms proficiency can be attained in a short period of time. The number of attempts to reach proficiency correlated with specific performance variables which can be used by educators to aid in training students on a robotic simulator. Continued investigations on robotic simulators should be performed to investigate their use in improving psychomotor skills in veterinary students.

Robotic simulation: validation and qualitative assessment of a general surgery resident training curriculum

BACKGROUND

The da Vinci skills simulation curriculum has been validated in the literature. The updated simulator, SimNow, features restructured exercises that have not been formally validated. The purpose of this study is to validate the SimNow resident robotic basic simulation curriculum. This study also consists of a qualitative assessment that gives greater insight into the learner's experience completing the robotic curriculum.

METHODS

There were 18 participants in this study: 6 novices, 6 competent surgeons, and 6 expert surgeons. The curriculum comprised 5 exercises; participants completed three consecutive scored trials. Computer-derived performance metrics were recorded. The NASA Task Load Index survey was used to assess subjective mental workload. Subjects were asked a series of open-ended questions regarding their experience that were recorded and transcribed. Codes were identified using an inductive method, and themes were generated.

RESULTS

Performance metrics were significantly different between novice versus competent and expert surgeons. There was no significant difference in any score metric between competent and expert surgeons. On average, overall score percentages for competent and expert surgeons were between 90.4 and 92.8% versus 70.5% for novices (p = 0.02 and p = 0.01). Expert surgeons perceived a higher level of performance completing the exercises than novice surgeons (15.8 vs. 45.8, p = 0.02). Participants noted a similar robotic experience, utilizing efficiency of motion and visual field skills. Participants agreed on exercise strengths, exercise weaknesses, and software limitations. Competent and expert surgeons were better able to assess the exercises' clinical application.

CONCLUSIONS

The SimNow curriculum is a valid simulation training as part of a general surgery resident robotic curriculum. The curriculum distinguishes between novices compared to competent and expert surgeons, but not between competent and expert surgeons. Clinical training level does not affect the experience and mental workload using the robotic simulator, except for competent and expert surgeons' ability to better assess clinical application.

Force-based assessment of tissue handling skills in simulation training for robot-assisted surgery

INTRODUCTION

Although robotic-assisted surgery is increasingly performed, objective assessment of technical skills is lacking. The aim of this study is to provide validity evidence for objective assessment of technical skills for robotic-assisted surgery.

METHODS

An international multicenter study was conducted with participants from the academic hospitals Heidelberg University Hospital (Germany, Heidelberg) and the Amsterdam University Medical Centers (The Netherlands, Amsterdam). Trainees with distinctly different levels of robotic surgery experience were divided into three groups (novice, intermediate, expert) and enrolled in a training curriculum. Each trainee performed six trials of a standardized suturing task using the da Vinci Surgical System. Using the ForceSense system, five force-based parameters were analyzed, for objective assessment of tissue handling skills. Mann-Whitney U test and linear regression were used to analyze performance differences and the Wilcoxon signed-rank test to analyze skills progression.

RESULTS

A total of 360 trials, performed by 60 participants, were analyzed. Significant differences between the novices, intermediates and experts were observed regarding the total completion time (41 s vs 29 s vs 22 s p = 0.003), mean non zero force (29 N vs 33 N vs 19 N p = 0.032), maximum impulse (40 Ns vs 31 Ns vs 20 Ns p = 0.001) and force volume (38 N³ vs 32 N³ vs 22 N³ p = 0.018). Furthermore, the experts showed better results in mean non-zero force (22 N vs 13 N p = 0.015), maximum impulse (24 Ns vs 17 Ns p = 0.043) and force volume (25 N³ vs 16 N³ p = 0.025) compared to the intermediates (p ≤ 0.05). Lastly, learning curve improvement was observed for the total task completion time, mean non-zero force, maximum impulse and force volume (p ≤ 0.05).

CONCLUSION

Construct validity for force-based assessment of tissue handling skills in robot-assisted surgery is established. It is advised to incorporate objective assessment and feedback in robot-assisted surgery training programs to determine technical proficiency and, potentially, to prevent tissue trauma.

The evolution of the general surgery resident operative case experience in the era of robotic surgery

BACKGROUND

Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents' operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience.

METHODS

The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value < 0.05.

RESULTS

Operative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans' hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents' robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach.

CONCLUSIONS

This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.

Robotic surgery training curricula: prevalence, perceptions, and educational experiences in general surgery residency programs

BACKGROUND

Utilization of robotics in general surgery has increased exponentially in the past decade. The purpose of this study was to provide an updated analysis of the prevalence of robotic training curricula among general surgery residency programs across the United States.

METHODS

A 19-item survey was distributed to program directors of the Association of Program Directors in Surgery email list. The survey focused on the programs' demographics, program directors' opinions of robotic surgery, and status of robotic surgery curricula. Data was compiled and analyzed using Qualtrics Survey Software, Microsoft Excel and IBM SPSS. Chi-Squared statistical significance was defined as a p value of < 0.05.

RESULTS

Of the 280 program directors, 107 (38.2%) responded. Overall, 75 (70%) residency programs provided a formal robotic surgery curriculum. Regarding the importance of robotics to general surgery training, 67 (89%) programs that provided a formal robotic surgery curriculum stated it was either 'Very important' or 'Probably important' as opposed to 23 (72%) programs that did not offer a formal robotic surgery curriculum (p = 0.017). 73 of the 75 residency programs with a formal robotic surgery training curriculum answered the curriculum specific questions. 58 (79%) had been present for 3 years or less. Bedside assisting began in 62 (85%) programs as a post-graduate year (PGY) 1 or PGY2 and residents began operating on the console as a PGY2 or PGY3 in 53 (72%) programs. However, there was variability regarding the percentage of the case a senior resident actually operated on the robotic console.

CONCLUSIONS

A majority of general surgery residency programs offer formal robotic surgery curricula and have been present for 3 years or less. Most residencies begin their curricula in PGY1 or PGY2 year, with an opportunity to bedside assist and operate on the robotic console in the first 3 years of residency. Operative barriers and defined milestones for general surgery trainees need to be identified.

Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery

Background

This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions.

Methods

A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery.

Results

The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review.

Conclusions

Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.

Current Barriers in Robotic Surgery Training for General Surgery Residents

OBJECTIVE

To assess the current barriers in robotic surgery training for general surgery residents.

DESIGN

Multi-institutional web-based survey.

SETTING

9 academic medical centers with a general surgery residency.

PARTICIPANTS

General surgery residents of at least PGY-3 training level.

RESULTS

163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console.

CONCLUSIONS

General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

Role and Training of the Bedside Surgeon in Robotic Surgery: A Survey Among French Urologists-in-Training

Introduction

Due to the development of robotic surgery, surgeons operating at the console are physically separated from the patient. They must rely on help from an assistant, also called bedside surgeon. This study aimed to investigate the habits and practices of French urologic residents when performing this role and to determine whether they expected specific training to qualify as bedside surgeons.

Materials and Methods

A web-based survey was sent to French urology residents and fellows using the mailing-list of the French Association of Urologists in Training (AFUF).

Results

Over a 3-month period, 86 residents and fellows responded to the survey. Seventy-five (87.2%) thought that an experience as bedside surgeon was useful to acquire console surgeon status and, more specifically, 48.2% of them indicated that this former experience was vital. Nearly 64% considered that learning robotic surgery was essential during residency and fellowship. Overall, 91.9% believed that bedside surgeons should receive a formal training. They were 69.7% to need 5 to 10 procedures to feel confident as bedside surgeon. Almost 75% underwent laparoscopic training on simulators. Having access to a surgery school significantly increased the probability of receiving laparoscopic training on simulators (p = 0.0033).

Conclusion

French urology residents and fellows expect a specific training program for bedside surgeons to increase their level of confidence and to get familiar with the device during their first robotic procedures. For them, a bedside surgeon program on a regional/national level would be required.

Training residents in robotic thoracic surgery

With growing integration of robotic technology in thoracic surgery, the need for structured training has never been greater with trainees expressing desire for additional experience. Determining the ideal education program is challenging as the collective experience is still relatively early and growing with many experienced surgeons still becoming facile with the platform. Understanding differences between robotic and thoracoscopic approaches including lung retraction and dissection, use of carbon dioxide insufflation, and lack of tactile feedback serves as the foundation for building a skillset. Currently, there is no standard accepted curriculum for residents. Inclusion of these trainees in structured programs has been shown to be safe with equivalent patient outcomes. There are multiple curricula under development, all of which incorporate use of simulation technology, dual console, and clear, graduated responsibilities within operations. These include introduction to the robotic system prior to progressing to bedside assistance and finally to time as console surgeon. The importance of clear definition of training milestones with deliberate graduation to more complex tasks once competency has been demonstrated cannot be overstated. It is crucial for surgeons practicing robotic surgery to make efforts to further the training of residents, but there has not been any perfect and suitable program identified yet.

Identifying curriculum content for a cross-specialty robotic-assisted surgery training program: a Delphi study

BACKGROUND

Robotic-assisted surgery is increasing and there is a need for a structured and evidence-based curriculum to learn basic robotic competencies. Relevant training tasks, eligible trainees, realistic learning goals, and suitable training methods must be identified. We sought to develop a common curriculum that can ensure basic competencies across specialties.

METHODS

Two robotic surgeons from all departments in Denmark conducting robotic-assisted surgery within gynecology, urology, and gastrointestinal surgery, were invited to participate in a three-round Delphi study to identify learning goals and rank them according to relevance for a basic curriculum. An additional survey was conducted after the Delphi rounds on what training methods were considered best for each learning goal and who (console surgeon/patient-side assistant) should master each learning goal.

RESULTS

Fifty-six robotic surgeons participated and the response rates were 86%, 89%, and 77%, for rounds 1, 2 and 3, respectively. The Delphi study identified 40 potential learning goals, of which 29 were ranked as essential, e.g., Understand the link between arm placement and freedom of movement or Be able to perform emergency un-docking. In the additional survey, the response rate was 70%. Twenty-two (55%) of the identified learning goals were found relevant for the patient-side assistant and twenty-four (60%) were linked to a specific suitable learning method with > 75% agreement.

CONCLUSIONS

Our findings can help training centers plan their training programs concerning educational content and methods for training/learning. Furthermore, patient-side assistants should also receive basic skills training in robotic surgery.

Transforming Surgical Education through a Resident Robotic Curriculum

Objective

Here, we describe a systematic approach to design, implement, and assess a robotic surgery curriculum for surgical residents. By describing our process, including identifying and addressing institutional challenges, we illustrate successful development of a robust curriculum.

Summary Background Data

As robotic-assisted surgeries increase, educational challenges have emerged and illustrate an alarming impact on medical training. Robotic curricula are frequently grounded in the industry's educational materials resulting in a variety of existing resident curricula that lack cognitive components and critical evaluation. As such, surgical educators struggle to identify the curricular restructuring needs that likely accompany emerging technologies. It is essential to develop a curricular framework for the surgical education community to approach the ongoing and inevitable integration of new technologies.

Methods

Our process parallels the widely accepted approach to curricular development in medical education described by Kern et al. Using this 6-step model, we describe derivation of a curriculum that was data driven, features multimodal educational strategies, and provides documentation methods that allow for continued evaluation and assessment at the individual and departmental level.

Results

This study highlights the systematic process of design, implementation and assessment of a robotic surgery curriculum for surgical residents. Built on a robust national and local needs assessment, and further strengthened by preemptive identification of institutional challenges, this curricular model includes a structured documentation system that allows for ongoing evaluation, assessment, and monitoring of curricular progress.

Conclusions

We illustrate a robustly built curricular structure that can be adopted, adapted, and successfully implemented at other training institutions around the world.

Trends of core versus subspecialty operative procedures completed in general surgery residency training programs

INTRODUCTION

General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training.

METHODS

Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero.

RESULTS

The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted.

CONCLUSIONS

Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

Robotics in Spine Surgery and Spine Surgery Training

The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on maximizing patient safety and outcomes. In addition, an increasing interest in minimally invasive spine surgery has further fueled robotic development, as robotic guidance systems are aptly suited for these procedures. This review aims to address 3 of the most critical aspects of robotics in spine surgery today: salient details regarding the current and future development of robotic systems and functionalities, the reported accuracy of implant placement over the years, and how the implementation of robotic systems will impact the training of future generations of spine surgeons. As current systems establish themselves as highly accurate tools for implant placement, the development of novel features, including even robotic-assisted decompression, will likely occur. As spine surgery robots evolve and become increasingly adopted, it is likely that resident and fellow education will follow suit, leading to unique opportunities for both established surgeons and trainees.

Robotic General Surgery Resident Training Curriculum: A Pilot Experience

BACKGROUND

The purpose of this study was to report the impact of a pilot robotic general surgery resident training curriculum.

MATERIALS AND METHODS

A single institution pilot robotic general surgery training curriculum was instituted in 2016. Accreditation Council for Graduate Medical Education operative case log trends, resident simulation performance, and surveys were analyzed.

RESULTS

Forty-three general surgery residents participated in the robotic surgery training curriculum, 2016 to 2019. In total, 161 robotic cases were logged, increasing each academic year. Residents acted as bedside assistant in 42.9% (n=69) and as console surgeon in 57.1% (n=92). Fifteen first-year residents were surveyed on the training curriculum. On the postcurriculum survey, 100% found the curriculum to be very helpful, notably the hands-on in-service and skills simulator.

CONCLUSIONS

Since the curriculum onset, residents participated in an increasing number of robotic operative cases and were actively engaged in simulation exercises. The establishment of this curriculum has facilitated the integration of resident education into the utilization of robotic technology. This study highlights the value of a formal robotic surgery curriculum for general surgery residency training.

Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study

BACKGROUND

The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon.

METHODS

A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019-2020 at a tertiary-care academic center (mentee 2 group).

RESULTS

257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor's times in the first three (mentee 1 group) and two (mentee 2 group) years (P < 0.05) but remained significantly longer than the mentor's times in the last two (mentee 1 group) and one (mentee 2 group) years (P < 0.05). There was no significant difference in venothromboembolic events (P = 0.89) or readmission rates (P = 0.93). The mean length of stay was 1.8 ± 0.5 days, 1.3 ± 0.5 days, and 1.5 ± 0.5 days in the mentor, mentee 1, and mentee 2 groups, respectively (P < 0.0001). There were no reoperations, conversion to laparoscopy or open, no staple line leaks, strictures, or deaths in any group.

CONCLUSIONS

This is one of the first series to show that the robotic platform can safely be taught and may translate into outcomes consistent with surgeons with more experience while mitigating the learning curve as early as the first year in practice. Long-term follow-up of mentees will be necessary to assess the evolution of fellowship training and outcomes.

Robotic Surgery: The Impact of Simulation and Other Innovative Platforms on Performance and Training

OBJECTIVE

To review the current status of robotic training and the impact of various training platforms on the performance of robotic surgical trainees.

DATA SOURCES

Literature review of Google Scholar and PubMed. The search terms included a combination of the following: "robotic training," "simulation," "robotic curriculum," "obgyn residency robotic training," "virtual reality robotic training," "DaVinci training," "surgical simulation," "gyn surgical training." The sources considered for inclusion included peer-reviewed articles, literature reviews, textbook chapters, and statements from various institutions involved in resident training.

METHODS OF STUDY SELECTION

A literature search of Google Scholar and PubMed using terms related to robotic surgery and robotics training, as mentioned in the "Data Sources" section.

RESULTS

Multiple novel platforms that use machine learning and real-time video feedback to teach and evaluate robotic surgical skills have been developed over recent years. Various training curricula, virtual reality simulators, and other robotic training tools have been shown to enhance robotic surgical education and improve surgical skills. The integration of didactic learning, simulation, and intraoperative teaching into more comprehensive training curricula shows positive effects on robotic skills proficiency. Few robotic surgery training curricula have been validated through peer-reviewed study, and there is more work to be completed in this area. In addition, there is a lack of information about how the skills obtained through robotics curricula and simulation translate into operating room performance and patient outcomes.

CONCLUSION

Data collected to date show promising advances in the training of robotic surgeons. A diverse array of curricula for training robotic surgeons continue to emerge, and existing teaching modalities are evolving to keep up with the rapidly growing demand for proficient robotic surgeons. Futures areas of growth include establishing competency benchmarks for existing training tools, validating existing curricula, and determining how to translate the acquired skills in simulation into performance in the operating room and patient outcomes. Many surgical training platforms are beginning to expand beyond discrete robotic skills training to procedure-specific and team training. There is still a wealth of research to be done to understand how to create an effective training experience for gynecologic surgical trainees and robotics teams.

Impact of bedside assistant on outcomes of robotic thyroid surgery: A STROBE-compliant retrospective case-control study

The importance of bedside assistants has been well established in various robotic procedures. However, the effect of assistants on the surgical outcomes of thyroid surgery remains unclear. We investigated the effects of a dedicated robot assistant (DRA) in robotic thyroidectomy. We also evaluated the learning curve of the DRA.Between January 2016 and December 2019, 191 patients underwent robotic total thyroidectomy, all of which were performed by a single surgeon. The DRA participated in 93 cases, while non-dedicated assistants (NRAs) helped with 98 cases. Demographic data, pathologic data, operative times, and postoperative complications were recorded and analyzed.Robotic thyroidectomy was successful in all 191 patients, and none required conversion to the conventional open procedure. Mean operative time was shorter in the DRA group than in the NRA group (183.2 ± 33.6 minutes vs 203.1 ± 37.9 minutes; P < .001). There were no significant differences in terms of sex distribution, age, preoperative serum thyroid stimulating hormone level, or pathologic characteristics between the groups. Cumulative summation analysis showed that it took 36 cases for the DRA to significantly reduce operative time. Mean operative time decreased significantly in the subgroup including the 37th to the 93rd DRA cases compared with the subgroup including only the first 36 DRA cases (199.7 ± 37.3 minutes vs 172.8 ± 26.4 minutes; P < .001). NRA group showed no definite decrease of operation time, which indicated that the NRAs did not significantly deviate from the mean performance.Increased experience of the bedside assistant reduced operative times in the robotic thyroidectomy. Assistant training should be considered as a component of robotic surgery training programs.

Expectations versus reality: trainee participation on the robotic console in academic surgery

INTRODUCTION

Trainees underestimate the amount of operative autonomy they receive, whereas faculty overestimate; this has not been studied in robotics. We aimed to assess the perceptions and expectations of our general surgery trainees and faculty on robotic console participation in academic surgery.

METHODS

A survey was administered to general surgery robotic faculty and trainees eligible to sit at the console. Participants estimated the average percentage of trainee console participation time (CPT) per case for robotic cholecystectomies (CCY) and inguinal hernia repairs (IHR) from January to June 2019. Trainees were additionally asked what CPT they expected according to their training level (novice or senior). Expected CPTs were compared to actual CPTs extracted from robotic console logs during the same time frame.

RESULTS

Survey response rate was 80% for faculty (4 of 5) and 65% for trainees (15 of 23). Novices expected a higher CPT than they perceived in CCY (42.8% ± 14.8% vs 19.0% ± 17.2%, p = 0.03) and IHR (36.1% ± 17.6% vs. 10.7% ± 13.7%, p = 0.01), but in actuality, they did more CPT than perceived (by 34.9% in CCY, p < 0.01; 14% in IHR, p = 0.10). Senior trainees accurately perceived their CPT in IHR, but expected a higher CPT by 15.9% (p = 0.04). In CCY, seniors perceived a 23.8% higher CPT than in reality (p = 0.04). Faculty generally overperceived trainee CPT by 12.8-16.3% (p > 0.05). Compared to faculty, novices perceived lower CPTs in both CCY by 29.9% (p = 0.16) and IHR by 26.8% (p = 0.07), but seniors tended to agree with the faculty-perceived CPTs (p > 0.05).

CONCLUSION

Our robotic trainees expect to do more on the console than they perceive. Faculty think they allow their trainees more participation than in reality. Compared to faculty perception, novice trainees perceive a much lower level of trainee participation than senior trainees do. Expectation setting and standardizing learning curves are important for robotic surgery training.

Stray energy transfer in single-incision robotic surgery

INTRODUCTION

Stray energy transfer from surgical monopolar radiofrequency energy instruments can cause unintended thermal injuries during laparoscopic surgery. Single-incision laparoscopic surgery transfers more stray energy than traditional laparoscopic surgery. There is paucity of published data concerning stray energy during single-incision robotic surgery. The purpose of this study was to quantify stray energy transfer during traditional, multiport robotic surgery (TRS) compared to single-incision robotic surgery (SIRS).

METHODS

An in vivo porcine model was used to simulate a multiport or single-incision robotic cholecystectomy (DaVinci Si, Intuitive Surgical, Sunnyvale, CA). A 5 s, open air activation of the monopolar scissors was done on 30 W and 60 W coag mode (ForceTriad, Covidien-Medtronic, Boulder, CO) and Swift Coag effect 3, max power 180 W (VIO 300D, ERBE USA, Marietta, GA). Temperature of the tissue (°C) adjacent to the tip of the assistant grasper or the camera was measured with a thermal camera (E95, FLIR Systems, Wilsonville, OR) to quantify stray energy transfer.

RESULTS

Stray energy transfer was greater in the SIRS setup compared to TRS setup at the assistant grasper (11.6 ± 3.3 °C vs. 8.4 ± 1.6 °C, p = 0.013). Reducing power from 60 to 30 W significantly reduced stray energy transfer in SIRS (15.3 ± 3.4 °C vs. 11.6 ± 3.3 °C, p = 0.023), but not significantly for TRS (9.4 ± 2.5 °C vs. 8.4 ± 1.6 °C, p = 0.278). The use of a constant voltage regulating generator also minimized stray energy transfer for both SIRS (0.7 ± 0.4 °C, p < 0.001) and TRS (0.7 ± 0.4 °C, p < 0.001).

CONCLUSIONS

More stray energy transfer occurs during single-incision robotic surgery than multiport robotic surgery. Utilizing a constant voltage regulating generator minimized stray energy transfer for both setups. These data can be used to guide robotic surgeons in their use of safe, surgical energy.

A Standardized Robotic Training Curriculum in a General Surgery Program

Background and Objectives:

The general surgery residency at the University of Illinois College of Medicine at Peoria has a long tradition of integrating robotic surgery into training since 2002. The purpose of this paper is to investigate our curriculum and evaluation system, which was designed to achieve a standardized format for education in general robotic surgery.

Methods:

The curriculum consists of two phases: phase 1 (PGY 1–2): Complete 4 robotic surgery training modules; read two assigned robotic surgery articles; and practice simulation modules on the robot. phase 2 (PGY 3–5): Refresh training modules, score >90% on the simulator modules every 6 months; bedside assist minimum of 4 robotic procedures; and act as console surgeon for a minimum of 10 procedures with 2 separate attending surgeons. The required simulator modules were specially selected to incorporate all of the skills categories documented in the simulator. The faculty evaluate the resident's operative performance using the Global Evaluative Assessment of Robotic Skills validated rubric.

Results:

Since the curriculum was instituted in June 2017, 73 evaluations from 8 surgeons have been collected. We examined data from 6 residents who had at least 5 Global Evaluative Assessment of Robotic Skills assessments completed. Correlation coefficient scores showed a positive correlation ranging from 0.476 to 0.862 for average skills and 0.334 to 0.866 for overall performance scores.

Discussion:

The preliminary results suggest an improvement of resident robotic surgical skills through tailored education. This curriculum is designed to enhance robotic general surgery education that could potentially produce general surgeons able to operate robotically without needing a robotic/MIS (Minimally Invasive Surgery) fellowship.