The robot doesn't lie: real-life validation of robotic performance metrics

Robotic performance metrics model fellow proficiency in living donor nephrectomy

We investigated the use of robotic objective performance metrics (OPM) to predict number of cases to proficiency and independence among abdominal transplant fellows performing robot-assisted donor nephrectomy (RDN). 101 RDNs were performed by 5 transplant fellows from September 2020 to October 2023. OPM included fellow percent active control time (%ACT) and handoff counts (HC). Proficiency was defined as ACT ≥ 80% and HC ≤ 2, and independence as ACT ≥ 99% and HC ≤ 1. Case number was significantly associated with increasing fellow %ACT, with proficiency estimated at 14 cases and independence at 32 cases (R2 = 0.56, p < 0.001). Similarly, case number was significantly associated with decreasing HC, with proficiency at 18 cases and independence at 33 cases (R2 = 0.29, p < 0.001). Case number was not associated with total active console time (p = 0.91). Patient demographics, operative characteristics, and outcomes were not associated with OPM, except for donor estimated blood loss (EBL), which positively correlated with HC. Abdominal transplant fellows demonstrated proficiency at 14-18 cases and independence at 32-33 cases. Total active console time remained unchanged, suggesting that increasing fellow autonomy does not impede operative efficiency. These findings may serve as a benchmark for training abdominal transplant surgery fellows independently and safely in RDN.

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.

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.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group

OBJECTIVE

A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education.

DESIGN

The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs.

SETTING

Virtual and in-person meetings in the United States.

PARTICIPANTS

Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators.

RESULTS

The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience.

CONCLUSIONS

The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

Introducing a novice surgeon to an experienced robotic gynaecological oncology team: An observational cohort study on the impact of a structured curriculum on outcomes of cervical cancer surgery

OBJECTIVE

To evaluate the effect on patient outcomes when introducing a novice robotic surgeon, trained in accordance with a structured learning curriculum, to an experienced robotic surgery team treating cervical cancer patients.

METHODS

Patients with early-stage cervical cancer who were treated with primary robot-assisted surgery between 2007 and 2019 were retrospectively included. In addition to the 165 patients included in a former analysis, we included a further 61 consecutively treated patients and divided all 226 patients over three groups: early learning phase of 61 procedures without structured training (group 1), experienced phase of 104 procedures (group 2), and the 61 procedures during introduction of a novice with structured training (group 3). Risk-adjusted cumulative sum (RA-CUSUM) analysis was performed to assess the learning curve effect. Patient outcomes between the groups were compared.

RESULTS

Based on RA-CUSUM analysis, no learning curve effect was observed for group 3. Regarding surgical outcomes, mean operation time in group 3 was significantly shorter than group 1 (p < 0.001) and similar to group 2 (p = 0.96). Proportions of intraoperative and postoperative adverse events in group 3 were not significantly different from the experienced group (group 2). Regarding oncological outcomes, the 5-year disease-free survival, disease-specific survival, and overall survival in group 3 were not significantly different from the experienced group.

CONCLUSIONS

Introducing a novice robotic surgeon, who was trained in accordance with a structured learning curriculum, resulted in similar patient outcomes as by experienced surgeons suggesting novices can progress through a learning phase without compromising outcomes of cervical cancer patients.

Is Robotic Console Time a Surrogate for Resident Operative Autonomy?

OBJECTIVE

Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy.

METHODS

Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed.

RESULTS

A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores.

CONCLUSIONS

Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

Common Components of General Surgery Robotic Educational Programs

OBJECTIVE

Robotically assisted surgery has become more common in general surgery, but there is limited guidance from the Accreditation Council for Graduate Medical Education (ACGME) regarding this type of training. We sought to determine common elements and differences in the robotic educational curricula developed by general surgery residency programs.

DESIGN

Robotic educational curricula were obtained from the 7 individuals who presented at the workshop, "Robotic Education in General Surgery" at the 2023 Association of Program Directors in Surgery annual meeting.

RESULTS

All 7 general surgery programs had training beginning intern year, required online robotic modules, had at least 1 dedicated simulation training console not used for clinical purposes, and ran dry and wet (tissue) robotic labs at least annually. All programs had bedside and console surgeon case minimums and had administrative support to run the educational programs. Differences existed regarding how training intern year was executed, the simulations required, clinical practice minimum requirements, how progress was monitored over time, and how case numbers were tracked. Some programs had salary support for a director of robotic education.

CONCLUSIONS

There are several common elements to robotic educational curricula in general surgery, however significant variation does exist between programs. Given the frequency of robotic use in general surgery and current lack of standardization, formal guidance from the ACGME specifically regarding robotic education in general surgery residency is warranted.

Crossover-effects in technical skills between laparoscopy and robot-assisted surgery

INTRODUCTION

Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery.

METHODS

An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated.

RESULTS

A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery.

CONCLUSION

The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.