Training in robotics: The learning curve and contemporary concepts in training

The robotic learning curve for a newly appointed colorectal surgeon

Robotic colorectal surgery allows for better ergonomics, superior retraction, and fine movements in the narrow anatomy of the pelvis. Recent years have seen the uptake of robotic surgery in all pelvic surgeries specifically in low rectal malignancies. However, the learning curve of robotic surgery in this cohort is unclear as established training pathways are not formalized. This study looks at the experience and learning curve of a single laparoscopic trained surgeon in performing safe and effective resections, mainly for low rectal and anal malignancies using the da Vinci robotic system by evaluating metrics related to surgical process and patient outcome. A serial retrospective review of the robotic colorectal surgery database, in the University Hospital Coventry and Warwickshire (UHCW), was undertaken. All 48 consecutive cases, performed by a recently qualified colorectal surgeon, were included in our study. The surgical process was evaluated using both console and total operative time recorded in each case along with the adequacy of resections performed; in addition, patient-related outcomes including intraoperative and postoperative complications were analyzed to assess differences in the learning curve. Forty eight sequential recto-sigmoid resections were included in the study performed by a single surgeon. The cases were divided into four cohorts in chronological order with comparable demographics, tumour stage, location, and complexity of the operation (mean age 65, male 79%, and female 29%). The results showed that the mean console time dropped from 3 to 2.5 h, while total operative time dropped from 6 h to 5.5 h as the surgeon became more experienced; however, this was not found to be statistically significant. In addition, no significant difference in pathological staging was seen over the study period. No major intra-op and post-op complications were observed and no 30-day mortality was recorded. Moreover, after 30 cases, the learning curve developed the plateau phase, suggesting the gain of maximum proficiency of skills required for robotic colorectal resections. The learning curve in robotic rectal surgery is short and flattens early; complication rates are low during the learning curve and continue to decrease with time. This shows that with proper training and proctoring, new colorectal surgeons can be trained in a short time to perform elective colorectal pelvic resections.

Parallel, component training in robotic total mesorectal excision

There has been widespread adoption of robotic total mesorectal excision (TME) for rectal cancer in recent years. There is now increasing interest in training robotic novice surgeons in robotic TME surgery using the principles of component-based learning. The aims of our study were to assess the feasibility of delivering a structured, parallel, component-based, training curriculum to surgical trainees and fellows. A prospective pilot study was undertaken between January 2021 and May 2021. A dedicated robotic training pathway was designed with two trainees trained in parallel per each robotic case based on prior experience, training grade and skill set. Component parts of each operation were allocated by the robotic trainer prior to the start of each case. Robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and the EARCS Global Assessment Score (GAS). Three trainees participated in this pilot study, performing a combined number of 52 TME resections. Key components of all 52 TME operations were performed by the trainees. GEARS scores improved throughout the study, with a mean overall baseline score of 17.3 (95% CI 15.1-1.4) compared to an overall final assessment mean score of 23.8 (95% CI 21.6-25.9), p = 0.003. The GAS component improved incrementally for all trainees at each candidate assessment (p < 0.001). Employing a parallel, component-based approach to training in robotic TME surgery is safe and feasible and can be used to train multiple trainees of differing grades simultaneously, whilst maintaining high-quality clinical outcomes.

Factors affecting the learning curve in robotic colorectal surgery

Learning related to robotic colorectal surgery can be measured by surgical process (such as time or adequacy of resection) or patient outcome (such as morbidity or quality of life). Time based metrics are the most commonly used variables to assess the learning curve because of ease of analysis. With analysis of the learning curve, there are factors which need to be considered because they may have a direct impact on operative times or may be surrogate markers of clinical effectiveness (unrelated to times). Variables which may impact on operation time include surgery case mix, hybrid technique, laparoscopic and open colorectal surgery experience, robotic surgical simulator training, technology, operating room team, and case complexity. Multidimensional analysis can address multiple indicators of surgical performance and include variables such as conversion rate, complications, oncological outcome and functional outcome. Analysis of patient outcome and/or global assessment of robotic skills may be the most reliable methods to assess the learning curve.

Meta-analysis on current status, efficacy, and safety of laparoscopic and robotic ventral mesh rectopexy for rectal prolapse treatment: can robotic surgery become the gold standard?

PURPOSE

Robotic-assisted surgery and robotic-assisted ventral mesh rectopexy are gaining attention in the treatment of rectal prolapse and increased positive findings are proposed. The objective of this meta-analysis was to investigate whether robotic-assisted ventral mesh rectopexy is comparable with the conventional laparoscopic approach surgery.

METHODS

Five major databases (PubMed, Sciencedirect, Web of Science, Embase, and Cochrane Library) were searched for eligible studies. Observational studies of the effect and safety of robotic-assisted and laparoscopic approaches on ventral mesh rectopexy were included. Odd ratios (OR) and weight mean difference (WMD) were used for dichotomous data and continuous data analysis. Clinical outcomes, functional outcomes, and cost-effectiveness data were extracted for meta-analysis.

RESULTS

Compared to the laparoscopic approach, a significant shorter length of hospital stay (LOS), lesser intraoperative blood loss, and lower post-operative complication rate of RVMR group were observed. However, operation time of RVMR was significant increased. The expense of RVMR was higher than LVMR; mean Wexner scores and fecal incontinence were lower in RVMR group while there were no statistical differences.

CONCLUSION

The result of the current analysis revealed that the robotic-assisted ventral mesh rectopexy is effective and feasible in the treatment of rectal prolapse. However, long-term follow-up and results are needed for the promotion of this approach. There is a long way for robotic-assisted surgery to become a gold standard in rectal surgery.

Learning Curve for Interlaminar Endoscopic Lumbar Discectomy: A Systematic Review

BACKGROUND

Interlaminar endoscopic lumbar discectomy (IELD) is an efficient surgical treatment for lumbar disc herniation. However, this minimally invasive procedure requires a considerable learning curve that has not yet been standardized. This review aimed to evaluate the learning curve's characteristics, including the cutoff point required to achieve technical proficiency and to discuss appropriate training methods.

METHODS

We systematically searched the core databases (PubMed, Embase, and Cochrane Library) for clinical studies that evaluated the learning curve using quantitative data. We performed a quality assessment using the Newcastle-Ottawa scale. We also compared descriptive statistics, including operative time and other variables before and after the cutoff point.

RESULTS

Six studies reporting 302 cases of IELD were selected from 7188 screened articles. The cutoff point was randomly set in 3 studies and determined as the curve's asymptote in 3 studies. The mean value for the cutoff point was 22.17 ± 12.40 cases (range: 10-43 cases) and mainly determined based on the operative time, which was shorter in the late group than that in the early group (P < 0.05). The cutoff points were not significant for patient outcome parameters such as pain score, functional result, surgical failure, or complications.

CONCLUSIONS

The evidence of published studies regarding the learning curve for the IELD technique is insufficient. The reported cutoff points may be significant only for task efficiency. Moreover, they may not represent the asymptote of the curve. Future studies should evaluate the actual plateau points using patient outcome data.

Fellowship training in robotic colorectal surgery within the current hospital setting: an achievable goal?

BACKGROUND

Although currently limited, the requirement for colorectal trainees to attain skills in robotic surgery is likely to increase due to further utilization of robotic platforms globally. The aim of the study is to describe the training programme utilized and assess outcomes of fellowship training in robotic colorectal surgery.

METHODS

A structured robotic training programme was generated across a tertiary hospital setting. Review of four prospectively maintained fellow operative logbooks was performed to assess caseload and skill acquisition. Operative and patient-related outcomes were compared with consultant trainer performed cases. Data were analysed using R with a P < 0.05 considered significant.

RESULTS

The structured robotic training scheme is a two-tiered system over a 12-month period. The trainer-directed pathway comprised of a robotic console safety course followed by cart-side assisting, a wet lab animal course, dual-console accreditation training course and onsite proctoring, prior to becoming an independent console surgeon. Over 2 years, 265 robotic (n = 143 primary/component surgeon) cases were undertaken with fellows A, B, C and D involved in 63, 77, 75 and 50 robotic colorectal cases, respectively. Individual learning curves revealed independent procedure competency at cases 11, 14, 15 and 12, respectively, for robotic anterior resection. There was no significant difference observed in operative time (P = 0.39), blood loss (P = 0.41), lymph node harvest (P = 0.35), conversion rates (2% versus 4%), anastomotic leaks (1% versus 3%) and R0 resection rates (100% versus 98% colonic, 96% versus 96% rectal, P = 0.48) between surgical fellows and consultant trainers. Clavien-Dindo(III-IV) complications were similar (10% versus 6%,P = 0.25) with no mortalities encountered.

CONCLUSION

It is feasible and safe to train fellows in robotic colorectal surgery without compromise of operative- and patient-related outcomes.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Learning Curve for Transforaminal Percutaneous Endoscopic Lumbar Discectomy: A Systematic Review

BACKGROUND

Transforaminal percutaneous endoscopic lumbar discectomy (TPELD) has become an alternative and minimally invasive surgical technique for soft lumbar disc herniation. However, the learning curve has been relatively long and difficult. In the present study, we have summarized the characteristics of the learning curve of TPELD, including the number of cases required to achieve technical proficiency, and discussed the strategies to improve the learning curve.

METHODS

The PubMed, Embase, Cochrane Library, and KoreaMed databases were searched for reports describing the learning curve for TPELD. Clinical studies involving human patients and evaluating the learning curve of TPELD with quantitative data were included. A strict quality assessment was completed, and descriptive statistics were calculated.

RESULTS

Of the 6884 screened titles and abstracts, 10 full-text reports, including 958 cases, were included in the analysis. All were cohort studies, which were grouped into early and late groups according to surgeon experience with TPELD. The most commonly used cutoff to differentiate between these groups was 20 (mean, 24.70 ± 18.99 cases; range, 10-72 cases). The most widely used measure was the operative time. Although most studies had reported better results in the operative time or pain scores in the late group, only 1 study had proposed a bona fide learning curve.

CONCLUSIONS

We found insufficient evidence to support a cutoff point of 20 or other numbers of cases for determining when the learning curve has reached a plateau. Therefore, these numbers should be interpreted with great care, and high-quality prospective studies evaluating the actual learning curve are required.

Trends of complications and innovative techniques' utilization for colectomies in the United States

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay.

Cost, training and simulation models for robotic-assisted surgery in pediatric urology

INTRODUCTION

Laparoscopic procedures in pediatric urology have been shown to be safe and effective over the last number of years. Coupled with this is the technological trend to provide minimally invasive options for even the most complex pediatric patients. Whilst robotic platforms continue to try to demonstrate superior patient outcomes in adults with mixed results, the utilization of robotic platforms for pediatric urology is increasing.

METHODS

A review of the current literature was undertaken to assess the evidence for training models and cost-effectiveness of robotic-assisted pediatric urology.

CONCLUSIONS

A growing body of evidence in this field has demonstrated that robotic platforms are safe and effective in children and can provide additional reconstructive benefits due to motion scaling, magnification, stereoscopic views, instrument dexterity and tremor reduction. The main drawbacks remain the financial implications associated with this platform through purchase, maintenance, and disposable costs. This review addresses some of the addresses issues pertaining to cost, training and simulation for robotic-assisted surgery in pediatric urology.

[Methods for training of robot-assisted radical prostatectomy]

Robotic surgery is a future method of minimal invasive surgery. Robot-assisted radical prostatectomy (RARP) is a common method of surgical treatment of prostate cancer. Due to significant differences of the surgical technique of RARP compared to open or laparoscopic radical prostatectomy (LRP) new methods of training are needed. At the moment there are many opinions how to train physicians best. Which model is the most effective one remains nowadays controversial.

OBJECTIVE

Analyze currently available data of training methods of RARP. Determine the most effective training model and evaluate its advantages and disadvantages. Establish a standardized plan and criteria for proper training and certification of the entire surgical team.

MATERIAL AND METHODS

Literature review based on PubMed database, Web of Science and Scopus by keywords: robot-assisted radical prostatectomy, training of robot-assisted prostatectomy, training in robot-assisted operations, a learning curve of robot-assisted prostatectomy, virtual reality simulators (VR-simulators) in surgery.

RESULTS

According to the literature in average 18 to 45 procedures are required for a surgeon to achieve the plateau of the learning curve of the RARP. Parallel training, pre-operative warm-up and the use of virtual reality simulators (VR-simulators) can significantly increase the learning curve. There are many described models of RARP training.

CONCLUSIONS

The absence of accepted criteria of evaluation of the learning curve does not allow to use this parameter as a guide for the surgeon's experience. Proper training of robotic surgeons is necessary and requires new methods of training. There are different types of training programs. In our opinion the most effective training program is when a surgeon observes the performance of tasks or any steps of operation on the VR-simulator, then he performs them and analyzes mistakes by video recording. Then the surgeon observes real operations and performs some steps of the operation which are already leant on the simulator under supervision of the mentor and analyzes mistakes by video recording. Thus, mastering first the simple stages under supervision of a mentor, the surgeon effectively adopts the surgical experience from him. It is necessary to train not only the surgeons but also the entire surgical team.

Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries

Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.

Robotics in urologic oncology

Robotic surgery was initially developed to overcome problems faced during conventional laparoscopic surgeries and to perform telesurgery at distant locations. It has now established itself as the epitome of minimally invasive surgery (MIS). It is one of the most significant advances in MIS in recent years and is considered by many as a revolutionary technology, capable of influencing the future of surgery. After its introduction to urology, robotic surgery has redefined the management of urological malignancies. It promises to make difficult urological surgeries easier, safer and more acceptable to both the surgeon and the patient. Robotic surgery is slowly, but surely establishing itself in India. In this article, we provide an overview of the advantages, disadvantages, current status, and future applications of robotic surgery for urologic cancers in the context of the Indian scenario.