The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons

Establishment of a 24/7 robotic acute care surgery program at a large academic medical center

BACKGROUND

For many years, robotic surgery has been an option for various elective surgical procedures. Though robotic surgery has not traditionally been the first choice for acute surgical patients, recent work has shown promise in broader applications. However, there are limited data regarding how to establish an institutional robotics program for higher acuity patients. This project aimed to map a pathway for the creation of an acute care surgery robotic program at a large academic medical center.

METHODS

Various stakeholders were gathered jointly with our surgical faculty: anesthesia, operating room leadership, surgical technologists, circulating nurses, Central Sterile Supply, and Intuitive Surgical Inc. representatives. Staff underwent robotics training, and surgical technologists were trained as bedside first assistants. Nontraditional robotic operating rooms were allocated for coordinated placement of appropriate cases, and pre-made case carts were arranged with staff to be available at all hours. A workflow was created between surgical faculty and staff to streamline add-on robotic cases to the daily schedule.

RESULTS

Six faculty and two fellows are now credentialed in robotics surgery, and additional surgeons are undergoing training. Numerous staff have completed training to perform operative assistant duties. The operating capacity of robotic acute care surgeries has more than doubled in just one year, from 77 to 172 cases between 2022 and 2023, respectively. Two add-on cases can be accommodated per day. Select patients are being offered robotic surgeries in the acute surgical setting, and ongoing efforts are being made to create guidelines for which patients would best benefit from robotic procedures.

CONCLUSIONS

Launching a successful robotic surgery program requires a coordinated, multidisciplinary effort to ensure seamless integration into daily operations. Additional assistance from outside technology representatives can help to ensure comfort with procedures. Further studies are needed to determine the acute patient population that may benefit most from robotic surgery.

What defines the "value" of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center

The use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high-level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient-centered, value-based healthcare models and reimbursement systems that embrace cost-effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value-based care, with a focus on robotic surgery for gastrointestinal cancers.

Preceptorship in robotic colorectal surgery: experience from the Australian private sector

This article describes a post-fellowship preceptorship training program to train sub-specialty colorectal surgeons in gaining proficiency in robotic colorectal surgery using a dual-surgeon model in the Australian private sector. The Australian colorectal surgeon faces challenges in gaining robotic colorectal surgery proficiency with limited exposure and experience in the public setting where the majority of general and colorectal surgery training is currently conducted. This training model uses graded exposure with a range of simulation training, wet lab training, and clinical operative cases to progress through both competency and proficiency in robotic colorectal surgery which is mutually beneficial to surgeons and patients alike. Ongoing audit of practice has shown no adverse impacts.

The compatibility of exoskeletons in perioperative environments and workflows: an analysis of surgical team members' perspectives and workflow simulation

Surgical team members in perioperative environments experience high physical demands. Interventions such as exoskeletons, external wearable devices that support users, have the potential to reduce these work-related physical demands. However, barriers such as workplace environment and task compatibility may limit exoskeleton implementation. This study gathered the perspectives of 33 surgical team members: 12 surgeons, four surgical residents, seven operating room (OR) nurses, seven surgical technicians (STs), two central processing technicians (CPTs), and one infection control nurse to understand their workplace compatibility. Team members were introduced to passive exoskeletons via demonstrations, after which surgical staff (OR nurses, STs, and CPTs) were led through a simulated workflow walkthrough where they completed tasks representative of their workday. Five themes emerged from the interviews (workflow, user needs, hindrances, motivation for intervention, and acceptance) with unique subthemes for each population. Overall, exoskeletons were largely compatible with the duties and workflow of surgical team members.

Use of Simulation For Training Advanced Colorectal Procedures

OBJECTIVE

Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC).

DESIGN

LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri.

PARTICIPANTS

Senior general surgery residents at large academic surgery program.

RESULTS

Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts.

CONCLUSIONS

Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

A prospective phase II clinical trial/IDEAL Stage 2a series of single-port robotic colorectal surgery for abdominal and transanal cases

AIM

Slow laparoscopy adoption accelerated the uptake of robotic surgery. However, the current robotic platforms have limitations in transanal applications and multiple port sites. The da Vinci single-port (SP) robot is currently used on trial for colorectal surgery, and broad assessment of outcomes is needed. We aimed to report findings of a phase II clinical trial of SP robotic colorectal surgery.

METHODS

A sequentially reported prospective case series was performed on patients using SP robotics at a tertiary referral centre from 1 October 2018 to 31 August 2021. Cases were stratified into abdominal and transanal cohorts. Demographics, intra-operative variables and 30-day postoperative outcomes were evaluated. Univariate analysis was performed, with statistical process control for the docking process. Main outcomes were conversion rates, morbidity, mortality and point of standardization of docking.

RESULTS

In all, 133 patients were included: 93 (69.92%) abdominal and 40 (30.08%) transanal. The main diagnosis was rectal cancer (n = 59) and the procedure performed a robotic transanal abdominal transanal radical proctosigmoidectomy (n = 30). There were no conversions to open surgery. Two abdominal (2.15%) and three transanal cases (7.50%) were converted to laparoscopy. All colorectal adenocarcinomas had negative margins, proper lymph node harvest and complete mesorectal excision, as appropriate. Docking became a standardized process at cases 34 (abdominal) and 23 (anorectal). After surgery, bowel function returned on mean day 2 (abdominal) and 1 (transanal). The morbidity rate was 15.05% (abdominal) and 27.50% (transanal). There were two major morbidities in each cohort. Overall, there were three (2.65%) readmissions, one reoperation and no mortality.

CONCLUSIONS

Single-port robotics is feasible for all types of colorectal procedures, with good clinical and oncological outcomes. With this development in colorectal surgery, further studies can develop best practices with this novel technology.

Current Status of Robotic Gastrointestinal Surgery

Development of surgical support robots began in the 1980s as a navigation and auxiliary device for endoscopic surgery. For remote surgery on the battlefield, a master-slave-type surgical support robot was developed, in which a console surgeon operates the robot at will. The da Vinci surgical system, which currently dominates the global robotic surgery market, received United States Food and Drug Administration and regulatory approval in Japan in 2000 and 2009 respectively. The latest, fourth generation, da Vinci Xi has a good field of view via a three-dimensional monitor, highly operable forceps, a motion scale function, and a tremor-filtered articulated function. Gastroenterological tract robotic surgery is safe and minimally invasive when accessing and operating on the esophagus, stomach, colon, and rectum. The learning curve is said to be short, and robotic surgery will likely be standardized soon. Therefore, robotic surgery training should be systematized for young surgeons so that it can be further standardized and later adapted to a wider range of surgeries. This article reviews current trends and potential developments in robotic surgery.

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.

Robotic-assisted Surgery: Expanding Indication to Colon Cancer in Japan

In recent years, robotic-assisted surgery has demonstrated remarkable progress as a minimally invasive procedure for colorectal cancer. While there have been fewer studies investigating robotic-assisted surgery for the treatment of colon cancer than rectal cancer, evidence regarding robotic-assisted colectomy has been accumulating due to increasing use of the procedure. Robotic-assisted colectomy generally requires a long operative time and involves high costs. However, as evidence is increasingly supportive of its higher accuracy and less invasive nature compared to laparoscopic colectomy, the procedure is anticipated to improve the ratio of conversion to laparotomy and accelerate postoperative recovery. Robotic-assisted surgery has also been suggested for a specific level of effectiveness in manipulative procedures, such as intracorporeal anastomosis, and is increasingly indicated as a less problematic procedure compared to conventional laparoscopy and open surgery in terms of long-term oncological outcomes. Although robotic-assisted colectomy has been widely adopted abroad, only a limited number of institutions have been using this procedure in Japan. Further accumulation of experience and studies investigating surgical outcomes using this approach are required in Japan.

Racial Disparity in the Surgical Management of Diverticular Disease

INTRODUCTION

Although minimally invasive surgery (MIS) has clearly been associated with improved colorectal surgery outcomes, not all populations benefit from this approach. Using a national database, we analyzed both, the trend in the utilization of MIS for diverticulitis and differences in utilization by race.

METHODS

Colon-targeted participant user files (PUFs) from 2012 to 18 were linked to respective PUFs in National Surgical Quality Improvement Project. Patients undergoing colectomy for acute diverticulitis or chronic diverticular disease were included. Surgical approach was stratified by race and year. To adjust for confounding and estimate the association of covariates with approach, data were fit using multivariable binary logistic regression main effects model. Using a joint effects model, we evaluated whether the odds of a particular approach over time was differentially affected by race.

RESULTS

Of the 46 713 patients meeting inclusion criteria, 83% were white, with 7% black and 10% other. Over the study period, there was a decrease in the rate of open colectomy of about 5% P < .001, and increase in the rate of utilization of laparoscopic and robotic approaches (RC) P < .0001. After adjusting for confounders, black race was associated with open surgery P < .0001.

CONCLUSION

There is disparity in the utilization of MIS for diverticulitis. Further research into the reasons for this disparity is critical to ensure known benefits of MIC are realized across all races.

Evaluating the Regional Uptake of Minimally Invasive Colorectal Surgery: a Report from the Surgical Care Outcomes Assessment Program

BACKGROUND

Minimally invasive surgery (MIS) for colorectal disease has well-known benefits, but many patients undergo open operations. When choosing an MIS approach, robotic technology may have benefits over traditional laparoscopy and is increasingly used. However, the broad adoption of MIS, and specifically robotics, across colorectal operations has not been well described. Our primary hypothesis is that rates of MIS in colorectal surgery are increasing, with different contributions of robotics to abdominal and pelvic colorectal operations.

METHODS

Rates of MIS colorectal operations are described using a prospective cohort of elective colorectal operations at hospitals in the Surgical Care Outcomes Assessment Program (SCOAP) from 2011 to 2018. The main outcome was proportion of cases approached using open, laparoscopic, and robotic surgery. Factors associated with increased use of MIS approaches were described.

RESULTS

Across 21,423 elective colorectal operations, rates for MIS (laparoscopic or robotic surgery) increased from 44% in 2011 to 75% in 2018 (p < 0.001). Approaches for abdominal operations (n = 12,493) changed from 2 to 11% robotic, 43 to 63% laparoscopic, and 56 to 26% open (p < 0.001). Approaches for pelvic operations (n = 8930) changed from 3 to 33% robotic, 40 to 42% laparoscopic, and 57 to 24% open(p < 0.001). These trends were similar for high-(100 + operations/year) and low-volume hospitals and surgeons.

CONCLUSIONS

At SCOAP hospitals, the majority of elective colorectal operations is now performed minimally invasively. The increase in the MIS approach is primarily driven by laparoscopy in abdominal procedures and robotics in pelvic procedures.

Will It Play in Peoria? A Pilot Study of a Robotic Skills Curriculum for Surgical Oncology Fellows

INTRODUCTION

To implement a mastery-based robotic surgery curriculum using virtual reality (VR) and inanimate reality (IR) drills at multiple Complex General Surgical Oncology (CGSO) fellowships.

PATIENTS AND METHODS

A prospective study of curriculum feasibility and efficacy was conducted at four CGSO fellowship sites. All sites had simulators, and kits were provided to perform 19 biotissue drills. Fellows from three non-UPMC sites (n = 15) in 2016-2018 were compared with fellows from University of Pittsburgh (UPMC; n = 15) where the curriculum was validated in 2014-2018.

RESULTS

All fellows completed the pre- and post-test. There was no difference in pre-test scores between UPMC and non-UPMC sites. Only 7 of 15 non-UPMC fellows completed the VR curriculum (47% compliance) compared with all 15 UPMC fellows completing the VR curriculum (100% compliance). UPMC had higher curriculum times (217 versus 93 mins) and % mastery (86% versus 55%). Time spent on curriculum was associated with % mastery (p = 0.01). Both groups showed improvement between pre- and post-test. Post-test VR scores trended higher for UPMC (221 versus 180). Between the non-UPMC sites, there was a difference in compliance (p = 0.03) and % mastery (p = 0.03). Zero non-UPMC fellows performed the biotissue drills, while five contemporary UPMC fellows completed 253 biotissue drills. Approximately 140 UPMC faculty and 300 staff hours were spent on the pilot.

CONCLUSIONS

A proficiency curriculum can result in improved robotic console skills. However, multiple barriers to implementation potentially exist, including availability of simulators, availability of a training robot, on-site support staff, and universal buy-in from fellows, faculty, and leadership.

Current status of robotic surgery in colorectal residency training programs

BACKGROUND

Robotic surgery (RS) has been increasingly incorporated into colorectal surgery (CRS) training. The degree to which RS has been integrated into CRS residency training is not well described.

METHODS

A web-based survey was sent to all 2019 accredited CRS residency programs within the United States and Canada. Program directors (PDs) were queried on how robotic surgery had been integrated into their program, specifics on RS curriculum and opinions on RS training during general surgery residency. We compared survey responses by program type (university-based, university-affiliated programs, or independent programs) and by geographic region. In addition, a chi-square test was used to evaluate differences in survey responses with respect to robotic curriculum components.

RESULTS

Of 66 programs, 42 (64%) responded to the survey. Of the responding programs, 35 (83%) were university-based or university-affiliated, while 7 (17%) were independent. Most programs were in the Midwest (33%). Forty-one (98%) reported having a surgical robot in use at their institution, with 95% reporting active participation of CRS residents in RS. While 74% of programs have a formal RS training curriculum for CRS residents, there was considerable variability in the curriculum elements employed by each institution, and the differences in proportions of these elements were significant (χ2 99.8, p < 0.001). The median operative approach to abdominopelvic cases was estimated to be 33% robotic, 40% laparoscopic and 20% open. There were no significant differences in the survey responses between university/university-affiliated and independent programs (p > 0.05) or among the different regions (p > 0.05).

CONCLUSIONS

This study demonstrated that almost all CRS residencies have integrated RS and have trainees operating at the robotic console. Most programs have a robotics curriculum and there are expanding indications for RS within CRS. This expansion calls for discussion on implementation of training standards such as curricular requisites, baseline competency assessments, and definitions of minimum case requirements to ensure adequate training.

Evaluating Non-operative Robotic Skills in Colorectal Surgical Training

BACKGROUND

Robotic-assisted surgery has become a common platform for performing colorectal procedures. Educators must determine how best to teach and train residents to use the technology safely. There is a paucity of literature on how non-operative skills are being taught and integrated into colorectal training. Herein we describe the implementation and assessment of a pilot simulation-based Robotic Colorectal Surgery Non-Technical Skills curriculum.

MATERIALS AND METHODS

Since 2017 six colon and rectal surgery residents participated in two scenarios: pelvic bleeding and CO₂ embolism. The scenarios were administered in a simulated operating room twice during the academic year (fall and spring), and audio-video recorded. In addition to self-assessment, videos were evaluated by faculty utilizing the validated Interpersonal and Cognitive Assessment for Robotic Surgery system. To understand the role of scenario difficulty with respect to perceived cognitive workload and performance residents completed a NASA-Task Load Index assessment form.

RESULTS

Between the fall and spring sessions residents significantly improved in intraoperative leadership skills for both the CO₂ embolism and bleeding scenarios, and decision-making and situational awareness for the embolism case. Assessment between resident (self) and expert (faculty) did not correlate (P < 0.05) for either scenario during the fall session. A correlation for both scenarios was appreciated following the spring session revealing resident non-technical skills improved over time. Other than for physical demand, NASA-Task Load Index scores were similar for both scenarios.

CONCLUSIONS

We were able to successfully develop and implement a pilot Robotic Colorectal Surgery Non-Technical Skills curriculum in a risk-free simulated environment. Non-technical skill curriculums should be considered for both training and assessment in robotic surgery.

Intracorporeal anastomosis versus extracorporeal anastomosis for minimally invasive colectomy

Outcomes advantages for the minimally invasive approach to colon and rectal surgery have been clearly described since the original report of a laparoscopic colectomy in 1991. Advancements in minimally invasive options for colon and rectal surgery have produced the need for critical evaluation of alternative and evolving techniques. The evolution and increased adoption of the minimally invasive robotic platform has allowed the intracorporeal anastomosis, previously described with the laparoscopic approach, to be more widely available to surgeon skill sets because of robotic articulating instruments and ergonomic advantages. Studies comparing intra- and extracorporeal techniques for laparoscopic right colectomy have demonstrated some outcomes advantages for the intracorporeal approach that include fewer conversions-to-open, fewer postoperative complications, and shorter hospital length of stay. Recent robotic-assisted comparisons have also shown an intracorporeal advantage and have extended the analysis to left-sided colorectal resections. Further upgrades in minimally invasive options and techniques warrant further evidence-based considerations for surgeons choosing between these options and techniques.

Assessment of Out-of-Pocket Costs for Robotic Cancer Surgery in US Adults

IMPORTANCE

Expensive technologies-including robotic surgery-experience rapid adoption without evidence of superior outcomes. Although previous studies have examined perioperative outcomes and costs, differences in out-of-pocket costs for patients undergoing robotic surgery are not well understood.

OBJECTIVE

To assess out-of-pocket costs and total payments for 5 types of common oncologic procedures that can be performed using an open or robotic approach.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, cross-sectional, propensity score-weighted analysis was performed using deidentified insurance claims for 1.9 million enrollees from the MarketScan database from January 1, 2012, to December 31, 2017. The final study sample comprised 15 893 US adults aged 18 to 64 years who were enrolled in an employer-sponsored health plan. Patients underwent either an open or robotic radical prostatectomy, hysterectomy, partial colectomy, radical nephrectomy, or partial nephrectomy for a solid-organ malignant neoplasm. Statistical analysis was performed from December 18, 2018, to June 5, 2019.

EXPOSURES

Type of surgical procedure-robotic vs open.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was out-of-pocket costs associated with robotic and open surgery. The secondary outcome of interest was associated total payments.

RESULTS

Among 15 893 patients (11 102 men; mean [SD] age, 55.4 [6.6] years), 8260 underwent robotic and 7633 underwent open procedures; patients undergoing robotic hysterectomy were older than those undergoing open hysterectomy (mean [SD] age, 55.7 [6.7] vs 54.6 [7.2] years), and patients undergoing open radical nephrectomy had more comorbidities than those undergoing robotic radical nephrectomy (≥2 comorbidities, 658 of 861 [76.4%] vs 244 of 347 [70.3%]). After adjustment for baseline characteristics, the robotic approach was associated with lower out-of-pocket costs for all procedures: -$137.75 (95% CI, -$240.24 to -$38.63) for radical prostatectomy (P = .006); -$640.63 (95% CI, -$933.62 to -$368.79) for hysterectomy (P < .001); -$1140.54 (95% CI, -$1397.79 to -$896.54) for partial colectomy (P < .001); -$728.32 (95% CI, -$1126.90 to -$366.08) for radical nephrectomy (P < .001); and -$302.74 (95% CI, -$523.14 to -$97.10) for partial nephrectomy (P = .003). The robotic approach was similarly associated with lower adjusted total payments: -$3872.62 (95% CI, -$5385.49 to -$2399.04) for radical prostatectomy (P < .001); -$29 640.69 (95% CI, -$36 243.82 to -$23 465.94) for hysterectomy (P < .001); -$38 151.74 (95% CI, -$46 386.16 to -$30 346.22) for partial colectomy; (P < .001); -$33 394.15 (95% CI, -$42 603.03 to -$24 955.20) for radical nephrectomy (P < .001); and -$9162.52 (95% CI, -$12 728.33 to -$5781.99) for partial nephrectomy (P < .001).

CONCLUSIONS AND RELEVANCE

This study found significant variation in perioperative costs according to surgical technique for both patients (out-of-pocket costs) and payers (total payments); the robotic approach was associated with lower out-of-pocket costs for all studied oncologic procedures.

Incorporating a Detailed Case Log System to Standardize Robotic Colon and Rectal Surgery Resident Training and Performance Evaluation

OBJECTIVE

This study was designed to evaluate a novel case log used as part of a standardized robotic colon and rectal surgery resident training program.

DESIGN

This observational study describes a detailed procedure log developed to standardize training of residents in robotic colorectal surgery. The procedure log tracks resident total case numbers and execution of specific steps of eleven colorectal procedures. Case log data were accumulated and analyzed to assess resident progress.

SETTING/PARTICIPANTS

The study includes colon and rectal surgery residents during the 2016-2017 academic year. The national Colon and Rectal Surgery Robotic Training Program was developed and implemented during the 2010-2011 academic year in response to increasing adoption of robotic-assisted colorectal surgery. This program evolved to include online modules, dry lab exercises, simulation and cadaveric courses.

RESULTS

Forty of 93 residents in 54 colon and rectal surgery programs participated in the case log system and the comprehensive training program. Residents participated as console surgeon in an average of 28 cases (range 1-115). Sixty-five percent of participating residents performed ≥20 complex colorectal cases as console surgeon. Of the 1080 operations entered, the three most frequently performed procedures were low anterior resections (n = 360, 33.3%), sigmoid resections (n = 172, 15.9%), and right colectomies with intracorporeal anastomosis (n = 138, 12.8%). Residents with 10 or more robotic cases had a 27% increase in cases as console surgeon and a 28% decrease in cases completed as bedside assistant. Experience and progression to the console varied by resident and by program.

CONCLUSION

This detailed standardized case log system provides comprehensive assessment of resident experience that allows preparation for a robotic colon and rectal surgery practice after fellowship. As adoption of the robotic approach for colon and rectal cases continues to increase, novel methods that evaluate teaching methods and resident progress warrant further study.

A propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery Pathway

INTRODUCTION

There may be short-term outcomes advantages for the intracorporeal approach to minimally invasive right colectomy.

METHODS

This is a retrospective propensity score-matched comparison of intracorporeal and extracorporeal techniques for robotic-assisted right colectomy in an Enhanced Recovery colorectal surgery service.

RESULTS

55 intracorporeal and 55 extracorporeal cases were compared. Operative time was significantly longer (p < 0.001) and incision length shorter in the intracorporeal group (p = 0.007). Outcomes significantly favorable for the intracorporeal group included conversion-to-open (p = 0.013), time to first flatus (p < 0.001), time to first bowel movement (p = 0.006), and dehydration (p = 0.03). There were more extraction site hernias in the midline compared to off-midline locations, though this difference did not reach statistical significance (p = 0.06).

CONCLUSION

There are outcomes advantages for the intracorporeal technique for robotic-assisted right colectomy when compared to the extracorporeal approach for patients in an Enhanced Recovery Pathway. Training efforts should continue to advocate the intracorporeal option.

Robotic colectomy with intracorporeal anastomosis is feasible with no operative conversions during the learning curve for an experienced laparoscopic surgeon developing a robotics program

The benefits of performing a colectomy robotically instead of laparoscopically have not conclusively been demonstrated. Evaluation of studies is limited by sample size, retrospective design, heterogeneity of operative techniques, sparse adjustment for learning curve, and mixed results. Consequently, adoption of robotic colectomy by surgeons has been expectedly slow. The objectives of the study were to compare the outcomes of robotic colectomy to laparoscopic colectomy for patients with right-sided tumors undergoing a standardized completely intracorporeal operation and to examine the impact of prior experience with laparoscopic right colectomies on the performance of robotic right colectomies. Retrospective review of outcomes of consecutive patients undergoing a robotic right colectomy (robot) compared to those undergoing laparoscopic colectomy (LAP). LAP patients were further subdivided into a group during the learning curve (LC) and after the learning curve (post-LC). Data collected included operative time (OT), conversion to laparotomy, lymph nodes harvested (LN), length of stay (LOS), 30-day morbidity, and mortality. Comparison of continuous and categorical variables was assessed with the independent samples t test and Chi-square test, respectively. Data are expressed as mean ± SD, and significance defined as p < 0.05. 122 patients underwent robot (n = 21), LAP (n = 101), LC (n = 51), or post-LC (n = 50). OT was decreased for post-LC compared to LC (198 vs. 228 min). There were no conversions in robot and five with LAP. Morbidity was similar for robot (14%) compared to LAP (22%), LC (24%), or post-LC cases (20%). Median LOS was similar for robot vs. LAP (3 vs. 5 days). Robot had greater mean LN yield vs. LAP (19 vs. 14, p = 0.02). The initial outcomes with completely intracorporeal colectomy achieved robotically were equivalent to results during or after LC for laparoscopic resection. Proficiency gained with LAP seems to positively impact the initial results with the robot.