The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula

Emergent robot-to-open conversion - Multidisciplinary simulation training in crisis management

Anticipating and addressing unexpected intraoperative events and anatomies are some of the most challenging aspects of pediatric urologic practice; uncontrolled hemorrhage is one of the most anxiety provoking and precarious. The increasing application of the robotic platform in pediatric urology adds another layer of complexity as surgeons are not immediately at the patient's bedside. Should hemorrhage occur in robotic cases, clear communication and seamless coordination between members of the operating room team are paramount to optimize patient safety and minimize errors. This is especially important in pediatric cases for which the margin of error is narrow. Non-technical skills, including leadership, decision-making, situational awareness, stress management, and team-communication, become increasingly critical. While many programs have focused on robotic training, few prepare the operating room team and surgical trainees to manage these unforeseen, emergent intraoperative scenarios. This review discusses the role of a multidisciplinary, in situ robot-to-open conversion simulation program in addressing this educational gap, ways to approach establishing these programs, and potential barriers.

Assessment and application of non-technical skills in robotic-assisted surgery: a systematic review

BACKGROUND

Undeniably, robotic-assisted surgery (RAS) has become very popular in recent decades, but it has introduced challenges to the workflow of the surgical team. Non-technical skills (NTS) have received less emphasis than technical skills in training and assessment. The systematic review aimed to update the evidence on the role of NTS in robotic surgery, specifically focusing on evaluating assessment tools and their utilisation in training and surgical education in robotic surgery.

METHODS

A systematic literature search of PubMed, PsycINFO, MEDLINE, and EMBASE was conducted to identify primary articles on NTS in RAS. Messick's validity framework and the Modified Medical Education Research Study Quality Instrument were utilised to evaluate the quality of the validity evidence of the abstracted articles.

RESULTS

Seventeen studies were eligible for the final analysis. Communication, environmental factors, anticipation and teamwork were key NTS for RAS. Team-related factors such as ambient noise and chatter, inconveniences due to repeated requests during the procedure and constraints due to poor design of the operating room may harm patient safety during RAS. Three novel rater-based scoring systems and one sensor-based method for assessing NTS in RAS were identified. Anticipation by the team to predict and execute the next move before an explicit verbal command improved the surgeon's situational awareness.

CONCLUSION

This systematic review highlighted the paucity of reporting on non-technical skills in robotic surgery with only three bespoke objective assessment tools being identified. Communication, environmental factors, anticipation, and teamwork are the key non-technical skills reported in robotic surgery, and further research is required to investigate their benefits to improve patient safety during robotic surgery.

Clinical Issues - October 2023

Pregnant personnel in the magnetic resonance environment Key words: magnetic resonance (MR), pregnant personnel, zone IV, exposure, scanner. Patients with tattoos in the magnetic resonance environment Key words: tattoo ink, permanent cosmetic tattoo, magnetic resonance (MR), scanning, burns. Robotic procedure emergency preparedness Key words: emergency readiness, conversion to open, robotic surgery, checklists, undocking. Communication during robotic procedures Key words: communication, teamwork, robotic procedures, familiarity, perioperative team.

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

BACKGROUND: Sensor technologies and data collection practices are changing and improving quality metrics across various domains. Surgical skill assessment in Robot-Assisted Minimally Invasive Surgery (RAMIS) is essential for training and quality assurance. The mental workload on the surgeon (such as time criticality, task complexity, distractions) and non-technical surgical skills (including situational awareness, decision making, stress resilience, communication, leadership) may directly influence the clinical outcome of the surgery. METHODS: A literature search in PubMed, Scopus and PsycNet databases was conducted for relevant scientific publications. The standard PRISMA method was followed to filter the search results, including non-technical skill assessment and mental/cognitive load and workload estimation in RAMIS. Publications related to traditional manual Minimally Invasive Surgery were excluded, and also the usability studies on the surgical tools were not assessed. RESULTS: 50 relevant publications were identified for non-technical skill assessment and mental load and workload estimation in the domain of RAMIS. The identified assessment techniques ranged from self-rating questionnaires and expert ratings to autonomous techniques, citing their most important benefits and disadvantages. CONCLUSIONS: Despite the systematic research, only a limited number of articles was found, indicating that non-technical skill and mental load assessment in RAMIS is not a well-studied area. Workload assessment and soft skill measurement do not constitute part of the regular clinical training and practice yet. Meanwhile, the importance of the research domain is clear based on the publicly available surgical error statistics. Questionnaires and expert-rating techniques are widely employed in traditional surgical skill assessment; nevertheless, recent technological development in sensors and Internet of Things-type devices show that skill assessment approaches in RAMIS can be much more profound employing automated solutions. Measurements and especially big data type analysis may introduce more objectivity and transparency to this critical domain as well. SIGNIFICANCE: Non-technical skill assessment and mental load evaluation in Robot-Assisted Minimally Invasive Surgery is not a well-studied area yet; while the importance of this domain from the clinical outcome's point of view is clearly indicated by the available surgical error statistics.

Work-system interventions in robotic-assisted surgery: a systematic review exploring the gap between challenges and solutions

BACKGROUND

The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers.

METHODS

A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion.

RESULTS

A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign.

CONCLUSION

The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

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.

Nursing performance in robotic surgeries: integrative review

OBJECTIVE

To know the scientific production on the performance of the nursing staff in robotic surgeries, identifying the role of the nurse in the three perioperative periods.

METHODS

Integrative review, search in the databases National Library of Medicine, National Institutes of Health, Scientific Electronic Library Online and Biblioteca Virtual em Saúde, performed from June to September, 2017; 17 selected articles met the inclusion criteria.

RESULTS

Most articles were published in foreign journals in English, nine in the United States, classified with evidence level of 4 and 5. The role of nursing in the perioperative period was identified, related mainly to patient safety. The most mentioned perioperative period in the articles was the intraoperative, with greater concern in the positioning of the patient.

CONCLUSION

The nursing performance and patient safety in robotic surgeries are similar to the ones in major surgeries, requiring from the patient a specific knowledge on the setting and preparation of the robot.

Understanding and Assessing Nontechnical Skills in Robotic Urological Surgery: A Systematic Review and Synthesis of the Validity Evidence

OBJECTIVE

Robotic urological surgery (RUS) has seen widespread adoption across institutions in the last decade. To match this rapid growth, it is imperative to develop a structured RUS curriculum that addresses both technical and nontechnical competencies. Emerging evidence has shown that nontechnical skills form a critical component of RUS training. The purpose of this review is to examine the validity evidence of available nontechnical skills assessment tools in RUS.

METHODS

A literature search of MEDLINE, EMBASE, and PsycINFO was conducted to identify primary articles using nontechnical skills assessment tools in RUS. Messick's validity framework and the Medical Education Research Study Quality Instrument were utilized to evaluate the quality of the validity evidence of the abstracted articles.

RESULTS

Of the 566 articles identified, 12 used nontechnical skills assessment tools in RUS. The metrics used ranged from self-assessment using global rating scales, to objective measures such as electroencephalography. The setting of these evaluations ranged from immersive and virtual reality-based simulators to live surgery.

CONCLUSIONS

Limited effort has been made to develop nontechnical skills assessment tools in RUS. Recently, there has been a shift from subjective to objective measures of nontechnical performance, as well as the development of assessments specific to RUS. However, the validity evidence supporting these nontechnical assessments is limited at this time, including their relationship to technical skills, and their impact on surgical outcomes.

How can the presence of a surgical care practitioner improve training for staff who are learning how to scrub for robotics cases in a urology theatre?

AIM

This study examines how a surgical care practitioner can contribute to the learning needs of junior scrub staff learning to scrub for urological robotics cases. Key themes include education, technical training, non-technical skills, patient safety and the specialist practitioner as educator.

METHODS

Data collection was via an online survey, distributed by a gatekeeper to 13 participants. These were junior scrub practitioners who had completed their robotic rotation.

RESULTS

A 62% response rate was achieved. The majority of respondents indicated that there was a difference in interactions when a surgical care practitioner was assisting compared to a surgical trainee. Half of the respondents felt more confident when the surgical care practitioner was assisting.

CONCLUSIONS

A range of approaches were proposed for how the surgical care practitioner could enhance learning. Structured input is likely to be more appropriate to avoid the surgical care practitioner being distracted from their own duties whilst assisting. There is scope for further research.

Getting ready for the first robotic prostatectomy, from basics to real practice

PURPOSE OF REVIEW

Robot-assisted radical prostatectomy (RARP) has been embraced by urologists and has become a treatment standard in many countries already. Learning how to perform a RARP is challenging and has not yet been standardized. The current review summarizes the latest concepts regarding the most effective way of training for RARP.

RECENT FINDINGS

The strategy to learn RARP should comprise didactic activities, skills lab training, participating in surgeries and mentorship. Skills lab and virtual simulators are valuable tools to develop manual abilities and to overcome the initial technical learning curve. Participating in surgeries is crucial for familiarization with the robot installation, steps of the surgical procedure and is essential for troubleshooting. Mentorship improves learning and is the safest way to initiate real practice. Innate and individual background variances were suggested to influence the learning process; however, there is paucity of robust evidence correlating previous surgical experience and, for example videogame playing with faster learning of RARP. Structured curricula were proposed to orient the training for robotic surgery; currently, only one is focused exclusively on urology.

SUMMARY

Systematic training is the most effective way to learn and surpass the possibly intense learning curve of RARP. Training activities should focus on developing cognitive and manual abilities. The existing curricula for robotic surgery training still require constant refinement; however, they offer good and structured guidance to train for RARP.

Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies

OBJECTIVE

To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group.

RESULTS

Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R² = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R² = 0.7 and group 2, R² = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1.

CONCLUSION

OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

[The robotic surgeon training]

The widespread robotic surgery in the world highlighted the relevance of the training programs for young urologists and residents. In the last years, urologic societies and some independent robotic surgeons strongly worked to standardize some general and specific training modules. Theoretical and practical sections of robotic training programs have been recently specified. The role of simulators, dry and wet laboratories, bedside assistance, and modular (step-by-step) training at console represent the most relevant elements of robotic surgeon training. Ideally, these didactic tools should be available in modern training centers. The development of structured robotic training programs should be considered as one of the priorities that the urologic community must take into account in the near future.