Robotic General Surgery Resident Training Curriculum: A Pilot Experience

Learning Curve of a Robotic Bio-Tissue Intestinal Anastomosis: Implications for Surgical Training Curricula

OBJECTIVE

The integration of robotic surgical training in a time-scarce residency program is a challenge for surgical educators. Simulation-based training is a tool that allows residents to acquire the necessary robotic skills without compromising patient safety. This study aimed to assess the learning curve of a robotic inanimate intestinal anastomosis drill.

DESIGN

Two trained graders performed a video-based assessment of each attempt of a side-to-side intestinal anastomosis drill using the Objective Structured Assessment of Technical Skill (OSATS) scale. Residents who achieved a passing score of 28 were included in the study. We assessed the number of attempts required to achieve a passing score and evaluated technical performance on different OSATS domains. Data were analyzed using independent t-test, 1-way ANOVA, and binary logistic regression.

SETTING

The University of Texas Southwestern PARTICIPANTS: 33 residents across 4 academic years RESULTS: Thirty-three residents performed 139 attempts with a mean of 4.2 ± 2 attempts per resident. On average, 3.3 attempts were required to achieve a passing score. Average OSATS score increased from 21.7 to 27.2 between the 1st and the 4th attempt, respectively (p < 0.001). Of the OSATS subcategories, time and motion showed the greatest score improvement of 1.5 on a 5-point Likert scale, 95% CI [0.82, 2.18] (p < 0.001). Despite varying baseline OSATS scores between residents on initial assessment, there was no significant difference in the final attempt score. On the initial attempt, a lower score and failure to finish were associated with greater odds of requiring 5 or more attempts to pass the drill.

CONCLUSION

All OSATS metrics improved on an intestinal anastomosis drill after simulation training. A maximum of 6 attempts were required to achieve a passing score. Initial performance strongly predicts the number of attempts required to achieve a passing score. This feasible and effective drill provides trainees with robotic intestinal anastomosis training.

Fellow perceptions of robotic surgery preparedness for fellowship

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The training pathway for residents: 'Robotic Curriculum for young Surgeons' (RoCS) does not impair patient outcome during implementation into clinical routine

The "Robotic Curriculum for young Surgeons" (RoCS) was launched 03/2020 to address the increasing importance of robotics in surgical training. It aims to provide residents with foundational robotic skills by involving them early in their training. This study evaluated the impact of RoCS' integration into clinical routine on patient outcomes. Two cohorts were compared regarding the implementation of RoCS: Cohort 1 (before RoCS) included all robot-assisted procedures between 2017 and 03/2020 (n = 174 adults) retrospectively; Cohort 2 (after RoCS) included all adults (n = 177) who underwent robotic procedures between 03/2020 and 2021 prospectively. Statistical analysis covered demographics, perioperative parameters, and follow-up data, including mortality and morbidity. Subgroup analysis for both cohorts was organ-related (upper gastrointestinal tract (UGI), colorectal (CR), hepatopancreaticobiliary system (HPB)). Sixteen procedures were excluded due to heterogeneity. In-hospital, 30-, 90-day morbidity and mortality showed no significant differences between both cohorts, including organ-related subgroups. For UGI, no significant intraoperative parameter changes were observed. Surgery duration decreased significantly in CR and HPB procedures (p = 0.018 and p < 0.001). Estimated blood loss significantly decreased for CR operations (p = 0.001). The conversion rate decreased for HPB operations (p = 0.005). Length of hospitalization decreased for CR (p = 0.015) and HPB (p = 0.006) procedures. Oncologic quality, measured by histopathologic R0-resections, showed no significant changes. RoCS can be safely integrated into clinical practice without compromising patient safety or oncologic quality. It serves as an effective training pathway to guide robotic novices through their first steps in robotic surgery, offering promising potential for skill acquisition and career advancement.

How to integrate robotic training in surgical residency? An example of a 2-week robotic rotation

General surgery residents should be proficiently trained in robotic surgery. However, there is currently no standardized robotic training curriculum. We aimed to evaluate two approaches to a robotic curriculum and how implementing a virtual reality (VR) simulation curriculum improves trainee robotic performance. From 2019 to 2022, two models of a robotic training curriculum were examined: an in-unit rotation (IUR) and a 2-week curriculum (2WR). The VR curriculum was completed using the da Vinci® Skill Simulator. The curriculum used a pre/post-test design. Residents completed a pre-test that consisted of 4 VR exercises (graded 0-100%) and 3 inanimate box trainer exercises (graded using modified Objective Structured Assessment of Technical Skills). Then, residents completed a VR curriculum of 23 modules. Following the curriculum, residents were given a post-test with the same pre-test exercises. Time necessary to complete the curriculum and compliance were recorded. Of the 11 residents who participated in the IUR, 4 completed the VR curriculum. Comparatively, 100% (n = 23) of residents in the 2WR completed the curriculum. Average time to complete the VR curriculum was 3.8 h. After completion of the 2WR curriculum, resident performance improved from pre-test to post-test: VR test scores increased (160% vs 223%, p < 0.001), OSATS scores increased (15.0 vs 21.0, p < 0.001), and time to complete inanimate exercises decreased (1083 vs 756 s, p = 0.001). Residents who mastered all modules had higher post-test VR scores (241% vs 214%, p = 0.024). General surgery residents demonstrated improved compliance with the 2WR. The VR curriculum improved resident robotic performance in both virtual and inanimate domains.

Survey shows all surgical residents have exposure to robotic surgery yet no formalized curricula exist amongst programs: A Southwest Surgical Congress Survey

BACKGROUND

Increased robotic surgery exposure during general surgery training occurs at many institutions without a formal education curriculum. Our study evaluates the current state of general surgery robotic training within programs represented by the Southwestern Surgical Congress (SWSC).

METHODS

A web-based survey regarding robot-assisted surgery (RAS) and general surgery training was developed and sent to member institutions of the SWSC. General surgery program directors were asked to voluntarily complete the survey. Results were evaluated in aggregate. Descriptive analysis was used.

RESULTS

In total, 28 programs responded. All reported resident exposure to RAS during training. Case mix was diverse with exposure to multiple general surgical subspecialties. 89% of programs reported the presence of a formal RAS curriculum, however, only 53% reported recognition of training completion. Case volumes also varied amongst programs with 46% of programs reporting residents logging 21-40 cases and 35% logging more than 40 cases in total.

CONCLUSION

Exposure to RAS among SWSC residency programs is ubiquitous, however, there is significant variation between programs in case volumes, case types, and elements of RAS curricula.

A systematic review of general surgery robotic training curriculums

Background

As of the most recent surveys of resident programs in 2018, only slightly more than half of programs have formal robotic training curriculums implemented. Fewer programs have further assessed their own curriculum and its benefit.

Method

We conducted a PubMed/MEDLINE literature search for robotic surgery curriculums and those that had assessment of their programs.

Results

A total of 11 studies were reviewed. When reviewed in chronological order, there has been a progression towards more robotic specific objective data analysis as opposed to subjective surveying. There is a wide variation in curriculums, but simulation use is pervasive.

Conclusions

Our review makes evident two important concepts-there is great variety in training curriculums and there is great benefit in implementation. The importance is in establishment of what makes resident training effective and supports the adaptable and successful surgeon. This may come from an adaptable curriculum but a structured test-out assessment.

Residents perform better technically, have less stress and workload, and prefer robotic to laparoscopic technique during inanimate simulation

INTRODUCTION

With the widespread adoption of minimally invasive surgery, there is a growing need for surgical residents to be trained by a procedure-specific curriculum. This study aimed to evaluate the technical performance and feedback of surgical residents undergoing the robotic and laparoscopic hepaticojejunostomy (HJ) and gastrojejunostomy (GJ) biotissue modules.

METHODS

A total of 23 PGY-3 surgical residents participated in this study and performed the laparoscopic and robotic HJ and GJ drills, which were recorded and scored by two independent graders using the modified objective structured assessment of technical skills (OSATS). After completing each drill, all participants filled out the NASA Task Load Index (NASA-TLX), Borg Exertion Scale, and Edwards Arousal Rating Questionnaire.

RESULTS

Twenty-two (95.7%) residents had already received fundamentals of laparoscopic surgery certification. Eighteen (78.3%) residents had robotic virtual simulation training and the median (range) number of robotic surgery console experience was 4 (0-30). In the HJ comparison of the six OSATS domains, the robotic system was superior in Gentleness (p = 0.031). In the GJ comparison, the robotic system was superior in Time and Motion (p < 0.001), Instrument Handling (p = 0.001), Flow of Operation (p = 0.002), Tissue Exposure (p = 0.013), and Summary (p < 0.001). Participants answered significantly higher demand scores for laparoscopy on all six facets of NASA-TLX for both HJ and GJ (p < 0.05). The Borg Level of Exertion was > 2 points higher for laparoscopic HJ and GJ (p < 0.001). Residents rated more Nervousness and Anxiety for laparoscopic compared to robotic (p < 0.05) HJ and GJ. Additionally, when asked to score preference for robotic and laparoscopic approach in terms of technique and ergonomics, residents scored robot as better (laparoscopy worse) for both HJ and GJ in both domains.

CONCLUSIONS

The robotic surgical system provided a more favorable environment for trainees with less mental and physical burden for minimally invasive HJ and GJ curriculum.

Is there a need for a technical certification system for gynecological robotic surgery? Questionnaire survey of members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy

The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) introduced a system for the certification of laparoscopic surgeons in 2002 and a system for the certification of facilities in 2014. We examined the opinions of the members of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE) regarding the necessity of a certification training system and a technical certification system for robotic surgery skills in Japan. Members of the JSGOE were surveyed with two questionnaires. Overall, 870 and 519 participants responded to the first and second questionnaires, respectively. Half of the respondents indicated that both systems were necessary. The breakdown by age and qualifications showed that this was especially true for the younger generation and respondents with more experience with robotic surgery. Overall, 40% of the respondents judged that a certification system for robotic surgery alone (with or without certification in laparoscopic surgery but with a requirement of experience in laparoscopic surgery) would be necessary. The opinions of the JSGOE members on making a certification system for robotic surgery were split into two clear-cut camps. Thus, we must further seek the extent of public demand for using a public survey so that a final decision can be made on whether to establish this system.

A systematic review of robotic surgery curricula using a contemporary educational framework

BACKGROUND

There has been a rising trend in robotic surgery. Thus, there is demand for a robotic surgery curriculum (RSC) for training surgical trainees and practicing surgeons. There are limited data available about current curricular designs and the extent to which they have incorporated educational frameworks. Our aim was to study the existing robotic surgery curricula using Kern's 6-step approach in curriculum development.

METHODS

A systematic review was conducted using PubMed, PubMed Central, Cochrane, Embase, and Scopus (we searched studies from 2001 to 2021). PRISMA Guidelines was used to guide the search. Curriculum designed for general surgery and its subspecialties were included. Urology and gynecology were excluded. The articles were reviewed by five reviewers.

RESULTS

Our review yielded 71 articles, including 39 curricula at 9 different settings. Using Kern's framework, we demonstrated that the majority of robotic surgery curricula contained all the elements of Kern's curricular design. However, there were significant deficiencies in important aspects of these curricula i.e., implementation, the quality of assessment tools for measurement of performance and evaluation of the educational value of these interventions. Most institutions used commercial virtual reality simulators (VRS) as the main component of their RSC and 23% of curricula only used VRS.

CONCLUSIONS

Although majority of these studies contained all the elements of Kern's framework, there are critical deficiencies in the components of existing curricula. Future curricula should be designed using established educational frameworks to improve the quality of robotic surgery training.

The value of surgical admissions for malignant uterine cancer. A comparative analysis of robotic, laparoscopic, and laparotomy surgery in a university hospital

Background

Robotic surgery for malignant uterine cancer raises issue of economic sustainability for providers. The objective of this study was to assess the value of surgical admissions for malignant uterine cancer in a University Hospital through an analysis of their costs and outcomes by comparing three different surgical approaches (laparotomy, laparoscopic, and robotic surgery).

Methods

Hospitalizations between 1 January 2019 and 31 October 2021 for malignant uterine cancer surgery were selected and stratified. For each surgical approach, mean values (with 95% confidence intervals, CI) were calculated for cost items. Moreover, 30-day readmission frequency was calculated for the three approaches compared to each other. ANOVA and Student's t-test and relative risk (RR) were used for statistical analysis. A break-even analysis was carried out by evaluating the volume of robotic and non-robotic surgical admissions.

Results

A total of 1,336 hospitalizations were included in the study, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery, compared to laparoscopic and laparotomy ones, showed a statistically significant difference (p < 0.001) in the economic margin, which was largely negative (-1069.18 €; 95%CI:-1240.44--897.92 €) mainly due to devices cost, and a lower percentage of 30-day readmissions (1.4%; 95%CI: 0.2-2.6%), with a statistically significant difference only vs. laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p < 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 €-1852.66 €) without a significant difference for 30-day readmissions. Break-even analysis showed that, on average, for each malignant uterine cancer elective surgery performed laparoscopically, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23-2.06).

Conclusion

Break-even analysis could be a useful tool to support hospital management in planning and governance of malignant uterine cancer surgery. Systematic application of this tool will allow defining over time right distribution of robotic, laparoscopic, and laparotomy surgeries' volumes to perform to ensure both quality and economic-financial balance and therefore value of uterine oncological surgery. Concerning research, this study paves the way for a multicentric study, the extension of outcomes of malignant uterine surgery to be considered and assessed, and the future inclusion of other therapeutic interventions in the analysis.

RoCS: Robotic Curriculum for young Surgeons

Robotic-assisted procedures gain increasing acceptance for daily surgical routine. However, structured training programs are designed for surgeons with high expertise. Hence, a comprehensive training curriculum was established to ensure a basic competence in robotic abdominal surgery for young surgeons during their residency. The aim of the current work is to propose a feasible and effective training concept. The development process of this training curriculum is based on a comprehensive literature review which led to the concept of "robotic curriculum for young surgeons" (RoCS). It was implemented in the daily routine of a German university hospital starting in 2020. The robotic assessment questionnaire (RAQ) was used for electronic data collection. After the initial phase adjustments, it led to an improvement of the initial version of the curriculum. RoCS is a multimodal training program containing basic training through assistance at the operation table during robotic-assisted operations and basic console training. Key elements are the robotic team time-out (rTTO), perioperative process standardization including feasible personnel scheduling and useful procedure clustering into organ systems, procedural steps and procedural step complexity. Evaluation of standardized communication, performance assessment, patient factors and individual overall workload using NASA Task Load Index is realizable. Flexibility and adaptability to internal organization processes of surgical departments are the main advantages of the concept. RoCS is a strong training tool to meet the specific needs of young surgeons and evaluate their learning success of robotic procedural training. Furthermore, comparison within the different robotic systems should be considered. Further studies are needed to validate a multicenter concept design.