Robotic surgery basic skills training: Evaluation of a pilot multidisciplinary simulation-based curriculum

Development and evaluation of a societal core robotic surgery accreditation curriculum for the UK

Standardised proficiency-based progression is the cornerstone of safe robotic skills acquisition, however, is currently lacking within surgical training curricula. Expert consensuses have defined a modular pathway to accredit surgeons. This study aimed to address the lack of a formal, pre-clinical core robotic skills, proficiency-based accreditation curriculum in the UK. Novice robotic participants underwent a four-day pre-clinical core robotic skills curriculum incorporating multimodal assessment. Modifiable-Global Evaluative Assessment of Robotic Skills (M-GEARS), VR-automated performance metrics (APMs) and Objective Clinical Human Reliability Analysis (OCHRA) error methodology assessed performance at the beginning and end of training. Messick's validity concept and a curriculum evaluation model were utilised. Feedback was collated. Proficiency-based progression, benchmarking, tool validity and reliability was assessed through comparative and correlational statistical methods. Forty-seven participants were recruited. Objective assessment of VR and dry models across M-GEARS, APMs and OCHRA demonstrated significant improvements in technical skill (p < 0.001). Concurrent validity between assessment tools demonstrated strong correlation in dry and VR tasks (r = 0.64-0.92, p < 0.001). OCHRA Inter-rater reliability was excellent (r = 0.93, p < 0.001 and 81% matched error events). A benchmark was established with M-GEARS and for the curriculum at 80%. Thirty (63.82%) participants passed. Feedback was 5/5 stars on average, with 100% recommendation. Curriculum evaluation fulfilled all five domains of Messick's validity. Core robotic surgical skills training can be objectively evaluated and benchmarked to provide accreditation in basic robotic skills. A strategy is necessary to enrol standardised curricula into national surgical training at an early stage to ensure patient safety.

Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review

BACKGROUND

There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula.

METHODS

A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.

RESULTS

Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.

CONCLUSIONS

Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.

Intentional enterotomies: validation of a novel robotic surgery training exercise

While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick's validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13 h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4 min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.

Artificial Intelligence in Surgical Training for Kidney Cancer: A Systematic Review of the Literature

The prevalence of renal cell carcinoma (RCC) is increasing due to advanced imaging techniques. Surgical resection is the standard treatment, involving complex radical and partial nephrectomy procedures that demand extensive training and planning. Furthermore, artificial intelligence (AI) can potentially aid the training process in the field of kidney cancer. This review explores how artificial intelligence (AI) can create a framework for kidney cancer surgery to address training difficulties. Following PRISMA 2020 criteria, an exhaustive search of PubMed and SCOPUS databases was conducted without any filters or restrictions. Inclusion criteria encompassed original English articles focusing on AI's role in kidney cancer surgical training. On the other hand, all non-original articles and articles published in any language other than English were excluded. Two independent reviewers assessed the articles, with a third party settling any disagreement. Study specifics, AI tools, methodologies, endpoints, and outcomes were extracted by the same authors. The Oxford Center for Evidence-Based Medicine's evidence levels were employed to assess the studies. Out of 468 identified records, 14 eligible studies were selected. Potential AI applications in kidney cancer surgical training include analyzing surgical workflow, annotating instruments, identifying tissues, and 3D reconstruction. AI is capable of appraising surgical skills, including the identification of procedural steps and instrument tracking. While AI and augmented reality (AR) enhance training, challenges persist in real-time tracking and registration. The utilization of AI-driven 3D reconstruction proves beneficial for intraoperative guidance and preoperative preparation. Artificial intelligence (AI) shows potential for advancing surgical training by providing unbiased evaluations, personalized feedback, and enhanced learning processes. Yet challenges such as consistent metric measurement, ethical concerns, and data privacy must be addressed. The integration of AI into kidney cancer surgical training offers solutions to training difficulties and a boost to surgical education. However, to fully harness its potential, additional studies are imperative.

Robotic Plastic Surgery Education: Developing a Robotic Surgery Training Program Specific to Plastic Surgery Trainees

Over the past two decades, the surgical community has increasingly embraced robotic-assisted surgery (RAS) due to its potential to enhance accuracy and decrease surgical morbidity. Plastic surgery as a field has been historically slow to incorporate RAS, with lack of adequate training posing as one of the most commonly cited barriers. To date, robot technology has been utilized for various reconstructive procedures including flap elevation and inset, pedicle dissection, and microvascular anastomosis. As RAS continues to integrate within plastic surgery procedures, the need for a structured RAS curriculum designed for plastic surgery trainees is rising. This article delineates the essential components of a plastic surgery-specific RAS curriculum and outlines current training models and assessment tools utilized across surgical subspecialties to date.

Feasibility, effectiveness and transferability of a novel mastery-based virtual reality robotic training platform for general surgery residents

Background

The annual number of robotic surgical procedures is on the rise. Robotic surgery requires unique skills compared to other surgical approaches. Simulation allows basic robot skill acquisition and enhances patient safety. The purpose of this study was to evaluate the feasibility, effectiveness, and transferability of a mastery-based curriculum using a new virtual reality (VR) robotic simulator for surgery resident training.

Methods

Nineteen PGY2s and 22 PGY4s were enrolled. Residents completed a pretest and posttest consisting of five VR and three previously validated inanimate tasks. Training included practicing 33 VR tasks until a total score ≥ 90% (“mastery”) was achieved using automated metrics (time, economy of motion). Inanimate performance was evaluated by two trained, blinded raters using video review metrics (time, errors, and modified OSATS). Outcomes were defined as: curriculum feasibility (completion rate, training time, repetitions), training effectiveness (pre/post training skill improvement), and skill transferability (skill transfer to validated inanimate drills). Wilcoxon signed-rank and Mann–Whitney U tests were used; median (IQR) reported.

Results

Thirty-four of 41 residents (83%) achieved mastery on all 33 VR tasks; median training time was 7 h (IQR: 5′26″–8′52″). Pretest vs. post-test performance improved (all p < 0.001) according to all VR and Inanimate metrics for both PGY2 and PGY4 residents. Significant pretest performance differences were observed between PGY2 and PGY4 residents for VR but not inanimate tasks; no PGY2 vs. PGY4 posttest performance differences were observed for both VR and inanimate tasks.

Conclusion

This mastery-based VR curriculum was associated with a high completion rate and excellent feasibility. Significant performance improvements were noted for both the VR and inanimate tasks, supporting training effectiveness and skill transferability. Additional studies examining validity evidence may help further refine this curriculum.

A review of robotic surgical training: establishing a curriculum and credentialing process in ophthalmology

Ophthalmic surgery requires a highly dexterous and precise surgical approach to work within the small confines of the eye, and the use of robotics offers numerous potential advantages to current surgical techniques. However, there is a lag in the development of a comprehensive training and credentialing system for robotic eye surgery, and certification of robotic skills proficiency relies heavily on industry leadership. We conducted a literature review on the curricular elements of established robotics training programs as well as privileging guidelines from various institutions to outline key components in training and credentialing robotic surgeons for ophthalmic surgeries. Based on our literature review and informal discussions between the authors and other robotic ophthalmic experts, we recommend that the overall training framework for robotic ophthalmic trainees proceeds in a stepwise, competency-based manner from didactic learning, to simulation exercises, to finally operative experiences. Nontechnical skills such as device troubleshooting and interprofessional teamwork should also be formally taught and evaluated. In addition, we have developed an assessment tool based on validated global rating scales for surgical skills that may be used to monitor the progress of trainees. Finally, we propose a graduating model for granting privileges to robotic surgeons. Further work will need to be undertaken to assess the feasibility, efficacy and integrity of the training curriculum and credentialing practices for robotic ophthalmic surgery.

An analysis of the cost of postgraduate training in surgery in Ireland compared to other specialties

Introduction

Postgraduate specialty training in Ireland is associated with considerable cost. Some of these are mandatory costs such as medical council fees, while others are necessary to ensure career progression, such as attendance at courses and conferences. In particular, surgical specialities are believed to be associated with high training costs. It is unknown how these costs compare to those borne by counterparts in other specialities.

Aims

The aims of this study were to

Quantify the amount that trainees in Ireland spend on postgraduate training

Determine whether a difference exists between surgery and other non-skill-based specialties in terms of expenditure on training

Methods

A standardised non-mandatory questionnaire was circulated to trainees across two training centres in Ireland. Trainees at all levels were invited to participate.

Results

Sixty responses were obtained. Fifty-seven questionnaires were fully completed and included for analysis. The median expenditure on training was higher for surgical than non-surgical specialities. Subgroup analysis revealed surgical training was associated with higher expenditure on higher degrees and courses compared to medical training (p = 0.035). > 95% of trainees surveyed felt that greater financial support should be available for trainees during the course of their training.

Conclusions

This study demonstrated that a career in surgery is associated with higher ongoing costs for higher degrees and courses than counterparts in non-surgical training. All surgical trainees surveyed felt that better financial support should be available. Increasing financial support for may be a tangible way to mitigate against attrition during training.

Assessing the learning curve associated with a novel flexible robot in the pre-clinical and clinical setting

Background

Transoral robotic surgery has been successfully used by head and neck surgeons for a variety of procedures but is limited by rigid instrumentation and line-of-sight visualization. Non-linear systems specifically designed for the aerodigestive tract are needed. Ease of use of these new systems in both training and clinical environments is critical in its widespread adoption.

Methods

Residents, fellows, and junior faculty performed four tasks on an anatomical airway mannequin using the Medrobotics FLEX™ Robotic System: expose and incise the tonsil, grasp the epiglottis, palpate the vocal processes, and grasp the interarytenoid space. These tasks were performed once a day for four days; after a 4-month time gap, subjects were asked to perform these same tasks for three more days. Time to task completion and total distance driven were tracked. In addition, a retrospective analysis was performed analyzing one attending physician’s experience with clinical usage of the robot.

Results

13 subjects completed the initial round of the mannequin simulation and 8 subjects completed the additional testing 4 months later. Subjects rapidly improved their speed and efficiency at task completion. Junior residents were slower in most tasks initially compared to senior trainees but quickly reached similar levels of efficiency. Following the break there was minimal degradation in skills and continued improvement in efficiency was observed with additional trials. There was significant heterogeneity in the analyzed clinical cases, but when analyzing cases of similar complexity and pathology, clear decreases in overall operative times were demonstrable.

Conclusion

Novice users quickly gained proficiency with the FLEX™ Robotic System in a training environment, and these skills are retained after several months. This learning could translate to the clinical setting if a proper training regimen is developed. The Medrobotics FLEX™ Robotic System shows promise as a surgical tool in head and neck surgery in this study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08445-7.

A Novel Transvaginal Cervical Cerclage Model for Resident Training

INTRODUCTION

Vaginal suturing can be challenging to teach and learn due to the surgical assistant's limited operative field visualization. Data on resident training and comfort with cerclage placement using models are limited. The aim of this activity was to assess learner satisfaction with practice using a novel model allowing for full visualization during transvaginal cervical cerclage placement.

METHODS

OB/GYN residents participated in a 1-hour combined lecture and hands-on cerclage training simulation with the novel model. Pre- and postsession survey responses were assessed with descriptive statistics and paired t tests.

RESULTS

Twenty residents with a median of 2 (SD = 1.6) years of residency experience participated. Ninety-five percent reported no prior cerclage simulation training; 60% reported placing cerclages in practice. Pre- and posttest analysis indicated a significant decrease in perceived need for further training (M = 4.05, SD = 1.07, vs. M = 3.45, SD = 0.86; p = .024) and an increase in comfort performing a cerclage placement (M = 2.55, SD = 1.16, vs. M = 3.85, SD = 0.79; p < .001). After the simulation, residents reported more comfort in cerclage placement with decreasing supervision (M = 2.05, SD = 1.02, vs. M = 2.30, SD = 1.01; p = .021); 90% reported that learning to place a cerclage was easy.

DISCUSSION

Implementing a novel, low-cost model allowing full operative field visualization significantly improved reported comfort regarding cervical cerclage placement and resulted in high satisfaction amongst residents. Future research should evaluate the training's impact on clinical skills.

Is robot-assisted retroperitoneal adrenalectomy safe? An investigation of perioperative hypertensive crisis among hypertensive and normotensive patients

BACKGROUND

Objective: We examined the incidence of perioperative hypertensive crisis in robot-assisted retroperitoneal laparoscopic adrenalectomy.

METHODS

A consecutive series of 120 patients with adrenal tumours undergoing robot-assisted retroperitoneal laparoscopic adrenalectomy were included. Patients were divided into two groups: group A (hypertension group, 58 cases, mean age 43.59 years) and group B (normotension group, 62 cases, mean age 48.01 years). General anaesthesia was applied using endotracheal intubation and haemodynamic changes were closely monitored.

RESULTS

A total of nine (7.5%) hypertensive crisis cases were observed. After intravenous infusion of sodium nitroprusside, seven cases of them were quickly controlled and two cases experienced transient severe hypertension. The incidence of hypertensive crisis was 13.7% and 1.6% in groups A and B, respectively (p < 0.05).

CONCLUSION

These findings highlight the importance of strengthening the monitoring of anaesthesia and taking various measures to effectively control the blood pressure in robot-assisted retroperitoneal laparoscopic adrenalectomy, especially among hypertensive patients.

Training in robot-assisted surgery

PURPOSE OF REVIEW

The aim of this narrative review is to identify the currently available training programs in the field of robotic-assisted surgery.

RECENT FINDINGS

The lack of well trained robotic surgeons represents the main obstacle facing robotic surgery. This calls for development of structured robotic training programs in order to improve patient safety and outcomes. Structured curriculum should consist of theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and final evaluation. Tele-mentoring might reveal mandatory in future curricula development. To date, several training programs are currently available for robotic surgery. However, the majority lack of clinical modular training that consists of progressive, proficiency-based training through surgical steps with increasing levels of complexity. Moreover, many of these curricula lack validation.

SUMMARY

This recent literature analysis suggests that there is an urgent need to develop and validate new structured training curricula for robotic surgery. This allows to improve the skills of the surgeons and of their team and to prevent patients from being used as a training module optimizing their safety.

Are basic robotic surgical skills transferable from the simulator to the operating room? A randomized, prospective, educational study

INTRODUCTION

We aimed to assess the transferability of basic robotic skills from the simulator to the operating room (OR) while performing robotic-assisted radical prostatectomy (RARP).

METHODS

Fourteen urology residents were randomized into two groups: group A was required to practice three sessions (nine tasks each) on the simulator, whereas group B was required to practice (same nine tasks) until they reached competency. Both groups were recorded while practicing on the da Vinci Surgical Skills Simulator. Both groups were then recorded while performing bladder mobilization during RARP. Senior residents from both groups were also recorded while performing urethro-vesical anastomosis during RARP. Recordings were assessed blindly using the validated Global Evaluative Assessment of Robotic Skills (GEARS) tool by C-SATS. Spearman's correlation coefficient (rho) was used to assess correlation between GEARS scores from practice sessions on the da Vinci Simulator and the GEARS scores from bladder mobilization and urethro-vesical anastomosis during RARP.

RESULTS

There was no difference in total GEARS scores between the two groups in the OR. Total GEARS scores for "ring and rail 2" and "suture sponge" tasks correlated with the total GEARS scores during urethro-vesical anastomosis (rho=0.86, p=0.007; rho=0.90, p=0.002, respectively). GEARS' efficiency component during "energy and dissection" task on the da Vinci Simulator correlated with GEARS' efficiency component during bladder mobilization (rho=0.62, p=0.03). GEARS' force sensitivity component during "ring and rail 2" and "dots and needles" tasks on the da Vinci Simulator correlated with GEARS' force sensitivity component during bladder mobilization (rho=0.58, p=0.047; rho =0.65, p=0.02, respectively).

CONCLUSIONS

Objective assessments of urology residents on the da Vinci Surgical Skills Simulator tasks ring and rail 2 and suture sponge correlated with their objective assessments of bladder mobilization and urethro-vesical anastomosis. Therefore, basic robotic skills could be transferred from the simulator to the OR.

The safety of urologic robotic surgery depends on the skills of the surgeon

PURPOSE

To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

METHODS

A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

RESULTS

Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

CONCLUSION

To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.

Impact and Outcomes of a Pediatric Robotic Urology Mini-Fellowship

Introduction: In order to support practicing pediatric surgeons and urologists to safely and effectively incorporate robotic surgery into their practice, we established a 5-day mini-fellowship program with a mentor, preceptor and proctor at our institution. This study was designed to report our experience with the pediatric robotic mini-fellowship (PRM) and to evaluate the impact this course had on the participants' practice.

Methods: The mini-fellowship training at our institution is provided in two modules, including upper and lower urinary tract surgery, over a 5-day period. The one to one teacher-to-attendee experience included tutorial sessions, hands-on inanimate, and animate skills training, clinical case observations and video discussions. Participants were asked to complete a detailed questionnaire on their practice patterns before and after the PRM.

Results: Between 2012 and 2018, a total of 29 national and international pediatric surgeons and urologists underwent robotic renal and bladder surgery training. Twenty-six fellows (90%) completed the surveys, all of which were included for analysis. The median age at the time of fellowship was 43 years (32–63), and participants had practiced urology for a median of 76 months (3–372). All of them had a laparoscopic background, with a median experience of 120 months (12–372), and an average of 454 (± 703) laparoscopic procedures performed, including the years of training. The most common primary goals of participants were to understand the concept of robotic surgery and its applications (38.5%), and to practice in the wet lab to shorten their learning curve (38.5%). After PRM completion, 24 graduates (92%) felt likely to incorporate robotic surgery into their practice, of which 15 (58%) actually started a robotic program at their home institution. At 24 months after PRM completion, the overall number of surgeries performed with a robotic approach (RA) by these 15 participants was 478 with an average of 32 (± 44) procedures per fellow, of which 109 (23%) were extirpative (nephrectomy, partial nephrectomy, etc.), and 369 (77%) reconstructive procedures (pyeloplasty, ureteral reimplantation, etc.). Before PRM, the same 15 participants performed 844 procedures with a laparoscopic approach (LA), of which 527 (62.4%) were extirpative, and 317 (37.6%) were reconstructive surgeries. These data mark a significant switch in indications for minimally invasive surgery (MIS) in pediatric urology. The rise in the number of reconstructive procedures (37.6% LA vs. 77% RA) has shown that robotic surgery has undoubtedly facilitated the performance of more challenging procedures in a minimally invasive fashion.

Conclusion: The success of a mini-fellowship program relies on the commitment of expert faculty to serve as tutorial instructors and proctors. In addition, a completely outfitted robotic laboratory with access to dry and wet lab is indispensable. A 5-day intensive PRM appears to enable postgraduate surgeons to successfully incorporate the robotic platform into their practice and to advance the complexity of minimally invasive procedures, allowing for more challenging surgeries, such as reconstructive urology.

Setting Benchmarks for the New User: Training on the Robotic Simulator

Background and Objectives:

Data showing the impact of the robotic simulator on fellowship training are limited. This study was conducted to determine whether simulator scores reflect the experience of the robotic gynecologic surgeon and to develop a simulator curriculum for trainees in gynecologic oncology.

Methods:

All faculty and fellows in the Department of Gynecologic Oncology and Reproductive Medicine were asked to participate. For phase 1, all participants were divided into 2 groups based on robotic surgical experience: beginner (0–50 cases) and experienced (>50 cases). Each participant completed 9 modules 3 times each to establish baseline data. Median module scores for the experienced group defined the benchmarks scores. In phase 2, all trainees who did not meet the benchmark score on a module were asked to repeat the module until they reached the score twice.

Results:

Twenty-four participants were included: 18 beginners and 6 experienced surgeons. For all modules, experienced surgeons received higher median scores than beginners. There was a significant difference between the scores of the 2 groups in the Energy Switching 1 (87.5 vs 92.5; P = .002) and Suture Sponge 2 (75.0 vs 87.3; P = .011) modules. Thirteen trainees participated in phase 2. For 8 of 9 of the modules, >75% of trainees met proficiency, with a median of 3 to 6 attempts (range, 2–24).

Conclusion:

Based on the findings, scores reflected each surgeon's experience. With repetition, most of the trainees were able to reach the benchmark scores. Further study is needed to determine the impact of surgical simulation on true intraoperative performance.

Use of Automated Performance Metrics to Measure Surgeon Performance during Robotic Vesicourethral Anastomosis and Methodical Development of a Training Tutorial

PURPOSE

We sought to develop and validate automated performance metrics to measure surgeon performance of vesicourethral anastomosis during robotic assisted radical prostatectomy. Furthermore, we sought to methodically develop a standardized training tutorial for robotic vesicourethral anastomosis.

MATERIALS AND METHODS

We captured automated performance metrics for motion tracking and system events data, and synchronized surgical video during robotic assisted radical prostatectomy. Nonautomated performance metrics were manually annotated by video review. Automated and nonautomated performance metrics were compared between experts with 100 or more console cases and novices with fewer than 100 cases. Needle driving gestures were classified and compared. We then applied task deconstruction, cognitive task analysis and Delphi methodology to develop a standardized robotic vesicourethral anastomosis tutorial.

RESULTS

We analyzed 70 vesicourethral anastomoses with a total of 1,745 stitches. For automated performance metrics experts outperformed novices in completion time (p <0.01), EndoWrist® articulation (p <0.03), instrument movement efficiency (p <0.02) and camera manipulation (p <0.01). For nonautomated performance metrics experts had more optimal needle to needle driver positioning, fewer needle driving attempts, a more optimal needle entry angle and less tissue trauma (each p <0.01). We identified 14 common robotic needle driving gestures. Random gestures were associated with lower efficiency (p <0.01), more attempts (p <0.04) and more trauma (p <0.01). The finalized tutorial contained 66 statements and figures. Consensus among 8 expert surgeons was achieved after 2 rounds, including among 58 (88%) after round 1 and 8 (12%) after round 2.

CONCLUSIONS

Automated performance metrics can distinguish surgeon expertise during vesicourethral anastomosis. The expert vesicourethral anastomosis technique was associated with more efficient movement and less tissue trauma. Standardizing robotic vesicourethral anastomosis and using a methodically developed tutorial may help improve robotic surgical training.

Implementing assessments of robot-assisted technical skill in urological education: a systematic review and synthesis of the validity evidence

OBJECTIVES

To systematically review and synthesise the validity evidence supporting intraoperative and simulation-based assessments of technical skill in urological robot-assisted surgery (RAS), and make evidence-based recommendations for the implementation of these assessments in urological training.

MATERIALS AND METHODS

A literature search of the Medline, PsycINFO and Embase databases was performed. Articles using technical skill and simulation-based assessments in RAS were abstracted. Only studies involving urology trainees or faculty were included in the final analysis.

RESULTS

Multiple tools for the assessment of technical robotic skill have been published, with mixed sources of validity evidence to support their use. These evaluations have been used in both the ex vivo and in vivo settings. Performance evaluations range from global rating scales to psychometrics, and assessments are carried out through automation, expert analysts, and crowdsourcing.

CONCLUSION

There have been rapid expansions in approaches to RAS technical skills assessment, both in simulated and clinical settings. Alternative approaches to assessment in RAS, such as crowdsourcing and psychometrics, remain under investigation. Evidence to support the use of these metrics in high-stakes decisions is likely insufficient at present.

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.

A research review on clinical needs, technical requirements, and normativity in the design of surgical robots

Nowadays robots play an important role in society, mainly due to the significant benefits they provide when utilized for assisting human beings in the execution of dangerous or repetitive tasks. Medicine is one of the fields in which robots are gaining greater use and development, especially those employed in minimally invasive surgery (MIS). However, due to the particular conditions of the human body where robots have to act, the design of these systems is complex, not only from a technical point of view, but also because the clinical needs and the normativity aspects are important considerations that have to be taken into account in order to achieve better performances and more secure systems for patients and surgeons. Thus, this paper explores the clinical needs and the technical requirements that will trace the roadmap for the next scientific and technological advances in the field of robotic surgery, the metrics that should be defined for safe technology development and the standards that are being elaborated for boosting the industry and facilitating systems integration.

Proctorship and mentoring: Its backbone and application in robotic surgery

In pursuit of continuing medical education in robotic surgery, several forms of training have been implemented. This variable application of curriculum has brought acquisition of skills in a heterogeneous and unstandardized fashion from different parts of the world. Recently, efforts have been made to provide cost effective and well-structured curricula with the aim of bridging the gap between formal fellowship training and short courses. Proctorship training has been implicated on some curriculum to provide excellent progression during the learning curve while ensuring patient safety.

Baseline Laparoscopic Skill May Predict Baseline Robotic Skill and Early Robotic Surgery Learning Curve

INTRODUCTION

Robotic surgery is associated with a learning curve unique to each trainee. Knowledge about a trainee's baseline skill and learning curve would facilitate the development of a more individualized training curriculum. The aim of our study was to determine whether baseline laparoscopic skill is predictive of one's baseline robotic skill and short-term learning curve.

METHODS

Trainees from four different surgical specialties were included in the study. Each trainee participated in a 4-week, simulation-based robotic surgery basic skills training course. Precourse, baseline laparoscopic and robotic skills were assessed using validated test tasks; a basic peg transfer (PT) and an advanced intracorporeal suturing and knot tying (ISKT) task. Trainee robotic skill was assessed again 1 week postcourse. Each task performance was video recorded and scored by two blinded expert surgeons.

RESULTS

A total of 32 trainees were included; 14 urology, 7 gynecology, 8 thoracic Sx, 3 general Sx. Most (91%) were senior residents or clinical fellows and 50% had no prior robotic experience. There were no differences in baseline laparoscopic and robotic skill related to reported prior robotic experience. Between specialties, no differences were seen on baseline laparoscopic skill and only small differences were seen on baseline robotic skill. Both baseline Lap PT (p = 0.01) and Lap ISKT (p = 0.01) performances correlated with baseline robotic ISKT performance, but not robotic PT scores. Only baseline Lap ISKT performance correlated with postcourse robotic PT (p = 0.01) and ISKT (p < 0.01) performance. Baseline robotic ISKT scores, but not PT scores, correlated with postcourse robotic performance (p = 0.02 for PT, p < 0.01 for ISKT).

CONCLUSIONS

In this study, a trainee's baseline laparoscopic skill correlated with certain baseline robotic skills. Better baseline performance on an advanced, but not basic, laparoscopic and robotic skill task may correlate with a shorter learning curve for basic robotic skills. Further exploration of this finding may yield better training curricula.

A Systematic Review of Virtual Reality Simulators for Robot-assisted Surgery

CONTEXT

No single large published randomized controlled trial (RCT) has confirmed the efficacy of virtual simulators in the acquisition of skills to the standard required for safe clinical robotic surgery. This remains the main obstacle for the adoption of these virtual simulators in surgical residency curricula.

OBJECTIVE

To evaluate the level of evidence in published studies on the efficacy of training on virtual simulators for robotic surgery.

EVIDENCE ACQUISITION

In April 2015 a literature search was conducted on PubMed, Web of Science, Scopus, Cochrane Library, the Clinical Trials Database (US) and the Meta Register of Controlled Trials. All publications were scrutinized for relevance to the review and for assessment of the levels of evidence provided using the classification developed by the Oxford Centre for Evidence-Based Medicine.

EVIDENCE SYNTHESIS

The publications included in the review consisted of one RCT and 28 cohort studies on validity, and seven RCTs and two cohort studies on skills transfer from virtual simulators to robot-assisted surgery. Simulators were rated good for realism (face validity) and for usefulness as a training tool (content validity). However, the studies included used various simulation training methodologies, limiting the assessment of construct validity. The review confirms the absence of any consensus on which tasks and metrics are the most effective for the da Vinci Skills Simulator and dV-Trainer, the most widely investigated systems. Although there is consensus for the RoSS simulator, this is based on only two studies on construct validity involving four exercises. One study on initial evaluation of an augmented reality module for partial nephrectomy using the dV-Trainer reported high correlation (r=0.8) between in vivo porcine nephrectomy and a virtual renorrhaphy task according to the overall Global Evaluation Assessment of Robotic Surgery (GEARS) score. In one RCT on skills transfer, the experimental group outperformed the control group, with a significant difference in overall GEARS score (p=0.012) during performance of urethrovesical anastomosis on an inanimate model. Only one study included assessment of a surgical procedure on real patients: subjects trained on a virtual simulator outperformed the control group following traditional training. However, besides the small numbers, this study was not randomized.

CONCLUSIONS

There is an urgent need for a large, well-designed, preferably multicenter RCT to study the efficacy of virtual simulation for acquisition competence in and safe execution of clinical robotic-assisted surgery.

PATIENT SUMMARY

We reviewed the literature on virtual simulators for robot-assisted surgery. Validity studies used various simulation training methodologies. It is not clear which exercises and metrics are the most effective in distinguishing different levels of experience on the da Vinci robot. There is no reported evidence of skills transfer from simulation to clinical surgery on real patients.

Current state of virtual reality simulation in robotic surgery training: a review

BACKGROUND

Worldwide, the annual number of robotic surgical procedures continues to increase. Robotic surgical skills are unique from those used in either open or laparoscopic surgery. The acquisition of a basic robotic surgical skill set may be best accomplished in the simulation laboratory. We sought to review the current literature pertaining to the use of virtual reality (VR) simulation in the acquisition of robotic surgical skills on the da Vinci Surgical System.

MATERIALS AND METHODS

A PubMed search was conducted between December 2014 and January 2015 utilizing the following keywords: virtual reality, robotic surgery, da Vinci, da Vinci skills simulator, SimSurgery Educational Platform, Mimic dV-Trainer, and Robotic Surgery Simulator. Articles were included if they were published between 2007 and 2015, utilized VR simulation for the da Vinci Surgical System, and utilized a commercially available VR platform.

RESULTS

The initial search criteria returned 227 published articles. After all inclusion and exclusion criteria were applied, a total of 47 peer-reviewed manuscripts were included in the final review.

CONCLUSIONS

There are many benefits to utilizing VR simulation for robotic skills acquisition. Four commercially available simulators have been demonstrated to be capable of assessing robotic skill. Three of the four simulators demonstrate the ability of a VR training curriculum to improve basic robotic skills, with proficiency-based training being the most effective training style. The skills obtained on a VR training curriculum are comparable with those obtained on dry laboratory simulation. The future of VR simulation includes utilization in assessment for re-credentialing purposes, advanced procedural-based training, and as a warm-up tool prior to surgery.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Pilot Validation Study of the European Association of Urology Robotic Training Curriculum

BACKGROUND

The development of structured and validated training curricula is one of the current priorities in robot-assisted urological surgery.

OBJECTIVE

To establish the feasibility, acceptability, face validity, and educational impact of a structured training curriculum for robot-assisted radical prostatectomy (RARP), and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

DESIGN, SETTING, AND PARTICIPANTS

A 12-wk training curriculum was developed based on an expert panel discussion and used to train ten fellows from major European teaching institutions. The curriculum included: (1) e-learning, (2) 1 wk of structured simulation-based training (virtual reality synthetic, animal, and cadaveric platforms), and (3) supervised modular training for RARP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The feasibility, acceptability, face validity, and educational impact were assessed using quantitative surveys. Improvement in the technical skills of participants over the training period was evaluated using the inbuilt validated assessment metrics on the da Vinci surgical simulator (dVSS). A final RARP performed by fellows on completion of their training was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) score and generic and procedure-specific scoring criteria.

RESULTS AND LIMITATIONS

The median baseline experience of participants as console surgeon was 4 mo (interquartile range [IQR] 0-6.5 mo). All participants completed the curriculum and were involved in a median of 18 RARPs (IQR 14-36) during modular training. The overall score for dVSS tasks significantly increased over the training period (p<0.001-0.005). At the end of the curriculum, eight fellows (80%) were deemed able by their mentors to perform a RARP independently, safely, and effectively. At assessment of the final RARP, the participants achieved an average score ≥4 (scale 1-5) for all domains using the GEARS scale and an average score >10 (scale 4-16) for all procedural steps using a generic dedicated scoring tool. In performance comparison using this scoring tool, the experts significantly outperformed the fellows (mean score for all steps 13.6 vs 11).

CONCLUSIONS

The European robot-assisted urologic training curriculum is acceptable, valid, and effective for training in RARP.

PATIENT SUMMARY

This study shows that a 12-wk structured training program including simulation-based training and mentored training in the operating room allows surgeons with limited robotic experience to increase their robotic skills and their ability to perform the surgical steps of robot-assisted radical prostatectomy.