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Achieving robotic surgery competency
Introduction
Embarking on robotic surgery training can be a daunting task for the robot-naïve surgeon. Robotics has a steep learning curve, and a pathway to robotic surgery competency has not yet been standardized. Surgical colleges have not yet developed credentialing for robotic surgery training. There is no surgical college accredited curriculum for robotics. The result is that training in robotics has been haphazard and is fragmented among hospitals, medical institutions, and robot vendors. The robot vendors provide a guide for a minimum required standard of training but defer responsibility to the hospital for credentialing. Some academic medical centers have established their own robotic training pathways, some of which are to a level of high proficiency. These institutions currently operate in silos. The aim of this chapter is to describe the evolution of robotic surgery training since its inception in 2000, when the da Vinci Surgical System received FDA approval. We suggest here a blueprint for a standardized training pathway to achieve robotic surgery competency and proficiency in line with the Dreyfus model of skill acquisition. Programs are vulnerable to “shadow learning,” where the attending robotic surgeon is reluctant to hand over control to the trainee because the attending is still on their own learning curve. We define competency, equipping the trainee with the skills to make a surgeon fit for purpose, although they may still lack refinement ( Fig. 8.1 ). The pillars of robotic surgical education comprise theory, simulation, and live surgery overlaid by nontechnical skills. Robotic surgery training requires a multifaceted pathway, involving various simulation platforms and didactics. , Robotic surgery training will most likely transition from live animal and cadaver training to a digital and synthetic organ training system.
History of robotic surgery training
When soft tissue robotics began in 2000, training occurred in a Halstedian fashion, where learning was mostly on the live patient by the early robotic surgery adopters. These early adopters undertook a short course by Intuitive Surgical that included an introduction to the robot buttons and features, dry lab exercises for instrument manipulation, a live porcine surgery, a cadaver surgery, observation of a small number of live cases, and then, finally, three proctored live cases. Intuitive’s current recommended training pathway has not changed significantly in 20 years, other than to include virtual reality (VR) simulation. In some instances, the training requirements for robotics today may be less than when this technology was introduced.
Surgeons who have no access to a residency program that includes a structured robotic program need to rely on the robot vendor directed pathway that offers minimal exposure to robotics training prior to live operating room cases. The current recommended Intuitive pathway includes a brief online course of 3 hours, dry laboratory sessions conducted by the robot company training staff, VR simulation only if available and then at the surgeon’s expense, and porcine and cadaver models. Proctoring by a surgeon with robotic experience is suggested for early procedures; however, this is not mandatory. The validity of this training pathway is not standardized and cannot allow the trainee to achieve basic robotic surgery competency considering the long learning curves in robotic surgery reported to require 300 cases for some procedures to become an “expert.” ,
In Europe and Australasia, robotic surgeons often travel internationally to complete a year-long robotic surgery fellowship. They are immersed in a robotic program under close observation of experienced expert robotic surgeons. In the United States, academic hospitals with access to robots have integrated robotic training pathways into their residency programs. In this setting, sometimes learning occurs by passive observation with limited hands-on experience. Currently, there is no standardized surgical college accredited robotic surgery curriculum, and most hospitals have arbitrary criteria as to what constitutes adequate training. The quality of robotic training in fellowships and residency programs is variable. The European Association of Urology’s (EAU) Robotic Urology Section (ERUS) has recently endorsed a 6 month curriculum aimed at fellowship level for robotic radical prostatectomy that has been adopted by a limited number of hospitals. An ERUS robot-assisted partial nephrectomy curriculum has also been developed and completed by a single trainee. These curricula are confined to urology and dependent on animal and cadaver models that have significant financial, ethical, and logistical drawbacks. This training method involves observation of master surgeons in the operating room, with sequential progress from simple tasks, such as tissue retraction and handling, to more advanced tasks. Many facets of the apprenticeship model remain today that can be challenging in an environment of safe working hour restrictions. Advances in digital education have been adopted by some robotic training centers to deliver a more adaptive surgical curriculum that meets the individual needs of the training robotic surgeon. Emerging digital and synthetic organs present new opportunities for an enhanced robotic surgery curriculum.
Robotic surgery education
The pillars of robotic surgery education are theory, low- and high-fidelity simulation, and live surgery underpinned by nontechnical skills or human factor training ( Fig. 8.2 ). A review of these training elements is provided below.
Theory
Foundational knowledge for robotic surgery is found in textbooks and online courses. Prior to commencing hands-on training, the surgeon should have an overview of the system features of surgical robots, be familiar with the steps for robot setup, be aware of anesthetic considerations, know the principles of good robotic surgical technique at the console and the bedside, understand how to achieve robotic surgical competency, and recognize the importance of human factors in robotic surgical practice. Robot vendors provide a limited online course that introduces the robot components, buttons, and functions. A comprehensive multispecialty and multivendor online course containing the theory and principles of robotic surgery has been developed by expert surgeons at the International Medical Robotics Academy with accreditation from the Royal Australasian College of Surgeons.
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