A comprehensive review of robotic surgery curriculum and training for residents, fellows, and postgraduate surgical education

Learning Curve for Robotic Inguinal Hernia Repair With da Vinci Single-Port Robotic System

BackgroundTransabdominal pre-peritoneal inguinal hernia repair using the da Vinci Single-Port robot (SP-TAPP) is currently performed in few centers. We aimed to define the learning curve for SP-TAPP by analyzing operative times.MethodsThe operative times of 122 SP-TAPP performed between 2019 and 2024 were retrospectively analyzed. The following phases were analyzed: docking time (DT); pre-robot time (PRT, from skin incision to side cart placement); flap closure time (FCT); console time (CT), and overall time (OT). Cumulative sum analysis (CUSUM) was used to analyze learning curves. Surgical and 30-day outcome were analyzed.ResultsThe DT has remained constant over time (P > 0.9). PRT was divided into 3 phases with n1 = 5, n2 = 95 and n3 = 4, in which there was a progressive decrease in time (14.8 vs 11.9 vs 6.8 min; P = 0.08). In FCT and CT, 3 phases were identified in which times remained stable (P > 0.9 and P = 0.7). CUSUM analysis of OT identified 3 phases consisting of n1 = 13, n2 = 100 and n3 = 9 in which there was a progressive decrease in times (82 vs 72 vs 62 min; P = 0.3). Analysis of complications and early surgical outcomes did not differ except for estimated blood loss, although this was a clinically insignificant finding.ConclusionsThe learning curve for SP-TAPP is rapid and it shows how the technical skills are transferable between the multiport platform and the da Vinci Single Port robotic system for an experienced surgeon. An improvement is evident in PRT and OT, also compared to multiport systems, showing a potential for the platform to increase surgical activity.

A systematic review of robotic colorectal surgery programs worldwide and a comprehensive description of local robotic training programme

BACKGROUND

Robotic-assisted colorectal surgery (RACS) is gaining widespread adoption, with a growing number of procedures performed globally. These have been performed mostly by consultants, many of whom have gained sufficient proficiency to begin to educate their trainees. RACS offers a range of benefits to the surgeon and patient, yet safe and effective utilisation hinges on well-structured training programs for colorectal trainees within their general surgery residency. This systematic review aimed to evaluate the structure currently employed worldwide in RACS training programs for colorectal surgery trainees. In addition it delineates the conceptualization and implementation of a locally developed RACS program tailored to senior colorectal trainees and fellows at our Trust.

METHODS

A comprehensive search of Ovid Medline and Embase databases (January 2010- March 2024) following PRISMA guidelines identified six studies reporting on RACS training curricula. Critical analysis of programme structure and curricula tools utilised was performed. Articles involving training of consultants were excluded. The quality and bias score of each study were assessed using the Newcastle Ottawa Score for observational studies.

RESULTS

Six out of 77 studies were selected as suitable for analysis describing RACS training using Da Vinci platform. All apart from one programme described a phased or parallel robotic curriculum with four studies incorporating theoretical knowledge and laboratory or cadaveric training. Six programmes incorporated simulation, bedside assisting and console training. The use of validated objective or subjective metrics at each phase varied. Formal feedback is provided in only two of the programmes. Reflecting on above results we present our Trust training program which run over the last two years. Our program ensures clear learning goals for trainees and trainers, maintains patient safety, and is easily replicated across other UK RACS units.

CONCLUSION

The establishment of a standardised curriculum for colorectal surgery training worldwide, including in the UK, is vital. Currently, there is a scarcity of validated, objective assessment methods, which must be adequately standardised to create consistent progression criteria and competency-based metrics. Standardising these methods will enable reliable and robust assessment of trainee progression and competence to create a generation of robotically competent colorectal surgeons within their standard training program timeframe.

PROSPERO DATABASE REGISTRATION

No.-CRD42024530340.

Robotic surgery governance structures: a systematic review

Since the Food and Drug Administration in the United States approved the first robotic platform for use in humans in 2000, there has been a steady increase in the popularity of robotic approaches to surgery. Robotic-assisted surgery (RAS) offers enhanced 3D visualisation of the operative field and increased flexibility and agility of the instruments, amongst other benefits. However, robotic platforms are complex systems and there is evidence that they may be associated with increased patient risk, particularly in the initial learning curve of a surgeon's robotic training. To ensure the continued safe use of RAS, adequate governance policies must be in place to regulate training, ensure patient safety and maximise the benefits of RAS programs. This systematic review synthesises all available evidence on RAS governance structures internationally for the first time. It was conducted and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review identified, for the first time, three guidelines offering recommendations on the Governance Structures for RAS programs. We extracted the key recommendations to provide a holistic set of guidelines. Through consensus, we offer recommendations for the composition of a RAS governance committee, the frequency with which the committee should sit, and the remit of the committee, including training, granting of privileges, quality assurance and continued professional development. We also stress future research needs in RAS team credentialing and vendor-agnostic training pathways. These recommendations may serve as a template for establishing future RAS programs.

The Future of Robotics in Plastic and Reconstructive Surgery: A Realistic Model for Trainee Certification

ABSTRACT

Robots have been used effectively in plastic and reconstructive surgery (PRS) for reconstruction. The utilization of robotics in all surgical specialties is expanding with the goal of offering the most appropriate patient-centered care possible, especially in complex multidisciplinary cases. Despite the safety, efficiency, and reproducibility of robotics in PRS, there is a paucity of required and formalized training in PRS residency programs. The ACGME and industry published guidelines were investigated. Robotic surgery case logs of Mayo Clinic Arizona General Surgery residents were analyzed with attention to equivalency certification (EQ). Over the past 5 years, the equivalency certification from Intuitive (Sunnyvale, CA) was obtained by 30% of all general surgery residents at our institution (range, 0-100). The case numbers to obtain the equivalence certification are industry recommendations, and proficiency is determined by the program director. The ACGME does not mandate robotics training in general surgery residency. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), trainees must complete 20 console cases and 10 bedside cases to become industry certified. With respect to training and advancing the field, PRS residents could successfully obtain certification in their residency programs. The minimum case requirement recommended by SAGES is not burdensome and can ensure robotic privileges in PRS practice immediately following graduation. By improving the training for minimally invasive robotic surgery in plastic surgery, patients and healthcare systems benefit from improved quality of life outcomes and decreased postoperative length of stay, which results in less strain on our entire medical system.

The evolution of surgical skills simulation education: Robotic skills

Robotic surgery is now widely used after the introduction and increase in popularity of the da Vinci Xi Surgical System 25 years ago. Starting with urology, it has expanded into most major surgical specialties, with millions of robotic operations performed each year. With this growth comes the need to educate and train surgeons on its use. Robotic surgery introduces unique cognitive, psychomotor, and team-based skills not used in open and laparoscopic techniques. These demand creation of curricula on the basis of comprehensive and validated educational frameworks, similar to the Fundamentals of Endoscopic Surgery and Fundamentals of Laparoscopic Surgery programs, to train surgeons. Although programs like the Fundamentals of Robotic Surgery have been developed, they focus most on basic skills. Beyond curricula for these and more advanced skills, how performance is assessed is equally critical. Beginning to fill this gap are the Global Evaluative Assessment of Robotic Skills, Robotic Objective Structured Assessment of Technical Skills, and Robotic Ottawa Surgical Competency Operating Room Evaluation assessment tools. Continued development and improvement in curricula and assessment must persist, particularly as new technologies develop rapidly. Sophisticated features of newer robotic systems including objective performance indicators, augmented reality, virtual reality, artificial intelligence, and machine learning are gaining pace and are positioned to expand robotic surgery, and robotic surgical simulation education, even further over the next 25 years.

Prediction of Basic Robotic Competence for Robotic Visceral Operations Using the O-Score within the "Robotic Curriculum for Young Surgeons" (RoCS)

INTRODUCTION

Surgical residency programs lack structured assessments of robotic surgery. The validated O-Score is an assessment tool for tracking robotic operative proficiency consisting of 9 items on a 5 point Likert scale. Surgical autonomy is one comprehensive binary item. This study aimed to establish a benchmark for the number of procedures and the O-Score sum score to achieve surgical autonomy in robotic visceral procedures.

MATERIAL AND METHODS

This single-center prospective pilot cohort study assessed robotic procedures between 2020 and 2023. Bedside and console assistance performances were analyzed separately based on the O-Score and the calculated total numerical sum of the individual item values of the O-Score. Bedside assistance was conducted for upper gastrointestinal, hepatopancreatobiliary, and colorectal procedures, whereas console assistance referred to either one of the three areas. The study participants included inexperienced robotic surgeons who were evaluated by 2 robotic experts.

RESULTS

In total, 273 procedures were included in this study. For 13 bedside assistants, 273 O-Score assessments were identified, and 62 O-Score assessments for six console assistants. Surgical autonomy was achieved in 50.9% for bedside assistance and in 11.3 % for assistance at the robotic console. Surgical autonomy was positively correlated with the O-Score sum for bedside (p = < 0.001) and console assistance (p = 0.004). The positive prediction of surgical autonomy for bedside (console) assistance ranged from 74% (60%) to 93% (100%), correlated with a range of the O-Score sum between 37 (37) and 40 (40) and a robotic caseload between 19 (17) and 33 (24) procedures.

CONCLUSIONS

A significant improvement in the basic robotic performance was observed. Benchmarks regarding number of cases and O-Score sum were established for bedside assistance regardless of the type of visceral robotic operation. Currently, data on console assistance are limited. Monitoring robotic operative skills and skill progression is feasible in daily routine using the O-Score and O-Score sum.

Experiences of robotic surgery nurses regarding technostress: a qualitative study

To qualitatively examine the experiences of robotic surgery nurses regarding technostress. It is thought that determining the impact and importance of technostress on nursing practices and roles that may be caused by robotic surgery technology, which has been widely used, will lead to the development of strategies to prevent or reduce technostress by understanding the challenges and opportunities involved in using new technology. This study was conducted in the operating theatre of a university hospital in Istanbul between May and September 2022. The sample of the study consisted of 11 operating room nurses with at least 6 months of robotic surgery nursing experience who agreed to participate in the study on the dates of the study. The data of the study were collected with a 'Personal Information Form' consisting of 14 questions and a 'Semi-Structured Interview Form' consisting of 6 questions, which were created in line with the literature and audio-recorded by in-depth interview technique. The majority of the robotic surgery nurses who participated in the study were female and received training on robotic surgery nursing. As a result of the analysis, the themes of the effect of technology on the practices of robotic surgery nurses, education and skill development, work stress and management, team dynamics and cooperation, thoughts about the future of robotic surgery, and suggestions for robotic surgery were obtained. The results of this study revealed that robotic surgery nurses working in high-tech environments are at high risk for technological stress.

How to reduce intraoperative preparation and docking time to minimal in a team with a robotic naïve surgical experience?

Purpose

To evaluate the effect of preoperative training in an experimental setting on the preparation and docking of the avatera robotic system.

Materials and Methods

Two different surgical groups (consisting of two nurses, one assistant, and one operating surgeon) attended an initial training on robot draping and docking procedures. Group 1 was involved in 10 robotic-assisted operations while Group 2 was trained in the dry lab using an artificial insufflated abdominal model (10 sessions). The decrease in time needed for docking and draping was evaluated. After the completion of the initial training, each group performed docking and draping procedures in five surgeries (including robotic-assisted radical prostatectomy and pyeloplasty) and the recorded times were compared.

Results

In Group 1, the docking and draping time were diminished during the initial training program from 17 to 7 min and from 12 to 5 min, respectively. In Group 2, the docking time was decreased from 9 to 6 min and the draping time from 8 to 5 min. Both types of training (during real-life OR program vs. dry laboratory setting inclusive an insufflated abdominal model) resulted in nearly the same positive training effect for Group 1 and Group 2, respectively.

Conclusions

Conducing a training of patient preparation and docking in the dry laboratory using an insufflated abdominal model facilitates experience acquisition in a safe and calm environment. The training method of Group 2 might help to avoid the potentially longer anesthesia times for patients during the early learning curve of Group 1.

Surgical training simulation modalities in minimally invasive surgery: How to achieve evidence-based curricula by translational research

BACKGROUND

Surgery has evolved from a hands-on discipline where skills were acquired via the "learning by doing" principle to a surgical science with attention to patient safety, health care effectiveness and evidence-based research. A variety of simulation modalities have been developed to meet the need for effective resident training. So far, research regarding surgical training for minimally invasive surgery has been extensive but also heterogenous in grade of evidence.

METHODS

A literature search was conducted to summarize current knowledge about simulation training and to guide research towards evidence-based curricula with translational effects. This was conducted using a variety of terms in PubMed for English articles up to October 2024. Results are presented in a structured narrative review.

RESULTS

For virtual reality simulators, there is sound evidence for effective training outcomes. The required instruments for the development of minimally invasive surgery curricula combining different simulation modalities to create a clinical benefit are known and published.

CONCLUSION

Surgeons are the main creators for minimally invasive surgery training curricula and often follow a hands-on oriented approach that leaves out equally important aspects of assessment, evaluation, and feedback. Further high-quality research that includes available evidence in this field promises to improve patient safety in surgical disciplines.

Training in the use of basic functions of the daVinci Xi® robot: a comparative study of residents' skills

The rapid spread of the robotic surgical system has not been accompanied by an equally rapid creation of standardized training courses for the use of this technology.The purpose of our study was to evaluate skill acquisition in the handling and use of the daVinci Xi by comparing two groups of surgical residents. Surgical residents from the University of Turin were enrolled. The participants were divided into two groups: Group A: residents who had participated in at least 8 robotic surgical procedures, and Group B: residents who had never attended robotic surgery. All were administered two instructional videos on the patient cart and console exercises to be performed. Subsequently, the residents were tested and recorded to be evaluated by a senior surgeon experienced in robotic surgery, according to a previously assessed evaluation score. The time of the procedure was also recorded for each test. Patient cart exercises were completed by all participants. We found statistically significant differences between two groups for the first (p = 0.0000) and third (p = 0.0002) patient cart tests and for every test on the surgeon's console except the endoscope handling exercise. Group A scored higher on the patient cart exercises, and the difference reached statistical significance (p = 0.0001). The placement of a single hand-sewn knot on the silicone suture pad was the only exercise that was not fully completed by all participants and showed no statistical difference. The correlation analysis between surgical experience and final score was significant in Group A. The daVinci Xi robotic platform can be properly operated in its basic functions by young surgeons after a short training program even in the absence of previous exposure to robotic clinical procedure.

Scoping review and proposed curriculum for robotic hepatopancreatobiliary surgery training

BACKGROUND

HPB surgery is being increasingly performed robotically worldwide. However, there is no consensus on what constitutes adequate training or an established curriculum. We evaluate the existing literature on formal education in robotic hepatopancreaticobiliary (HPB) surgery and propose a curriculum using Kern's six-step curriculum development model.

METHODS

A systematic search was performed across major databases and the methodology of the Joanna Briggs Institute was followed. The PRISMA-ScR was conformed in reporting. Evidence pertaining to cholecystectomy alone was excluded and studies that described formal training pathways were included.

RESULTS

Fifteen curricula were included with predilection towards the pancreas (n = 7, liver: n = 5, combination: n = 3). Almost all studies proposed initial robot system training through online modules, observership and console simulation exercises. Following this, six curricula described procedure-specific anastomosis training. Almost all studies described mentorship and proctorship. The assessment for implementation commonly described includes objective structured assessment of technical skill (OSATS) and cumulative sum technique (CUSUM) for operation time, conversion-to-open rate and postoperative complications.

DISCUSSION

This study has summarised the formal curricula for learning robotic HPB surgery. The majority share similar implementation tools. A comprehensive curriculum based on validated educational principles has been proposed which incorporates these elements.

Novel Robotic Esophagogastric Anastomosis Simulation Model for Skill Development and Training

Background

Esophagogastric anastomosis is a critical step of esophagectomy. We aimed to develop a novel robotic esophagectomy simulator with high rates of fidelity and educational value for trainee surgeons to advance these skills in a low-risk setting.

Methods

A porcine esophagus-stomach block was secured on a platform resembling the anatomy during an esophagectomy, and a da Vinci Xi (Intuitive Surgical) robotic system was docked above it. Participants completed 5 key steps (creating the gastric conduit, transecting the esophagus, making the gastrotomy and esophagotomy, creating the anastomosis, and sewing the common enterotomy). The model was assessed through surveys under domains of fidelity (surgical field, reality of materials, anatomy, and experience) and value as a training tool on a scale of 1 to 5 (strongly disagree to strongly agree).

Results

Of 14 participants, 8 (57.1%) were women, 9 (64.3%) were integrated cardiothoracic surgery residents, 1 (7.1%) was a thoracic-track resident, and 10 (71.4%) were in postgraduate year 4 or higher. Participants thought most aspects of the model had high fidelity, including the anatomy of conduit (4.8 ± 0.4) and proximal esophagus (4.9 ± 0.4), realism of the stomach (4.9 ± 0.4) and esophagus (4.9 ± 0.4), stapling (4.7 ± 0.6), suturing (4.8 ± 0.4), and tissue handling (4.4 ± 0.6). Participants rated the model highly overall (4.7 ± 0.5) and as a training tool (4.9 ± 0.4), with strong interrater reliability (0.69).

Conclusions

The robotic esophagogastric simulation model demonstrated high fidelity and value as a training tool, suggesting its potential effectiveness for surgeons with limited experience. However, it warrants further refinement to address limitations and to optimize its value as a training tool.

How effective and sustainable is proctoring in robotic surgery? A retrospective analysis based on interviews with surgeons

BACKGROUND

Robot-assisted surgery is one of several minimally invasive techniques which have become increasingly important in recent years. Education and training are key factors of sustainable success, and surgical tutoring by an experienced external surgeon (proctoring) has emerged as a very useful method of training surgeons. Proctoring enables surgeons to train their respective skills and eventually improve the overall quality of surgical care.

METHODS

To evaluate the sustainability of proctoring, we conducted telephone interviews with colleagues who participated in a single-center surgical proctoring program. The aim was to analyze the feasibility of the concept for being established in the future, how well it suits the surgeons (depending on their individual work experience), and which areas of clinical practice would benefit from proctoring. Furthermore, the surgeons provided free-text comments to the questions on a feedback form handed out after the proctoring.

RESULTS

Surgical skills were significantly enhanced and operating times were reduced after proctoring. Given favorable structural conditions, the number of cases and the case-mix index were also significantly increased. It was found that the learning needs of surgeons differ, depending on their medical function, work experience, and the frequency of robotic surgery. On the feedback forms, proctoring was consistently rated as a positive and supportive measure.

CONCLUSIONS

Proctoring is an important aspect of the individual development of surgeons. Depending on learning needs, a structured curriculum is crucial and should be established for the future. Regular feedback modules should be a part of any surgical training concept.

Objective surgical skill assessment based on automatic recognition of dissection and exposure times in robot-assisted radical prostatectomy

PURPOSE

Assessing surgical skills is vital for training surgeons, but creating objective, automated evaluation systems is challenging, especially in robotic surgery. Surgical procedures generally involve dissection and exposure (D/E), and their duration and proportion can be used for skill assessment. This study aimed to develop an AI model to acquire D/E parameters in robot-assisted radical prostatectomy (RARP) and verify if these parameters could distinguish between novice and expert surgeons.

METHODS

This retrospective study used 209 RARP videos from 18 Japanese institutions. Dissection time was defined as the duration of forceps energy activation, and exposure time as the combined duration of manipulating the third arm and camera. To measure these times, an AI-based interface recognition model was developed to automatically extract instrument status from the da Vinci Surgical System® UI. We compared novices and experts by measuring dissection and exposure times from the model's output.

RESULTS

The overall accuracies of the UI recognition model for recognizing the forceps type, energy activation status, and camera usage status were 0.991, 0.998, and 0.991, respectively. Dissection time was 45.2 vs. 35.1 s (novice vs. expert, p = 0.374), exposure time was 195.7 vs. 89.7 s (novice vs. expert, p < 0.001), and the D/E ratio was 0.174 vs. 0.315 (novice vs. expert, p = 0.003).

CONCLUSIONS

We successfully developed a model to automatically acquire dissection and exposure parameters for RARP. Exposure time may serve as an objective parameter to distinguish between novices and experts in RARP, and automated technical evaluation in RARP is feasible.

TRIAL REGISTRATION NUMBER AND DATE

This study was approved by the Institutional Review Board of the National Cancer Center Hospital East (No.2020 - 329) on January 28, 2021.

Cross Sectional Survey of Ob/Gyn Residents' Graduated Experience With Robotic Surgery

STUDY OBJECTIVE

Obstetrics and gynecology (Ob/Gyn) resident experience with robotic gynecologic surgery has been evaluated at time of graduation, but no specific surgical procedures were identified to differentiate the experiences of residents at each level. This study proposes to determine which factors are correlated with more hands-on robotic surgery experience and resident satisfaction.

DESIGN

An Investigational Review Board-approved, 15-question survey was distributed electronically. Ninety-eight responses were received for a rate of 44%. Linear regression and Analysis of Variance statistical analysis were performed.

SETTING

Current residents at 8 Ob/gyn residency programs in the US were surveyed.

PATIENTS

N/A.

INTERVENTIONS

Survey administration.

MEASUREMENT AND MAIN RESULTS

The majority of respondents were satisfied (48%) or had neutral feelings (20%) with regard to their robotic surgery experience. All respondents reported experience with uterine manipulation or bedside assistance by postgraduate year (PGY) 2. Earliest experience performing hysterectomy was most common in PGY2 or PGY3. Seventy-six percent of PGY3 or PGY4 residents report operating on the console for some or all major robotic surgeries, with 69% having participated in greater than 20 robotic surgery cases during residency. Only exposure to Minimally Invasive Gynecologic Surgery faculty is significantly associated with high robotic surgery experience (p = .022). Overall satisfaction with robotic surgery experience increased significantly with higher level of participation (p <.0001), particularly operating at the console during some or most of the surgery; longitudinal experiences with hysterectomy, myomectomy, and salpingectomy/oophorectomy (p <.05); but not with sole bedside assisting or vaginal cuff closure. Factors limiting robotic console experience included case time constraints, lack of first assists, case complexity, and attending comfort.

CONCLUSIONS

Ob/Gyn resident satisfaction with training is significantly related to level and duration of robotic surgery participation. Minimally Invasive Gynecologic Surgery faculty contribute to more resident experience, and limiting factors include time constraints, case complexity, and lack of first assists. These results can provide a framework for structuring resident training in robotic surgery.

Artificial Intelligence, the ChatGPT Large Language Model: Assessing the Accuracy of Responses to the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) Level 1-2 knowledge tests

Background

In 2022, OpenAI launched ChatGPT 3.5, which is now widely used in medical education, training, and research. Despite its valuable use for the generation of information, concerns persist about its authenticity and accuracy. Its undisclosed information source and outdated dataset pose risks of misinformation. Although it is widely used, AI-generated text inaccuracies raise doubts about its reliability. The ethical use of such technologies is crucial to uphold scientific accuracy in research.

Objective

This study aimed to assess the accuracy of ChatGPT in doing GESEA tests 1 and 2.

Materials and Methods

The 100 multiple-choice theoretical questions from GESEA certifications 1 and 2 were presented to ChatGPT, requesting the selection of the correct answer along with an explanation. Expert gynaecologists evaluated and graded the explanations for accuracy.

Main outcome measures

ChatGPT showed a 59% accuracy in responses, with 64% providing comprehensive explanations. It performed better in GESEA Level 1 (64% accuracy) than in GESEA Level 2 (54% accuracy) questions.

Conclusions

ChatGPT is a versatile tool in medicine and research, offering knowledge, information, and promoting evidence-based practice. Despite its widespread use, its accuracy has not been validated yet. This study found a 59% correct response rate, highlighting the need for accuracy validation and ethical use considerations. Future research should investigate ChatGPT's truthfulness in subspecialty fields such as gynaecologic oncology and compare different versions of chatbot for continuous improvement.

What is new?

Artificial intelligence (AI) has a great potential in scientific research. However, the validity of outputs remains unverified. This study aims to evaluate the accuracy of responses generated by ChatGPT to enhance the critical use of this tool.

From gaming to surgery: the influence of digital natives on robotic skills development

Our study investigates the potential correlation between generational differences, like age and previous experience with digital innovations, such as video games and smartphones, and the performance on the Da Vinci Skills Simulator, the cornerstone of robotic surgery training. Thirty participants were involved from three age groups: Generation Alpha, Generation Z, and Generation X. None had prior robotic surgical experience. Participants performed the Wrist Articulation 1 task on the Da Vinci Skills Simulator after two practice rounds. Analysis of performance metrics and statistical tests were conducted to assess the differences between groups. Additionally, participants had completed a survey on their habits related to video gaming, smartphone, and computer usage. A trend was observed where performance declined with age, meaning that Generation Alpha performed the most successfully compared to the other generations, although the difference was not statistically significant (p = 0.51). However, significant differences were found in Glass Movement (GM) by Generation Z showing superior precision, making less errors (p = 0.019). The study found no correlation between simulator performance and early or frequent exposure to smartphones or video games. Interestingly, frequent two-thumb typing on smartphones correlated with better performance in the GM metric (p = 0.006). Generation Z demonstrated greater precision in handling the simulator, reflecting that robotic surgery training might be best to be started at the beginning of residency programs. Young doctors using two-thumb typing develop robotic surgery skills faster. Further studies are needed to determine whether this quicker learning would also lead to better skills later on.

Consensus guidelines on the bedside assistant skills required in robotic surgery

BACKGROUND

While bedside assistants play a critical role in many robotic operations, substantial heterogeneity remains in bedside assistant training pathways. As such, this study aimed to develop consensus guidelines for bedside assistant skills required for team members in robotic operations.

METHODS

We designed a study using the Delphi process to develop consensus guidelines around bedside assistant skills. We generated an initial list of bedside assistant skills from the literature, training materials, and expert input. We selected experts for the Delphi process based on prior scholarship in the area of robotic bedside assistant education and experience facilitating robotic bedside assistant training. For each item, respondents specified which robotic team members should have the skill from a list of "basic" bedside assistants, "advanced" bedside assistants, surgeons, surgical technologists, and circulating nurses. We conducted two rounds of the Delphi process and defined 80% agreement as sufficient for consensus.

RESULTS

Fourteen experts participated in two rounds of the Delphi process. By the end of the second round, the group had reached consensus on 253 of 305 items (83%). The group determined that "basic" bedside assistants should have 52 skills and that "advanced" bedside assistants should have 60 skills. The group also determined that surgeons should have 54 skills, surgical technologists should have 25 skills, and circulating nurses should have 17 skills. Experts agreed that all participants should have certain communication skills and basic knowledge of aspects of the robotic system.

CONCLUSIONS

We developed consensus guidelines on the skills required during robotic surgery by bedside assistants and other team members using the Delphi process. These findings can be used to design training around bedside assistant skills and assess team members to ensure that each team member has the appropriate skills. Hospitals can also use these guidelines to standardize expectations for robotic team members.

Robotic versus laparoscopic surgery for colorectal disease: a systematic review, meta-analysis and meta-regression of randomised controlled trials

INTRODUCTION

Robotic surgery (RS) is gaining prominence in colorectal procedures owing to advantages like three-dimensional vision and enhanced dexterity, particularly in rectal surgery. Although recent reviews report similar outcomes between laparoscopic surgery (LS) and RS, this study investigates the evolving trends in outcomes over time, paralleling the increasing experience in RS.

METHODS

A systematic review, meta-analysis and meta-regression were conducted of randomised controlled trials exploring postoperative outcomes in patients undergoing RS or LS for colorectal pathology. The primary outcome measure was postoperative complications. Risk of bias was evaluated using the Cochrane Collaboration's assessment tool. Randomised controlled trials were identified from the PubMed®, Embase® and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases via the Cochrane Central Register of Controlled Trials.

RESULTS

Of 491 articles screened, 13 fulfilled the inclusion criteria. Meta-analysis of postoperative complications revealed no significant difference between RS and LS (relative risk [RR]: 0.96, 95% confidence interval [CI]: 0.79 to 1.18, p=0.72). Meta-regression analysis of postoperative complications demonstrated a significant trend favouring RS over time (yearly change in Ln(RR): -0.0620, 95% CI: -0.1057 to -0.0183, p=0.005). Secondary outcome measures included operative time, length of stay, blood loss, conversion to open surgery, positive circumferential resection margins and lymph nodes retrieved. The only significant findings were shorter operative time favouring LS (mean difference: 41.48 minutes, 95% CI: 22.15 to 60.81 minutes, p<0.001) and fewer conversions favouring RS (RR: 0.57, 95% CI: 0.37 to 0.85, p=0.007).

CONCLUSIONS

As experience in RS grows, evidence suggests an increasing safety profile for patients. Meta-regression revealed a significant temporal trend with complication rates favouring RS over LS. Heterogeneous reporting of complications hindered subgroup analysis of minor and major complications. LS remains quicker. Rising adoption of RS coupled with emerging evidence is expected to further elucidate its clinical efficacy.

Differences in coaching in single- versus dual-console robotic cases: a mixed-methods study

BACKGROUND

A growing importance has been placed on development of trainee robotic surgical skills through simulation curricula and intraoperative experience. However, few studies have examined how console case type impacts learning outcomes. We sought to evaluate how intraoperative coaching and resident autonomy differ based on the use of a single- versus dual-console robot.

METHODS

Robotic single- and dual-console cases from February to September 2023 at a single institution were included. Faculty and trainees wore microphones to capture audio during the case. Pre/post surveys were administered, which included metrics on faculty coaching based on the Wisconsin Surgical Coaching Rubric (WiSCoR) and on trainee technical performance based on the Global Evaluative Assessment of Robotic Skills (GEARS). Statistical analysis of survey data was performed using SPSS. Audio from cases was coded by 2 researchers with a deductive approach using WiSCoR as a framework.

RESULTS

Data were collected for 7 (38.9%) single and 11 (61.1%) dual-console cases across 9 case types from 4 surgical specialties. Chi-square analysis demonstrated no significant difference in percentage of case trainee spent in the operating surgeon role based on trainee level or console case type. Independent t-tests showed no significant difference in trainee autonomy, trainee performance, or faculty coaching scores based on console case type. Trainees rated faculty highest in WiSCoR Domains 1 (sharing responsibility) and 3 (providing constructive feedback). Qualitative analysis showed that for single-console cases, Domain 4 (goal setting) was most represented (34.0% of comments), while for dual-console cases, Domain 1 was most represented (37.0% of comments).

CONCLUSIONS

Qualitative analysis highlights that despite similar survey-based faculty ratings across domains, coaching on self-reflection (Domain 2) is infrequently done, highlighting an opportunity for improvement in this area of coaching during robotic surgery.

Development and Videographic Evaluation of a Vascular Access Simulation-Based Curriculum for Surgical and Medical Trainees

Background

There is a paucity of data evaluating femoral arterial access training, despite significant morbidity/mortality associated with incorrect femoral arterial access. The aim of this study was to develop and evaluate a novel 2-component simulation-based curriculum to address a lack of standardized access training and identify the most frequent errors in access.

Methods

The femoral arterial access curriculum was developed through a multi-disciplinary collaboration and utilized in-person simulation sessions in conjunction with online and in-person didactic training. Access errors and curriculum efficacy were assessed using mixed-methodology evaluation of video recordings of trainee arterial access pre- and postcurriculum. All recordings were reviewed and scored by 2 blinded, independent investigators.

Results

Twenty-six participants completed the curriculum with pre- and postcurriculum recordings. Sixteen participants (62%) were in their first year of residency training. Fifteen participants (58%) belonged to general surgery residency, 9 (35%) to emergency medicine, 1 to vascular surgery, and 1 to interventional radiology residency programs. The global rating for the overall ability to obtain femoral arterial access under ultrasound guidance (0 = fail, 4 = excellent) improved following the curriculum (0.87 ± 0.15, 2.79 ± 1.26, P < 0.0001). Fourteen participants (54%) were unable to independently complete the procedure before training, compared to only 2 participants (8%) following the curriculum. Procedural completion time decreased from 7.14 ± 4.26 to 3.81 ± 2.53 minutes (P < 0.001). Most frequent errors, determined through qualitative analysis, included difficulty using the ultrasound and unsafe maneuvers.

Conclusions

Before the curriculum, there were significant frequent errors in junior resident femoral arterial access with major patient safety concerns. A novel simulation-based femoral arterial access curriculum resulted in improved procedural skills across all metrics.

Current status of resident simulation training curricula: pearls and pitfalls

BACKGROUND

Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation.

MATERIALS AND METHODS

Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected.

RESULTS

Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding.

CONCLUSIONS

While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

Skill progress during a dedicated societal robotic surgery training curriculum including several robotic surgery platforms

BACKGROUND

Robot-assisted procedures are increasingly common, and several systems are available for thoraco-abdominal surgery. Specific structured training is necessary, while access to these systems is still limited. This study aimed to assess surgeons' skill progress during consecutive training days of a curriculum with exposure to different robotic systems.

METHODS

This prospective observational study enrolled 47 surgeons with anonymized analysis of SimNow™ simulator performance scores and dedicated questionnaires after written consent. The primary outcome was the overall score, based on economy of motion, time to complete the exercise, and penalty for errors. Course participants in 2022-2023 had chosen 2 full hands-on days on Da Vinci® consoles with either virtual reality (VR) simulation training using the SimNow (n = 21, 44.7%) or digestive surgery procedures with a live animal model (n = 26, 55.3%). In all participants, training on Da Vinci® systems included console functions and principles of docking, camera, and instrument use for console and procedural training. They additionally had access to introductory dry-lab and VR simulator exercises on the Versius, HugoTMRAS, and Dexter systems and to VR exercises on the ROBOTiS simulator.

RESULTS

The participants (16F/31M, median age 40 years, range 29-58) from various surgical specialties (general/visceral/vascular) had no (n = 35, 74.5%) or little (n = 12, 25.5%) robotic experience including bedside assistance only and 20 (42.6%) had robotic simulator experience. The demographic variables fully completed by 44/47 participants (93.6%) and choice of module had no significant impact on the primary outcome. The considerable performance improvement from days 1 to 2 was exemplified by a significantly increased economy of motion and decreased amount of excessive force.

CONCLUSION

Robotic surgical training is increasingly complex with several systems on the market. Within a dedicated robotic surgery curriculum and based on integrated performance metrics, a significant improvement of skill levels was observed in a relatively short period of time.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review

INTRODUCTION

Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility.

METHODS

A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed.

RESULTS

Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room.

CONCLUSIONS

Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Original Clinical Research.

Step-by-step roadmap to building a robotic acute care surgery program (RACSP) in a level I trauma center: outcomes and lessons learned after 1-year implementation

Minimally invasive surgical techniques have demonstrated superior outcomes across various elective procedures. Laparoscopic surgery (LS) is established in general surgery with laparoscopic operations for acute appendicitis and cholecystitis being the standard of care. Robotic surgery (RS) has been associated with equivalent or improved postoperative outcomes compared with LS. This increasing uptake of RS in emergency general surgery has encouraged the adoption of robotic acute care programs across the world. The key elements required to build a sustainable RS program are an enthusiastic surgical team, intensive training, resources and marketing. This review is a comprehensive layout elaborating the step-by-step process that has helped our high-volume level I trauma center in establishing a successful robotic acute care surgery program.

Navigating the Metaverse: A New Virtual Tool with Promising Real Benefits for Breast Cancer Patients

BC, affecting both women and men, is a complex disease where early diagnosis plays a crucial role in successful treatment and enhances patient survival rates. The Metaverse, a virtual world, may offer new, personalized approaches to diagnosing and treating BC. Although Artificial Intelligence (AI) is still in its early stages, its rapid advancement indicates potential applications within the healthcare sector, including consolidating patient information in one accessible location. This could provide physicians with more comprehensive insights into disease details. Leveraging the Metaverse could facilitate clinical data analysis and improve the precision of diagnosis, potentially allowing for more tailored treatments for BC patients. However, while this article highlights the possible transformative impacts of virtual technologies on BC treatment, it is important to approach these developments with cautious optimism, recognizing the need for further research and validation to ensure enhanced patient care with greater accuracy and efficiency.

European Robotic Surgery Consensus (ERSC): Protocol for the development of a consensus in robotic training for gastrointestinal surgery trainees

BACKGROUND

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process.

METHODS AND ANALYSIS

In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document.

REGISTRATION DETAILS

The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

[State of the art: Simulation in US]

Technical simulation of diagnostic and therapeutic procedures is of growing relevance for student education and advanced medical training and has already been introduced in the field of ultrasound. This review gives a broad overview on different levels of simulation for ultrasound diagnostics and highlights the technical background of the methodology. A critical review of the literature reveals recommendations for implementing simulation techniques in medical studies and professional ultrasound training. An analysis of strengths and weaknesses shows the advantages of simulation especially in the context of individual learning situations and COVID-19-related restrictions for personal interaction. However, simulation techniques cannot replace the experiences of complex clinical examinations with direct interaction to real patients. Therefore, future applications may focus on repetition and assessment of achieved competencies by using standardized feedback mechanisms in order to preserve the limited resources for practical medical training.

Training and assessment for colorectal surgery and appendicectomy- a systematic review

AIM

There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach.

METHOD

A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported.

RESULTS

Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery.

CONCLUSION

This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

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.

Optimizing laparoscopic and robotic skills through simulation in participants with limited or no prior experience: a systematic review and meta-analysis

BACKGROUND

Simulation is an innovative tool for developing complex skills required for surgical training. The objective of this study was to determine the advancement of laparoscopic and robotic skills through simulation in participants with limited or no previous experience.

METHODS

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. We conducted searches using MEDLINE (PubMed), Web of Science, Google Scholar, and Cochrane Library. Variables analyzed were study characteristics, participant demographics, and characteristics of the learning program. Our main measures were effectiveness, surgical time, and errors. These were reported using standardized mean difference (SMD) with 95% CI (P < .05). Secondary measures included skill transfer and learning curve.

RESULTS

A total of 17 RCTs were included and comprised 619 participants: 354 participants (57%) were in the simulation group and 265 (43%) in the control group. Results indicated that laparoscopic simulation effectively enhanced surgical skills (SMD, 0.59 [0.18-1]; P = .004) and was significantly associated with shorter surgical duration (SMD, -1.08 [-1.57 to -0.59]; P < .0001) and a fewer errors made (SMD, -1.91 [-3.13 to -0.70]; P = .002). In the robotic simulation, there was no difference in effectiveness (SMD, 0.17 [-0.19 to 0.52]; P = .36) or surgical time (SMD, 0.27 [-0.86 to 1.39]; P = .64). Furthermore, skills were found to be transferable from simulation to a real-life operating room (P < .05).

CONCLUSION

Simulation is an effective tool for optimizing laparoscopic skills, even in participants with limited or no previous experience. This approach not only contributes to the reduction of surgical time and errors but also facilitates the transfer of skills to the surgical environment. In contrast, robotic simulation fails to maximize skill development, requiring previous experience in laparoscopy to achieve optimal levels of effectiveness.

[How I Teach It: Robotic Surgery in the Upper GI Tract]

In this manuscript, we present our concept for training in robotic surgery of the upper gastrointestinal tract. The training concept presented here focuses on the two surgical "user groups", assistants (table assists) and specialists (surgeons), and presents the core aspects of training for each group separately.For table assistants, we present opportunities for early involvement in robotics and our approach to learning the first steps in preparing for surgery, assisting during surgery, as well as communication as a key factor in robotic surgery and alternative training.For specialists who are to learn how to perform robotic procedures independently, we discuss virtual training using SimNow Trainer and our preferred early clinical application. We will also present assistance options such as the dual console setup and the telestration system. Finally, we present our training concept for developing robotic surgical skills in the upper gastrointestinal tract through a combination of partial steps and increasing difficulty of the procedures. In our view, it is essential to teach the stepstones of robotic surgery and to master them safely. To this end, training must be structured and regular so that more complex sub-steps and procedures can be taken over step by step.

The deconstructed procedural description in robotic colorectal surgery

Increasing robotic surgical utilisation in colorectal surgery internationally has strengthened the need for standardised training. Deconstructed procedural descriptions identify components of an operation that can be integrated into proficiency-based progression training. This approach allows both access to skill level appropriate training opportunities and objective and comparable assessment. Robotic colorectal surgery has graded difficulty of operative procedures lending itself ideally to component training. Developing deconstructed procedural descriptions may assist in the structure and progression components in robotic colorectal surgical training. There is no currently published guide to procedural descriptions in robotic colorectal surgical or assessment of their training utility. This scoping review was conducted in June 2022 following the PRISMA-ScR guidelines to identify which robotic colorectal surgical procedures have available component-based procedural descriptions. Secondary aims were identifying the method of development of these descriptions and how they have been adapted in a training context. 20 published procedural descriptions were identified covering 8 robotic colorectal surgical procedures with anterior resection the most frequently described procedure. Five publications included descriptions of how the procedural description has been utilised for education and training. From these publications terminology relating to using deconstructed procedural descriptions in robotic colorectal surgical training is proposed. Development of deconstructed robotic colorectal procedural descriptions (DPDs) in an international context may assist in the development of a global curriculum of component operating competencies supported by objective metrics. This will allow for standardisation of robotic colorectal surgical training and supports a proficiency-based training approach.

"Role-sharing surgery": a new surgical education system that gives beginner surgeons more chances to operate while ensuring the surgical quality of robotic surgery

It has been pointed out that robotic surgery is more time-consuming than laparoscopic surgery, and a major challenge for the future is educating young surgeons while maintaining the surgical quality. To solve these problems, we report a role-sharing surgery (RSS) approach in which the surgery is divided into several areas and timetabled, with roles shared by several operators. We performed RSS for 19 standard colorectal cancer surgeries. The surgery was completed within + 28 min of the scheduled operation time, and a beginner robotic surgeon (BRS) was able to perform approximately 66% of the total surgery. There were no statistically significant differences in the short-term outcomes between the RSS and conventional surgery groups. Based on these findings, RSS has the potential to be the best practice for educating BRSs in robotic surgery, the use of which is expected to increase steadily in the future.

Perception of robotic-assisted surgery (RAS) among medical students: a systematic review and meta-analysis

INTRODUCTION

Robotic surgery, also known as robotic-assisted surgery (RAS), involves a camera and a small surgical instrument attached to a robotic arm. A trained surgeon operates the robot from a viewing screen while being in the same room.

METHODOLOGY

This review was prepared following Cochrane collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Two authors independently searched and appraised the studies published in PubMed, cumulative index to nursing and allied health literature (CINAHL), Embase, Clinical Key, and Google Scholar. Pooled data analyzed and reported in RevMan software version-5.4.

RESULTS

This systematic review and meta-analysis comprised 1400 medical students, from 8 studies. The participants' age ranged from 23 to 49 years. Similarly, the sample size ranged from 25 and 300. The pooled prevalence of the existing studies revealed that 29.8% of medical students, were favorable towards RAS. Effect size (ES), 95% confidence intervals (CI) and heterogeneity (I2) [ES = 29.8, 95% CI 16.4-43.2, I2 = 95.1%, P < 0.00]. About 40% of Australian medical students' positive opinion on RAS [ES = 40.4, 95% CI 25.7-55.2]. Similarly, 34.2% of students from Saudi Arabia [ES = 29.8, 95% CI 22.4-90.8, I2 = 99.3%, P < 0.00], 27.8% students from Canada [ES = 27.8, 95% CI 15.9-39.6], 24.8% from USA [ES = 24.8, 95% CI 6.9-42.7, I2 = 77.3%, P < 0.00] and 24% [ES = 24, 95% CI 18-30] from India favorable towards RAS.

DISCUSSION

Medical students from developed nations display favorable attitudes towards RAS. However, implementing of revised curriculum at the beginning of the graduation level sparks medical students' attitude towards robotic surgery.

Comparison of Attempts Needed for Veterinary Students to Reach Proficiency in a Basic and Advanced Robotic Simulator Task

Surgical training of students is one of the most difficult aspects of veterinary medical education. Competing interests of house officers, owners' wishes, and ethical concerns have led to increasing use of inanimate models for basic surgical skills training. Robotic simulators have benefits for psychomotor training but have not been previously investigated in veterinary medicine. Understanding the necessary practice time for new training devices is important when determining their potential value. The aim of this study was to compare the number of attempts needed for veterinary students to reach proficiency in both a basic and advanced robotic simulator task, and to assess the predictive nature of performance variables. Each student performed a basic and advanced tasks on the Mimic dV-Trainer™ until proficiency was reached. Students required a median of eight attempts (95% CI = 7-8, range: 6-11) to reach proficiency for the basic task versus 22 attempts (95% CI = 20-26, range: 11-62) for the advanced task. The median time required to complete training for the basic and advanced task was 13.5 minutes (range: 8-24 minutes) and 26.5 minutes (range: 11-82 minutes) respectively. The difference in task attempts supports the training protocol and confirms proficiency can be attained in a short period of time. The number of attempts to reach proficiency correlated with specific performance variables that can be used by educators to aid in training students on a robotic simulator. Continued investigations on robotic simulators should be performed to investigate their use in improving psychomotor skills in veterinary students.

Robotic surgery education in Australia and New Zealand: primetime for a curriculum

BACKGROUND

Globally, robotic surgery (RS) has witnessed remarkable growth, yet Australia and New Zealand (ANZ) lack dedicated RS training programs, creating a workforce gap. This narrative review synthesises international research to explore trends and challenges in robotic education.

METHODS

We conducted a comprehensive literature review, searching PubMed, Google Scholar, and MEDLINE using keywords like 'robotic surgery', 'surgical education', 'robotic surgery training', and 'robotic surgery curriculum'. We selected studies contributing to understanding current curricula, training tools, and issues in robotic education, utilising the international experience and how it might apply to the ANZ context.

RESULTS

RS in ANZ has grown significantly over two decades, but formal curricula for trainees are absent. North America and Europe employ diverse training tools and curricula. Barriers include cost, access, time constraints, equipment complexity, changing training environments, and competition from emerging robotic surgical systems. Balancing the curriculum's demands with trainees' existing requirements is essential.

CONCLUSION

Developing a tailored RS curriculum within ANZ's surgical training is crucial for RS to become the primary surgical approach in the future. By working towards a national curriculum we can prepare skilled trainees in robotics to meet the rising demand. The most significant barrier is the lack of robotics in public hospital where trainees are based. This curriculum should encompass online teaching modules, bedside assistance, surgical simulation, dual console mentoring, and primary operator experience.

Use of targeted educational resources to improve robotic bariatric surgery training

BACKGROUND

Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures.

METHODS

Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied.

RESULTS

From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5).

CONCLUSION

Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

Implementation of a robotic surgical practice in inflammatory bowel disease

Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.

Conception and prospective multicentric validation of a Robotic Surgery Training Curriculum (RoSTraC) for surgical residents: from simulation via laboratory training to integration into the operation room

There is a lack of training curricula and educational concepts for robotic-assisted surgery (RAS). It remains unclear how surgical residents can be trained in this new technology and how robotics can be integrated into surgical residency training. The conception of a training curriculum for RAS addressing surgical residents resulted in a three-step training curriculum including multimodal learning contents: basics and simulation training of RAS (step 1), laboratory training on the institutional robotic system (step 2) and structured on-patient training in the operating room (step 3). For all three steps, learning content and video tutorials are provided via cloud-based access to allow self-contained training of the trainees. A prospective multicentric validation study was conducted including seven surgical residents. Transferability of acquired skills to a RAS procedure were analyzed using the GEARS score. All participants successfully completed RoSTraC within 1 year. Transferability of acquired RAS skills could be demonstrated using a RAS gastroenterostomy on a synthetic biological organ model. GEARS scores concerning this procedure improved significantly after completion of RoSTraC (17.1 (±5.8) vs. 23.1 (±4.9), p < 0.001). In step 3 of RoSTraC, all participants performed a median of 12 (range 5-21) RAS procedures on the console in the operation room. RoSTraC provides a highly standardized and comprehensive training curriculum for RAS for surgical residents. We could demonstrate that participating surgical residents acquired fundamental and advanced RAS skills. Finally, we could confirm that all surgical residents were successfully and safely embedded into the local RAS team.

Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation

Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.

The application of objective clinical human reliability analysis (OCHRA) in the assessment of basic robotic surgical skills

BACKGROUND

Using a validated, objective, and standardised assessment tool to assess progression and competency is essential for basic robotic surgical training programmes. Objective clinical human reliability analysis (OCHRA) is an error-based assessment tool that provides in-depth analysis of individual technical errors. We conducted a feasibility study to assess the concurrent validity and reliability of OCHRA when applied to basic, generic robotic technical skills assessment.

METHODS

Selected basic robotic surgical skill tasks, in virtual reality (VR) and dry lab equivalent, were performed by novice robotic surgeons during an intensive 5-day robotic surgical skills course on da Vinci® X and Xi surgical systems. For each task, we described a hierarchical task analysis. Our developed robotic surgical-specific OCHRA methodology was applied to error events in recorded videos with a standardised definition. Statistical analysis to assess concurrent validity with existing tools and inter-rater reliability were performed.

RESULTS

OCHRA methodology was applied to 272 basic robotic surgical skills tasks performed by 20 novice robotic surgeons. Performance scores improved from the start of the course to the end using all three assessment tools; Global Evaluative Assessment of Robotic Skills (GEARS) [VR: t(19) = - 9.33, p < 0.001] [dry lab: t(19) = - 10.17, p < 0.001], OCHRA [VR: t(19) = 6.33, p < 0.001] [dry lab: t(19) = 10.69, p < 0.001] and automated VR [VR: t(19) = - 8.26, p < 0.001]. Correlation analysis, for OCHRA compared to GEARS and automated VR scores, shows a significant and strong inverse correlation in every VR and dry lab task; OCHRA vs GEARS [VR: mean r = - 0.78, p < 0.001] [dry lab: mean r = - 0.82, p < 0.001] and OCHRA vs automated VR [VR: mean r = - 0.77, p < 0.001]. There is very strong and significant inter-rater reliability between two independent reviewers (r = 0.926, p < 0.001).

CONCLUSION

OCHRA methodology provides a detailed error analysis tool in basic robotic surgical skills with high reliability and concurrent validity with existing tools. OCHRA requires further evaluation in more advanced robotic surgical procedures.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

Influence of Otolaryngological Subspecialties on Perception of Transoral Robotic Surgery: An International YO-IFOS Survey

BACKGROUND

To investigate perception, adoption, and awareness on the part of otolaryngology and head and neck surgeons (OTO-HNS) of transoral robotic surgery (TORS).

METHODS

Several items assessed: awareness/perception; access to TORS; training; indications and advantages/hurdles to TORS practice. A subanalysis was performed to assess differences according to the identified otolaryngological subspecialties.

RESULTS

A total of 359 people completed the survey. Among subspecialties, while for otolaryngologists 30/359 (8.4%) and H&N surgeons 100/359 (27.9%) TORS plays an effective role in hospital stay, laryngologists frequently disagreed (54.3%). There was a lower incidence among rhinologists and otologists (1.9%). Pediatric surgeons (0.8%) reported a positive response regarding the adoption of robotic surgery, and head and neck specialists expressed an even greater response (14.2%). Low adherence was related to perceived cost-prohibitive TORS, by 50% of H&N surgeons.

CONCLUSIONS

Perception, adoption, and knowledge about TORS play a key role in the application of the robotic system, significantly varying across subspecialties.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

A dedicated robotic bedside physician assistant significantly enhances trainee console operating time in general thoracic surgery

Objective

As trainees rotate through thoracic subspecialties within their curricula, a crucial portion of their robotic training consists of actual console operating time. The more time spent on the surgeon console, the greater the development will be through the course of their training. Implementing a physician assistant at the bedside may increase the operative console time for the trainee and develop robotic skills in a more expeditious rate. The objective was to evaluate the impact a designated robotic physician assistant can have on trainee console learning opportunity.

Methods

Operating room data collected consisted of all robotic general thoracic surgical cases that trainees participated in with and without a physician assistant present. Metrics regarding case efficiency included anesthesia ready-to-incision, incision-to-console, and raw resident console times. By using PRISM software, a nonparametric t test was used to analyze each averaged data group compared between when a physician assistant was present and not present.

Results

The mean resident console time without and with a physician assistant assist was 45.8 minutes and 80.9 minutes, respectively (P < .0001). The average portion of a case performed by a trainee similarly without and with a physician assistant present was 28.0% and 77.1%, respectively (P < .0001). Case efficiency metrics between physician assistant presence cohorts showed no difference.

Conclusions

Thoracic surgical trainees have increased opportunity for robotic skill development within a fellowship or resident program curriculum when a designated robotic physician assistant is present in the operating room. These findings are significant for the improvement of residency and fellowship robotic training models moving forward by incorporating robotic-specialized physician assistants in academic institutions.

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.

Safe implementation of a minimally invasive hepatopancreatobiliary program, a narrative review and institutional experience

Laparoscopic and robotic-assisted approaches to hepatopancreatobiliary (HPB) operations have expanded worldwide. As surgeons and medical centers contemplate initiating and expanding minimally invasive surgical (MIS) programs for complex HPB surgical operations, there are many factors to consider. This review highlights the key components of developing an MIS HPB program and shares our recent institutional experience with the adoption and expansion of an MIS approach to pancreaticoduodenectomy.

Characterization of the robotic surgery experience in minimally invasive surgery fellowships from 2010 to 2021

BACKGROUND

Robotic surgery has experienced exponential growth in the past decade. Few studies have evaluated the impact of robotics within minimally invasive surgery (MIS) fellowship training programs. The purpose of our study was to examine and characterize recent trends in robotic surgery within MIS fellowship training programs.

METHODS

De-identified case log data from the Fellowship Council from 2010 to 2021 were evaluated. Percentage of operations performed with robot assistance over time was assessed and compared to the laparoscopic and open experience. Case logs were further stratified by operative category (e.g., bariatric, hernia, foregut), and robotic experience over time was evaluated for each category. Programs were stratified by percent robot use and the experience over time within each quartile was evaluated.

RESULTS

MIS fellowship training programs with a robotic platform increased from 45.1% (51/113) to 90.4% (123/136) over the study period. The percentage of robotic cases increased from 2.0% (1127/56,033) to 23.2% (16,139/69,496) while laparoscopic cases decreased from 80.2% (44,954/56,033) to 65.3% (45,356/69,496). Hernia and colorectal case categories had the largest increase in robot usage [hernia: 0.7% (62/8614) to 38.4% (4661/12,135); colorectal 4.2% (116/2747) to 31.8% (666/2094)]. When stratified by percentage of robot utilization, current (2020-2021) programs in the > 95th percentile performed 21.8% (3523/16,139) of robotic operations and programs in the > 50th percentile performed 90.0% (14,533/16,139) of all robotic cases. The median number of robotic cases performed per MIS fellow significantly increased from 2010 to 2021 [0 (0-6) to 72.5 (17.8-171.5), p < 0.01].

CONCLUSIONS

Robotic use in MIS fellowship training programs has grown substantially in the past decade, but the laparoscopic and open experience remains robust. There remains an imbalance with the top 50% of busiest robotic programs performing over 90% of robot trainee cases. The experience in MIS programs varies widely and trainees should examine program case logs closely to confirm parallel interests.