Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum

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.

National survey on data governance and digital surgery: Challenges and opportunities for surgeons in the era of artificial intelligence

INTRODUCTION

This study evaluates the knowledge of Spanish surgeons regarding data governance and Digital Surgery, their usage, errors, and training deficiencies, as well as differences in knowledge between those who perform robotic surgery and those who do not.

METHODS

A descriptive study was conducted using a closed survey promoted by the Minimally Invasive Surgery and Technological Innovation Section of the Spanish Association of Surgeons, directed at its members between February and March 2024.

RESULTS

Out of 1086 surgeons contacted, 396 responded (36.46%). While 98.3% use electronic medical records, 45.4% lack organized data recording systems. Although 55.9% have access to robotic technology, 70.6% do not use it directly. Surgeons who perform robotic surgery show a higher general knowledge of Digital Surgery terms (7.2 vs 6.619; P = .215) and specifically of "Artificial Intelligence" (57.14% compared to less than 25% for other terms), although these differences are not significant. However, there are significant differences in interest in digital technology between those who perform robotic surgery and those who do not (P = .023). Additionally, surgeons who support training in digital technology during residency are nearly twice as likely to research Digital Surgery.

CONCLUSION

Surgeons are crucial for the digital transformation in surgery, but many are poorly prepared and insufficiently involved. Those who practice robotic surgery have more knowledge and interest in digital technology, highlighting the need for improved training and governance frameworks to better integrate surgeons into the digital era.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access

BACKGROUND

Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption.

METHODS

A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results.

RESULTS

Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training.

CONCLUSIONS

This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

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

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

Advancing minimally invasive hepato-pancreato-biliary surgery: ensuring safety with implementation

BACKGROUND

Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs.

METHODS

Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used.

RESULTS

Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery.

CONCLUSIONS

Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.

The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants"

OBJECTIVE

To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework.

BACKGROUND

The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program.

METHODS

Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned."

RESULTS

Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome.

CONCLUSIONS

The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.

The importance of robotic surgery training in HPB fellowship: a survey of the 2022 AHPBA fellows

BACKGROUND

The 2022 incoming fellows' expectations for their robotics training, as well as their perceptions of the utility of the surgical robot, are not well defined.

METHODS

Cross-sectional survey of 24 AHPBA fellows in 2022, analyzed with descriptive statistics and Spearman's rho.

RESULTS

Of 33 current AHPBA fellows, 22 completed the survey (66.7%). Study participants had limited-to-moderate experience with robotics prior to fellowship (mean 2.5 ± SD 1.1; range 1-4). Most participants agreed that robotics influenced their fellowship choice (mean 4.14 ± SD 0.87; range 1-5), would make then more marketable (mean 4.77 ± SD 0.52; range 1-5) and improve job prospects (mean 4.68 ± SD 0.87; range 1-5). Of the study participants, 55% responded that robotics training is "essential" in fellowship, while 64% responded that it is "essential" for their careers. Fellows were only slightly satisfied with overall robotics training within their respective programs (mean 3.44 ± SD 1.17; range 1-5) The majority (73.7%) expect that robotics will comprise <25% of their training. Notably, the majority (75%) have no formal robotics training curriculum.

DISCUSSION

This survey identifies potential gaps where robotics training could be improved for future incoming AHPBA fellows.

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

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

The Atlantic divide: contrasting surgical robotics training in the USA, UK and Ireland

The uptake of robotic surgery is rapidly increasing worldwide across surgical specialties. However, there is currently a much higher use of robotic surgery in the United States of America (USA) compared to the United Kingdom (UK) and Ireland. Reduced exposure to robotic surgery in training may lead to longer learning curves and worse patient outcomes. We aimed to identify whether any difference exists in exposure to robotic surgery during general surgical training between trainees in the USA, UK and Ireland. Over a 15-week period from September 2021, a survey was distributed through the professional networks of the research team. Participants were USA, UK or Irish trainees who were part of a formal general surgical training curriculum. 116 survey responses were received. US trainees (n = 34) had all had robotic simulator experience, compared to only 37.93% of UK (n = 58) and 75.00% of Irish (n = 24) trainees (p <  0.00001). 91.18% of US trainees had performed 15 or more cases as the console surgeon, compared to only 3.44% of UK and 16.67% of Irish trainees (p <  0.00001). Fifty UK trainees (86.21%) and 22 Irish trainees (91.67%) compared to 12 US trainees (35.29%) do not think they have had adequate robotics training (p <  0.00001). Surgical trainees in the USA have had significantly more exposure to training in robotic surgery than their UK and Irish counterparts.

Auswirkungen der COVID-19-Pandemie auf die robotische Viszeralchirurgie in Deutschland

Einleitung

Der Einsatz roboterassistierter Operationen verzeichnet in der Viszeralchirurgie gegenwärtig einen stetigen Zuwachs. Im Jahr 2020 hat die COVID-19-Pandemie den klinischen und chirurgischen Alltag unerwartet wesentlich verändert. Wir haben in einer Umfrage den Status der roboterassistierten Viszeralchirurgie in Deutschland sowie die gegenwärtigen Ausbildungskonzepte evaluiert und deren Veränderungen unter dem Einfluss der COVID-19-Pandemie untersucht.

Material und Methoden

In einer umfangreichen Recherche wurden 89 Kliniken identifiziert, welche ein Robotersystem für die Viszeralchirurgie 2020 einsetzten. Diese Kliniken wurden über eine webbasierte anonyme Umfrage mit 35 Fragen dreimal kontaktiert. Die Fragen bezogen sich auf die Einsatzgebiete eines Operationsroboters in der Viszeralchirurgie, die dazugehörige klinische Ausbildung und den Einfluss der COVID-19-Pandemie auf das bestehende Programm.

Ergebnisse

Von den angeschriebenen Kliniken haben 22 (24,7%) eine Rückmeldung gegeben. Hiervon waren 17 (19,1%) Fragebögen auswertbar. Es beteiligten sich 58,8% Universitätsklinika, 17,6% Maximalversorger und 23,5% Schwerpunktkrankenhäuser an der Studie. Der Operationsroboter wurde am oberen Gastrointestinaltrakt (OGIT; 88,2%), am hepatopankreatikobiliären System (HPB; 82,4%) und im kolorektalen Bereich (KRK; 94,1%) sowie bei der Hernienversorgung (35,3%) eingesetzt. Der relative Anteil robotischer Eingriffe am operierten Gesamtkollektiv lag dabei zwischen 0,3% und 15,4%. Die Konversionsraten für 2020 lag im Mittel bei 4,6 ± 3,2%. Die Operationsroboter wurden zum Großteil im interdisziplinären Setting wechselweise mit anderen chirurgischen Disziplinen (82,4%) genutzt. Zu Lehrzwecken stand in sieben Kliniken (41,2%) eine zweite Konsole zur Verfügung. Die Ausbildungsstrukturen waren sehr heterogen und nur 13,2 ± 6,5% der Chirurg*innen pro Klinik waren in das Roboterprogramm involviert. In 82,4% existierten feste Teams, die sich aus Ober‑, Fach- und Assistenzärzt*innen zusammensetzen und in 76,5% wurden Ärzt*innen und Pflegepersonal über klinikinterne Ausbildungsprogramme geschult. Die COVID-19-Pandemie hatte einen Fallzahlrückgang robotischer Eingriffe im Vergleich zu 2019 bei 70% der Kliniken vor allem im zweiten Jahresquartal 2020 (64,7%) zur Folge. Dies wurde auf Personalmangel nichtchirurgischer Disziplinen (Anästhesie 35,3%, OP-Pflege 35,3%, Intensivmedizin 17,6%), interne Regularien (58,8%) und begrenzte Intensiv- oder Überwachungskapazitäten (47,1%) zurückgeführt. Die COVID-19-Pandemie führte in der robotischen Ausbildung teilweise bei der Assistenz am OP-Tisch (23,5%) und der Assistenz an der zweiten Konsole (42,9%) zu einem kompletten Ausbildungsstopp. Ausschlaggebend für diese Entwicklung war überwiegend der Rückgang der Operationszahlen.

Schlussfolgerung

Die Robotik wird mittlerweile in einem breiten Spektrum der Viszeralchirurgie an Kliniken mit unterschiedlichen Versorgungsschwerpunkten in Deutschland eingesetzt. Der relative Anteil der Eingriffe am Gesamtspektrum ist allerdings noch gering. Roboterassistierte Eingriffe sind expertenfokussiert und es bestehen sehr heterogene Ausbildungskonzepte. Ein Lernerfolg mit konstanten und niedrigen Konversionsraten ist nach wenigen Jahren mit zunehmender Erfahrung zu erkennen. Die COVID-19-Pandemie hatte insgesamt einen negativen Einfluss auf die robotischen OP-Fallzahlen und die damit verbundenen Ausbildungsmöglichkeiten bei freien chirurgischen Personalressourcen. Hier ist eine kreative Gestaltung optimierter Ausbildungsmodalitäten erforderlich.

Development and Validation of a Virtual Reality Simulator for Robot-Assisted Minimally Invasive Liver Surgery Training

The value of kinematic data for skill assessment is being investigated. This is the first virtual reality simulator developed for liver surgery. This simulator was coded in C++ using PhysX and FleX with a novel cutting algorithm and used a patient data-derived model and two instruments functioning as ultrasonic shears. The simulator was evaluated by nine expert surgeons and nine surgical novices. Each participant performed a simulated metastasectomy after training. Kinematic data were collected for the instrument position. Each participant completed a survey. The expert participants had a mean age of 47 years and 9/9 were certified in surgery. Novices had a mean age of 30 years and 0/9 were certified surgeons. The mean path length (novice 0.76 ± 0.20 m vs. expert 0.46 ± 0.16 m, p = 0.008), movements (138 ± 45 vs. 84 ± 32, p = 0.043) and time (174 ± 44 s vs. 102 ± 42 s, p = 0.004) were significantly different for the two participant groups. There were no significant differences in activating the instrument (107 ± 25 vs. 109 ± 53). Participants considered the simulator realistic (6.5/7) (face validity), appropriate for education (5/7) (content validity) with an effective interface (6/7), consistent motion (5/7) and realistic soft tissue behavior (5/7). This study showed that the simulator differentiates between experts and novices. Simulation may be an effective way to obtain kinematic data.

RoCS: Robotic Curriculum for young Surgeons

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

Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study

BACKGROUND

Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology.

METHODS

Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental.

RESULTS

All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE.

CONCLUSION

The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.

Augmented Reality and Image-Guided Robotic Liver Surgery

Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.

Identifying curriculum content for a cross-specialty robotic-assisted surgery training program: a Delphi study

BACKGROUND

Robotic-assisted surgery is increasing and there is a need for a structured and evidence-based curriculum to learn basic robotic competencies. Relevant training tasks, eligible trainees, realistic learning goals, and suitable training methods must be identified. We sought to develop a common curriculum that can ensure basic competencies across specialties.

METHODS

Two robotic surgeons from all departments in Denmark conducting robotic-assisted surgery within gynecology, urology, and gastrointestinal surgery, were invited to participate in a three-round Delphi study to identify learning goals and rank them according to relevance for a basic curriculum. An additional survey was conducted after the Delphi rounds on what training methods were considered best for each learning goal and who (console surgeon/patient-side assistant) should master each learning goal.

RESULTS

Fifty-six robotic surgeons participated and the response rates were 86%, 89%, and 77%, for rounds 1, 2 and 3, respectively. The Delphi study identified 40 potential learning goals, of which 29 were ranked as essential, e.g., Understand the link between arm placement and freedom of movement or Be able to perform emergency un-docking. In the additional survey, the response rate was 70%. Twenty-two (55%) of the identified learning goals were found relevant for the patient-side assistant and twenty-four (60%) were linked to a specific suitable learning method with > 75% agreement.

CONCLUSIONS

Our findings can help training centers plan their training programs concerning educational content and methods for training/learning. Furthermore, patient-side assistants should also receive basic skills training in robotic surgery.

The Role of Simulation in Attaining Proficiency in Minimally Invasive Hepatopancreatobiliary Surgery

The implementation of robotic surgery in the field of hepato-pancreato-biliary (HPB) has been a slow but significant process. HPB procedures offer a unique challenge when for new technologies, as the surgeries themselves are complex, with long learning curves. Yet the benefits of the robotic approach for this patient population are notable: decreased length of stay, blood loss, postoperative complications, and improving quality of life. The use of robotic simulation focused curriculum plays a crucial role in mentoring experienced surgeons and surgical trainees. Although further study remains, early studies suggest a structured simulation curriculum decreases time, technical errors, and improves proficiency, ultimately leading to a more expedited and safe implementation of robotic techniques in the HPB field.

Simulation-Based Training in Robotic Surgery: Contemporary and Future Methods

While robotic surgery has grown in popularity and scope over the past decade, there is a persistent need for simulation-based training as surgeons adapt from the working at the bedside to the immersive and multisensory tasks at the console. From dry laboratory to virtual reality (VR) environments, simulation can be used to train surgeons in basic tasks, complex operative steps, and coordination of whole operations with members of the entire operating room (OR) staff. By integrating simulation into mentored training programs, surgeons can reduce the number of cases required to master a complex operation. Future VR based simulation will become essential to the adaptation of the surgical workforce to new technologies and adoption of emerging robotic platforms. Ultimately, robotic simulation will set standards for credentialing of new surgeons.

[New techniques and training methods for robot-assisted surgery and cost-benefit analysis of Ivor Lewis esophagectomy]

INTRODUCTION

Robotic surgery was introduced into general surgery more than 20 years ago. Shortly afterwards, Horgan performed the first robotic-assisted esophagectomy in 2003 in Chicago. The aim of this manuscript is to elucidate new developments and training methods in robotic surgery with a cost-benefit analysis for robotic-assisted Ivor Lewis esophagectomy.

METHODS

Systematic literature search regarding new technology and training methods for robotic surgery and cost analysis of intraoperative materials for hybrid and robotic-assisted Ivor Lewis esophagectomy.

RESULTS

Robotic-assisted esophageal surgery is complex and involves an extensive learning curve, which can be shortened with modern teaching methods. New robotic systems aim at the use of image-guided surgery and artificial intelligence. Robotic-assisted surgery of esophageal cancer is significantly more expensive that surgery without this technology.

CONCLUSION

Oncological short-term and long-term benefits need to be further evaluated to support the higher cost of robotic esophageal cancer surgery.

Short-term clinical outcomes of a European training programme for robotic colorectal surgery

BACKGROUND

Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery-EARCS).

METHODS

Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors.

RESULTS

Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups.

CONCLUSIONS

Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.

Safety and oncologic efficacy of robotic compared to open pancreaticoduodenectomy after neoadjuvant chemotherapy for pancreatic cancer

BACKGROUND

Emerging data from multi-institutional and national databases suggest that robotic pancreaticoduodenectomy is safe and feasible for pancreatic adenocarcinoma. Nevertheless, there are limited reports evaluating its safety and oncologic efficacy following neoadjuvant chemotherapy.

METHOD

This is a retrospective study from the 2010-2016 National Cancer Database comparing the postoperative, pathological and long-term oncologic outcomes between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) for pancreatic adenocarcinoma following neoadjuvant chemotherapy.

RESULTS

We identified 155 (5%) RPD and 3329 (95%) OPD following neoadjuvant chemotherapy. The use of the robot increased from 3 cases in 2010 to 50 cases in 2016. RPD patients were more likely to receive adjuvant chemotherapy and to be treated at academic centers. After adjustment, RPD was associated with a higher proportion of adequate lymphadenectomy, receipt of adjuvant chemotherapy, decreased rate of prolonged length of stay, and similar 90-day mortality. There was no difference in median overall survival between RPD and OPD (25.6 months vs. 27.5 months, Log Rank p = 0.879). The 1-, 3- and 5-year overall survival rates for RPD were 83%, 36% and 22% and for OPD were 86%, 38% and 22%. After adjustment, the use of robotic surgery was associated with similar overall survival compared to the open approach (HR 1.011, 95% confidence interval (CI) 0.776-1.316).

CONCLUSIONS

Following neoadjuvant chemotherapy, RPD is associated with similar short- and long-term mortality with the advantage of shorter length of stay, higher proportion of adequate lymphadenectomy and receipt of adjuvant chemotherapy.