The evolution of the general surgery resident operative case experience in the era of robotic surgery

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.

The use of advanced robotic simulation labs to advance and assess senior resident robotic skills and operating room leadership competency: a pilot study

BACKGROUND

General surgery has the fastest growing robotic operative volume in the United States, but most robotic curricula are focused on basic psychomotor skills. There are limited curricula focused on advanced robotic technical and related non-technical skills. We describe a novel pilot curriculum for robotic hiatal hernia repair developed for senior surgical residents to provide training and standardized assessment of higher-order robotic technical and leadership skills.

METHODS

Twelve senior residents, post-graduate year (PGY) 4 & 5, participated in a robotic hiatal hernia repair skills curriculum. Residents completed a pre- and post-survey on confidence and ability ratings on a 5-point Likert-type Scale, and a knowledge assessment. An informal faculty-led didactic was provided prior to the simulation. Residents were scored on two validated assessment tools: Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) and Global Ratings Scale of Operative Performance (GRS) by faculty proctors.

RESULTS

Confidence in ability to independently complete a robotic hiatal hernia case increased from mean of 2.6 ± 0.8 to 3.3 ± 0.6 (p = 0.0007). Following the simulation, residents reported increased overall confidence and ability to operate independently with mean scores of 3.3 ± 0.8 and 3.8 ± 0.9, respectively. Mean O-SCORE and GRS scores were 3.6 (range 2 - 4) and 25.4 (range 12 - 31), respectively. Number of prior live robotic cases was strongly positively correlated to O-SCORE (R = 0.84, p = 0.0006) and GRS (R = 0.88, p = 0.0002).

CONCLUSION

Our pilot study suggests live-operative robotic training is not sufficient alone for advanced robotic skill training. Simulations such as this can be used to (1) practice advanced robotic technical and relevant non-technical skills such as communication and operating room leadership in a low stake setting and (2) assess residents in a standardized environment to eventually evaluate robotic competency.