A comprehensive method to train residents in robotic hysterectomy techniques

Validation of a Simulation Model for Robotic Myomectomy

STUDY OBJECTIVE

Several simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training.

DESIGN

Prospective cohort simulation study.

SETTING

Surgical simulation laboratory.

PARTICIPANTS

Twelve obstetrics and gynecology residents and 4 fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio.

INTERVENTIONS

A robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving 2 steps: fibroid enucleation and hysterotomy repair. Video-recorded performances were timed and scored by 2 blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds 3 novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility.

MEASUREMENTS AND MAIN RESULTS

Median task completion time was shorter for experts than novices (9.7 vs 24.6 min, p = .001). Experts scored higher than novices on both the GEARS scale (median 23 vs 12, p = .004) and modified GEARS scale (36 vs 20, p = .004). Experts made fewer task errors than novices (median 15.5 vs 37.5, p = .034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%).

CONCLUSION

We have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

Training for next generation surgeons: a pilot study of robot-assisted hysterectomy managed by resident using dual console

PURPOSE

To assess feasibility of a standardized robot-assisted hysterectomy managed by resident and supervised by senior surgeon using dual-console on a 21-step grid (max score = 42) assessing resident autonomy.

METHODS

A total of seven patients managed between September 2019 and March 2020 by six residents in gynecology and obstetrics were included. Standardized robot-assisted hysterectomy for endometrial cancer or adenomyosis was performed.

RESULTS

No conversion to laparotomy, no intra- or post-operative incidents were reported. Mean score on the evaluation scale was 29.8 out of 42 (SD = 7.3). Mean operative time was 104 min (SD = 23). Mean average suturing time was, respectively, 335 s (SD = 57 s) and 270 s (SD = 53 s) for the first and the fourth knot. There was a 65 s improvement between the first and the fourth intracorporeal knot (p = 0.043). The perceived workload evaluated with the NASA TLX score showed a low level of stress (Temporal demand = 1.6 /10), and a low level of frustration (Frustration level = 3.6/10). Experience gained during the surgery was felt to be important (Commitment = 8.6/10).

CONCLUSION

Standardized robot-assisted hysterectomy managed by a resident supervised by a senior surgeon using the dual-console seems feasible. This tool could be useful to assess residents' surgical skills.

Vaginal Cuff Closure in Minimally Invasive Hysterectomy: A Review of Training, Techniques, and Materials

Hysterectomy is one of the most common surgeries performed each year and can be indicated for many gynecologic conditions. The development of minimally invasive surgery has transformed this procedure, resulting in improved outcomes, superior cosmesis, and quicker return to normal function. Vaginal cuff closure is a critical component of hysterectomy, with many variations in surgical technique and materials. This review provides an overview of intracorporeal suturing and knot-tying techniques at the level of a junior resident in obstetrics and gynecology and describes several validated models that have been developed to test resident skill level in vaginal cuff closure. We also provide a review of the literature regarding vaginal cuff closure techniques and suture materials, including knotless barbed sutures. Finally, a brief discussion of single-site surgery, the latest development in minimally invasive hysterectomy, will be provided. We hope to provide a better understanding of vaginal cuff closure for residents in the field of obstetrics and gynecology.

Incorporating resident/fellow training into a robotic surgery program

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.

Trainee performance at robotic console and benchmark operative times

INTRODUCTION AND HYPOTHESIS

It is an ongoing challenge to maintain surgical efficiency while integrating trainee participation. We hypothesize that a program of graduated surgical responsibility for trainees does not hinder operative efficiency.

METHODS

This was a retrospective cohort study of trainee performance times, collected prospectively in real time, for robotic cases performed at one university hospital between September 2008 and August 2011. The primary aim was to compare overall operative times between cases performed by trainees versus attendings. Secondary aims were to compare operative times for major portions of each operation by level of training and to establish benchmark operative times for trainees.

RESULTS

During the study period, 98 cases had recorded trainee performance times. Total robot docked time was longer for trainees than for attendings (155 vs 132 min, p = 0.011), but mean performance times for hysterectomy (70 vs 59 min, p = 0.096) and sacrocolpopexy (76 vs 79 min, p = 0.545) were similar. Within the trainees, there was no correlation between surgical time and rank for each step of the procedures. Utilizing mean performance times for all trainees, benchmark operative times were established for each step of hysterectomy in minutes: right side (21), left side (21), bladder flap (10), colpotomy (15), and cuff closure (19); similarly, for sacrocolpopexy: sacral and peritoneal dissection (12), anterior cuff dissection (10), posterior cuff dissection (8), anterior mesh attachment (15), posterior mesh attachment (18), sacral mesh attachment (12), and peritoneal closure (9).

CONCLUSION

In a program of graduated surgical responsibility, robotic operative efficiency was comparable when trainees were involved as console surgeons.

Training and learning robotic surgery, time for a more structured approach: a systematic review

BACKGROUND

Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons.

OBJECTIVES

To review the literature on training and learning strategies for robotic assisted laparoscopic surgery.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed.

SELECTION CRITERIA

We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism.

DATA COLLECTION AND ANALYSIS

Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation.

MAIN RESULTS

We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme.

AUTHORS' CONCLUSIONS

Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.