Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit

Essential components and validation of multi-specialty robotic surgical training curricula: a systematic review

INTRODUCTION

The rapid adoption of robotic surgical systems has overtook the development of standardized training and competency assessment for surgeons, resulting in an unmet educational need in this field. This systematic review aims to identify the essential components and evaluate the validity of current robotic training curricula across all surgical specialties.

METHODS

A systematic search of MEDLINE, EMBASE, Emcare, and CINAHL databases was conducted to identify the studies reporting on multi-specialty or specialty-specific surgical robotic training curricula, between January 2000 and January 2024. We extracted the data according to Kirkpatrick's curriculum evaluation model and Messick's concept of validity. The quality of studies was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

From the 3687 studies retrieved, 66 articles were included. The majority of studies were single-center ( n = 52, 78.8%) and observational ( n = 58, 87.9%) in nature. The most commonly reported curriculum components include didactic teaching ( n = 48, 72.7%), dry laboratory skills ( n = 46, 69.7%), and virtual reality (VR) simulation ( n = 44, 66.7%). Curriculum assessment methods varied, including direct observation ( n = 44, 66.7%), video assessment ( n = 26, 39.4%), and self-assessment (6.1%). Objective outcome measures were used in 44 studies (66.7%). None of the studies were fully evaluated according to Kirkpatrick's model, and five studies (7.6%) were fully evaluated according to Messick's framework. The studies were generally found to have moderate methodological quality with a median MERSQI of 11.

CONCLUSIONS

Essential components in robotic training curricula identified were didactic teaching, dry laboratory skills, and VR simulation. However, variability in assessment methods used and notable gaps in curricula validation remain evident. This highlights the need for standardized evidence-based development, evaluation, and reporting of robotic curricula to ensure the effective and safe adoption of robotic surgical systems.

Concurrent robotic colorectal surgical oncology training within a structured mentored international fellowship program

Robotic colorectal surgery is increasingly adopted worldwide, with mentored programs for established surgeons becoming more common. However, there is a paucity of dedicated robotic training programs for colorectal fellows. This study aims to assess the feasibility and efficacy of a structured, apprentice-based robotic colorectal training program delivered to multiple fellows concurrently. The fellowship program incorporates simulation training, dry/wet laboratory work, dedicated robotic console time in the operating room (OR) and individualised mentorship. Overall robotic proficiency was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and procedure-specific proficiency was assessed using a modified European Academy of Robotic Colorectal Surgery (EARCS) Global Assessment Score (GAS) throughout the fellowship. A total of 59 cases (29 right hemicolectomies, 30 anterior resections) were evaluated between August 2023 and July 2024. Significant improvements were observed in GEARS scores (p = 0.0065) and modified GAS for both right hemicolectomies (p = 0.0052) and anterior resections (p = 0.0005), demonstrating a high level of competence and independence. Mean operative times were 213 min (right hemicolectomy) and 328 min (anterior resection). Median length of stay in the hospital was 2 days (right hemicolectomy) and 4 days (anterior resection). Median lymph node yield was 29 (right hemicolectomy) and 26 (anterior resection). There was 0% involved margins for both procedures. Robotic colorectal surgical oncology training delivered to multiple fellows concurrently in an apprenticeship model with dedicated console time is achievable and successful, leading to high levels of robotic competency and independence, whilst maintaining a high standard of clinical care and oncological outcome.

Learning Curve for Robotic Colorectal Surgery

With the increasing adoption of robotic surgery in clinical practice, institutions intending to adopt this technology should understand the learning curve in order to develop strategies to help its surgeons and operating theater teams overcome it in a safe manner without compromising on patient care. Various statistical methods exist for the analysis of learning curves, of which a cumulative sum (CUSUM) analysis is more commonly described in the literature. Variables used for analysis can be classified into measures of the surgical process (e.g., operative time and pathological quality) and measures of patient outcome (e.g., postoperative complications). Heterogeneity exists in how performance thresholds are defined during the interpretation of learning curves. Factors that influence the learning curve include prior surgical experience in colorectal surgery, being in a mature robotic surgical unit, case mix and case complexity, robotic surgical simulation, spending time as a bedside first assistant, and being in a structured training program with proctorship.

Emergency robotic surgery: the experience of a single center and review of the literature

BACKGROUNDS

Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.

METHODS

We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).

RESULTS

36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.

CONCLUSIONS

Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.

The training pathway for residents: 'Robotic Curriculum for young Surgeons' (RoCS) does not impair patient outcome during implementation into clinical routine

The "Robotic Curriculum for young Surgeons" (RoCS) was launched 03/2020 to address the increasing importance of robotics in surgical training. It aims to provide residents with foundational robotic skills by involving them early in their training. This study evaluated the impact of RoCS' integration into clinical routine on patient outcomes. Two cohorts were compared regarding the implementation of RoCS: Cohort 1 (before RoCS) included all robot-assisted procedures between 2017 and 03/2020 (n = 174 adults) retrospectively; Cohort 2 (after RoCS) included all adults (n = 177) who underwent robotic procedures between 03/2020 and 2021 prospectively. Statistical analysis covered demographics, perioperative parameters, and follow-up data, including mortality and morbidity. Subgroup analysis for both cohorts was organ-related (upper gastrointestinal tract (UGI), colorectal (CR), hepatopancreaticobiliary system (HPB)). Sixteen procedures were excluded due to heterogeneity. In-hospital, 30-, 90-day morbidity and mortality showed no significant differences between both cohorts, including organ-related subgroups. For UGI, no significant intraoperative parameter changes were observed. Surgery duration decreased significantly in CR and HPB procedures (p = 0.018 and p < 0.001). Estimated blood loss significantly decreased for CR operations (p = 0.001). The conversion rate decreased for HPB operations (p = 0.005). Length of hospitalization decreased for CR (p = 0.015) and HPB (p = 0.006) procedures. Oncologic quality, measured by histopathologic R0-resections, showed no significant changes. RoCS can be safely integrated into clinical practice without compromising patient safety or oncologic quality. It serves as an effective training pathway to guide robotic novices through their first steps in robotic surgery, offering promising potential for skill acquisition and career advancement.

Robotic colorectal surgery training: Portsmouth perspective

This study aims to discuss the principles and pillars of robotic colorectal surgery training and share the training pathway at Portsmouth Hospitals University NHS Trust. A narrative review is presented to discuss all the relevant and critical steps in robotic surgical training. Robotic training requires a stepwise approach, including theoretical knowledge, case observation, simulation, dry lab, wet lab, tutored programs, proctoring (in person or telementoring), procedure-specific training, and follow-up. Portsmouth Colorectal has an established robotic training model with a safe stepwise approach that has been demonstrated through perioperative and oncological results. Robotic surgery training should enable a trainee to use the robotic platform safely and effectively, minimize errors, and enhance performance with improved outcomes. Portsmouth Colorectal has provided such a stepwise training program since 2015 and continues to promote and augment safe robotic training in its field. Safe and efficient training programs are essential to upholding the optimal standard of care.

Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery

Importance

Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery.

Objectives

To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures.

Design, Setting, and Participants

A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included.

Exposure

Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair.

Main Outcomes and Measures

The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups.

Results

During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days).

Conclusions and Relevance

While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.

The current status of robotic colorectal surgery training programmes

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

Structured training curricula for robotic colorectal surgery in China: does laparoscopic experience affect training effects?

Background

Robotic surgery has been widely adopted for colorectal cancer (CRC). Many surgeons in China have completed structured training programs and have performed robotic colorectal surgeries. This multicenter study aimed to evaluate the training effects of structured training curricula in China for surgeons with different laparoscopic experiences during their initial implementation of robotic colorectal surgery.

Methods

Ten surgeons from five high-volume centers participated in this retrospective study. The baseline characteristics, perioperative data, and pathological outcomes were compared between the first 15 robotic surgeries performed by five surgeons with extensive laparoscopic experience (group A) and the first 15 robotic surgeries performed by five surgeons with limited laparoscopic experience (group B) at each center.

Results

Compared with group B, group A showed shorter operation time (200.9 vs. 254.2 min, P<0.001), less blood loss (100.0 vs. 150.0 mL, P=0.025), and a lower incidence of intraoperative complications (2.7% vs. 21.4%, P=0.015). The reoperation rate (1.3% vs. 5.3%, P=0.036) and postoperative complication rate (6.7% vs. 22.7%, P=0.025) were significantly lower in group A than in group B. There were no statistically significant differences in baseline characteristics (e.g., age, sex, and tumor location) and pathological information (e.g., tumor stage, lymph node count, and tumor size) between the two groups. Radical resection (R0) was performed in all cases.

Conclusions

In China, structured training curricula can help surgeons with extensive laparoscopic experience make a smooth transition from laparoscopic to robotic surgery. However, the higher intraoperative and postoperative complication rates indicate that structured training curricula still require further refinement for surgeons with limited laparoscopic experience.

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.

Survey Regarding Gastrointestinal Stoma Construction and Closure in Japan

Background and Aim

In Japan, the actual number of stoma constructions and stoma closures is not known. The aim of this study was to conduct a survey to determine the number of gastrointestinal stoma constructions and closures in Japan.

Methods

Enrolled participants comprised patients undergoing selected gastrointestinal surgeries who were recorded in the National Clinical Database. This database uses the "Common Items for Gastrointestinal Surgeons." These procedures were formulated by the Japanese Society of Gastroenterological Surgery during 2013-2018.

Results

According to the National Clinical Database, a total of 154,323 gastrointestinal stomas were constructed between January 1, 2013 and December 31, 2018. By procedure, there were 78,723 cases of stoma construction, 39,653 of abdominoperineal resection, 2470 total pelvic exenteration procedures, and 33,572 Hartmann's procedures. The ratio of stoma closures to stoma constructions increased annually in patients under 70 y of age but not in older patients. Approximately 35% of total colectomies, 60% of proctocolectomies, and 20% of low anterior resections were accompanied by stoma construction. The number of patients with rectal cancer who underwent colostomy increased gradually during the study period and the number who underwent stoma construction increased among older patients.

Conclusion

The number of cases of gastrointestinal stoma construction has increased gradually in Japan, and the proportion of older patients is increasing each year. The purposes and surgical techniques for stoma construction are diverse and are expected to increase in Japan, a super-aged society.

Robotic surgery in emergency setting: 2021 WSES position paper

BACKGROUND

Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.

METHODS

This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.

RESULTS

Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.

CONCLUSIONS

Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.