Teaching and Training Surgeons in Robotic Colorectal Surgery

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.

Implementation of a robotic hepato-pancreato-biliary surgery program: a swedish referral center's experience

Robotic-assisted surgery has been recognized for enhancing the feasibility of minimally invasive procedures, particularly in high-complexity fields like hepato-pancreato-biliary (HPB) surgery. This study aims to describe the implementation and development of a robotic HPB surgery program at a Swedish referral center, during a structured transition from mostly open surgery, as well as evaluating perioperative outcomes. A retrospective observational study at Karolinska University Hospital (September 2020-July 2024) included patients undergoing robotic HPB resections. Data on demographics, procedure types, intraoperative metrics, and outcomes were collected. Program implementation followed a stepwise approach. A total of 495 robotic resections were performed by three generations of surgeons, including 235 liver, 208 pancreatic, and 52 biliary resections. The overall conversion rate to open surgery was 7.7%. Major complications were observed in 10.9% of cases, with a mortality rate of 0.8%. Exposure and training improved outcomes over time, indicating the value of a structured implementation approach and a stepwise introduction of new surgeons into the robotic program. The transition to robotic HPB surgery requires a well-organized approach that includes thorough training and close collaboration within a multidisciplinary team. The program focused on helping junior surgeons develop their skills, starting with simpler procedures to reduce risks and ensure patient safety. After 8 semesters, minimally invasive HPB surgeries have increased from 15 to 41%. Results show that the program is safe and effective, highlighting the importance of institutional support, teamwork, and strategic planning in building a successful and lasting robotic surgery program.

Key steps in exposure techniques for robotic total mesorectal excision (TME)

AIM

The use of robotic surgery is increasing significantly. Specific training is fundamental to achieve high quality and better oncological outcomes. This work defines key exposure techniques in robotic total mesorectal excision (TME). Based on a modular approach, macro- and microtractions for exposure in every step of a robotic TME are identified and described. The aim is to develop a step-by-step technical guide of the exposure techniques for a robotic TME.

METHODS

Twenty-five videos of robotic rectal resections performed at Champalimaud Foundation (Lisbon, Portugal) with the Da Vinci™ Xi robotic platform were examined. Robotic TME was divided into modules and steps. Modules are essential phases of the procedure. Steps are exposure moments of each module. Tractions are classified as macro- and microtractions. Macrotraction is the grasping of a structure to expose an area of dissection. Microtraction consists in the dynamic grip of tissue to optimize macrotraction in a defined area of dissection.

RESULTS

The procedure videos reviewed showed homogeneity concerning surgical methodology. Eight modules are outlined: abdominal cavity inspection and exposure, approach to and ligation of the inferior mesenteric vessels, medial to lateral dissection of the mesocolon, lateral colon mobilization, splenic flexure takedown, proctectomy with TME, rectal transection, and anastomosis. Each module was divided into steps, with a total of 45 steps for the entire procedure. This manuscript characterizes macrotraction and microtraction fine-tuning, detailing the large-scale macrotractions and the precision of microtractions at each step.

CONCLUSION

Tissue exposure techniques in robotic TME are key to precise dissection. This modular guide provides a functional system to reproduce this procedure safely; the addition of the exposure techniques could serve as a training method for robotic rectal cancer surgery.

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.

The rise of robotic colorectal surgery: better for patients and better for surgeons

Robotic colorectal surgery represents a major technological advancement in the treatment of patients with colorectal disease. Several recent randomized controlled trials comparing robotic colorectal surgery with laparoscopic surgery have demonstrated improved short-term patient outcomes in the robotic group. Whilst the primary focus of research in robotic surgery has been on patient outcomes, the robotic platform also provides unparalleled benefits for the surgeon, including improved ergonomics and surgeon comfort, with the potential to reduce occupational injuries and prolong career longevity. It is becoming clear that robotic surgical systems improve patient outcomes and may provide significant benefits to the surgical workforce.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group

OBJECTIVE

A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education.

DESIGN

The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs.

SETTING

Virtual and in-person meetings in the United States.

PARTICIPANTS

Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators.

RESULTS

The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience.

CONCLUSIONS

The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

The role of the bedside assistant in robot-assisted surgery: A critical synthesis

INTRODUCTION

Robot-assisted surgery has grown exponentially since its inception and first approval in the United States in the year 2000. The surgeon operating with the assistance of the robot sits remotely to the patient and another practitioner assists at the bedside. The role of the bedside assistant and the training that is required to undertake this role are understudied topics.

AIM

To explore the functions, training and professional development of the bedside assistant in robot-assisted surgery and propose the necessary foundations for the safe enactment of the role in the United Kingdom.

METHODS

Through critical interpretative synthesis, relevant literature was systematically searched and analysed to inform integration of evidence.

RESULTS

Seventy-three studies were retrieved from the literature, across several health care disciplines and surgical specialities. These were critically analysed to inform a theoretically sound account grounded on evidence.

CONCLUSION

The role, functions and skills of the bedside assistant in robot-assisted surgery vary across contexts. These were analysed and critically synthetised to produce several keys to the success of bedside assistants in robot-assisted surgery in the context of the United Kingdom and of its national regulations.