Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs

INTRODUCTION

Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases.

METHODS

We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA.

RESULTS

The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT.

CONCLUSIONS

Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Active control time: an objective performance metric for trainee participation in robotic surgery

Trainee participation and progression in robotic general surgery remain poorly defined. Computer-assisted technology offers the potential to provide and track objective performance metrics. In this study, we aimed to validate the use of a novel metric-active control time (ACT)-for assessing trainee participation in robotic-assisted cases. Performance data from da Vinci Surgical Systems was retrospectively analyzed for all robotic cases involving trainees with a single minimally invasive surgeon over 10 months. The primary outcome metric was percent ACT-the amount of trainee console time spent in active system manipulations over total active time from both consoles. Kruskal-Wallis and Mann-Whitney U statistical tests were applied in analyses. A total of 123 robotic cases with 18 general surgery residents and 1 fellow were included. Of these, 56 were categorized as complex. Median %ACT was statistically different between trainee levels for all case types taken in aggregate (PGY1s 3.0% [IQR 2-14%], PGY3s 32% [IQR 27-66%], PGY4s 42% [IQR 26-52%], PGY5s 50% [IQR 28-70%], and fellow 61% [IQR 41-85%], p =  < 0.0001). When stratified by complexity, median %ACT was higher in standard versus complex cases for PGY5 (60% vs. 36%, p = 0.0002) and fellow groups (74% vs. 47%, p = 0.0045). In this study, we demonstrated an increase in %ACT with trainee level and with standard versus complex robotic cases. These findings are consistent with hypotheses, providing validity evidence for ACT as an objective measurement of trainee participation in robotic-assisted cases. Future studies will aim to define task-specific ACT to guide further robotic training and performance assessments.

The case for a new post-graduate hernia designation: a review of fellowship council case logs from the past twelve-years

BACKGROUND

The Fellowship Council (FC) is a robust accreditation body with numerous fellowships; however, no specific criteria exist for hernia fellowships. This study analyzed the case log database to evaluate trends in fellowship exposure to hernia repairs.

METHODS

FC hernia case log records (2007-2019) were coded as inguinal or ventral hernias and with or without mesh repair. Retrospective analysis examined total hernia repairs logged, type of repair, program designation, and robotic adoption. Robotic adoption was categorized by quartiles of program performance according to the final year of analysis (2018-2019); yearly performance was then graphed by quartiles.

RESULTS

Over this twelve-year period, 93,334 hernia repairs, 5 program designations, 152 unique programs and 1,558 unique fellows were analyzed. The number of fellows grew from 106 (2007-2008) to > 130 (2018-2019). Total hernias repairs per fellow increased from an average of 41.2 in 2007-2008 to 75.7 in 2018-2019 (183.7%). Open and robotic hernia repairs increased by 241.9% and 266.3%, respectively; laparoscopic hernia repairs decreased by 14.8%. Inguinal and ventral hernia repairs comprised 48.1% and 51.9% of total cases, respectively. Advanced GI/MIS and Advanced GI/MIS/Bariatrics programs logged the majority of hernia repairs (86.0-90.2%). 2014 began an exponential rise in robotic adoption, with fellows averaging < 1 robotic repairs before and > 25 repairs in 2019. A significant difference was found between all groups when comparing quartiles of robotic adopters (median robotic repairs per fellow; IQR): first quartile (72.0; 47.9-108.8), second quartile (25.5; 21.0-30.6), third quartile (13.0; 12.0-14.3) and fourth quartile (3.5; 0.5-5.0) (p-value < 0.05).

CONCLUSIONS

This twelve-year analysis shows a near doubling in the growth of total hernia repairs, with a decrease in laparoscopic repairs as robotic repairs increased. These data show the importance of hernia repairs in FC fellows' training and warrant further granular analysis to determine specific accreditation criteria for hernia fellowship designations.

Implementation of robot-assisted groin hernia repair diminishes the prospects of young surgeons' training: a nationwide register-based cohort study

PURPOSE

Robot-assisted groin hernia repair is becoming more popular in recent years but may remove operations from surgical trainees. We aimed to investigate the educational level of the surgeons who performed robot-assisted groin hernia repair and the rate of supervision and compare this to open and laparoscopic groin hernia repair.

METHODS

This register-based study was reported according to the RECORD statement and used linked data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. We included surgeons that performed robot-assisted, laparoscopic, and/or open groin hernia repairs performed between January 1, 2015, and June 15, 2021 in Denmark.

RESULTS

A total of 916 surgeons performing 43,856 groin hernia repairs were included in this study. Surgical specialists performed 98% of the robot-assisted groin hernia repairs, 89% of the laparoscopic repairs (p < 0.0001), and 54% of the Lichtenstein repairs (p < 0.0001). Only 5% of the robot-assisted groin hernia repairs were supervised compared with 11% of the laparoscopic repairs (p < 0.0001) and 28% of the open repairs (p < 0.0001).

CONCLUSION

Almost all groin hernia repairs performed with the robot-assisted technique were performed by surgeons specialized in general surgery. The proportions of surgeons specialized in surgery were higher for robot-assisted operations compared with laparoscopic or open groin hernia surgery. Thus, our data suggest a lack of involvement of surgeons in training, and this diminishes the educational potential in the pool of groin hernia operations by the use of robot-assisted repairs.

Robotic Cholecystectomies: What Are They Good for? - A Retrospective Study - Robotic versus Conventional Cases

INTRODUCTION

Robot-assisted cholecystectomies are often criticized as expensive with uncertain benefit to patients. Characterization of robotic surgery benefits, as well as specific factors that drive cost, has the potential to shape the current debate.

METHODS

The surgical cost and outcomes among patients who underwent robotic (n = 283) or non-robotic (n = 1438) laparoscopic cholecystectomies between 2012 and 2018 at a single academic institution were examined retrospectively. All cholecystectomies were primary surgical procedures with no secondary procedures. We also examined the subset of robotic (n = 277) and non-robotic (n = 1108) outpatient procedures.

RESULTS

Robotic cholecystectomies were associated with higher median total cost compared to conventional procedures, largely attributable to variable costs and surgical costs. Patients who underwent conventional cholecystectomy had longer mean lengths of stays (1.7 versus 1.1 days) compared to robotic procedures-with over 10 times as many requiring hospital admission.

CONCLUSIONS

At present, robotic cholecystectomies have a little value to patients and institutions outside of surgical training. Prior to narrowing the analysis to outpatient cases, difference in total cost between procedures was less pronounced due to more frequent inpatient management following conventional procedures. Future optimization of robotic consumables and free market competition among system manufacturers may increase financial feasibility by decreasing variable costs associated with robotic surgery.

More than surgical tools: a systematic review of robots as didactic tools for the education of professionals in health sciences

Within the field of robots in medical education, most of the work done during the last years has focused on surgeon training in robotic surgery, practicing surgery procedures through simulators. Apart from surgical education, robots have also been widely employed in assistive and rehabilitation procedures, where education has traditionally focused in the patient. Therefore, there has been extensive review bibliography in the field of medical robotics focused on surgical and rehabilitation and assistive robots, but there is a lack of survey papers that explore the potential of robotics in the education of healthcare students and professionals beyond their training in the use of the robotic system. The scope of the current review are works in which robots are used as didactic tools for the education of professionals in health sciences, investigating the enablers and barriers that affect the use of robots as learning facilitators. Systematic literature searches were conducted in WOS and Scopus, yielding a total of 3812 candidate papers. After removing duplicates, inclusion criteria were defined and applied, resulting in 171 papers. An in-depth quality assessment was then performed leading to 26 papers for qualitative synthesis. Results show that robots in health sciences education are still developed with a roboticist mindset, without clearly incorporating aspects of the teaching/learning process. However, they have proven potential to be used in health sciences as they allow to parameterize procedures, autonomously guide learners to achieve greater engagement, or enable collective learning including patients and instructors "in the loop". Although there exist documented added-value benefits, further research and efforts needs to be done to foster the inclusion of robots as didactic tools in the curricula of health sciences professionals. On the one hand, by analyzing how robotic technology should be developed to become more flexible and usable to support both teaching and learning processes in health sciences education, as final users are not necessarily well-versed in how to use it. On the other, there continues to be a need to develop effective and standard robotic enhanced learning evaluation tools, as well good quality studies that describe effective evaluation of robotic enhanced education for professionals in health sciences. As happens with other technologies when applied to the health sciences field, studies often fail to provide sufficient detail to support transferability or direct future robotic health care education programs.

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

BACKGROUND

Robotic-assisted general surgery procedures are becoming commonplace, requiring more residency programs to establish training curricula for residents. Concerns exist regarding the impact this will have on surgical residents' operative case distribution in laparoscopic and open surgery. This study aimed to analyze the impact of a growing robotic operative case volume and established robotic surgery training curriculum on the general surgery resident operative experience.

METHODS

The robotic surgery training curriculum at the Medical College of Wisconsin was established in 2017. ACGME operative case logs of residents from 2014 to 2020 were analyzed to determine resident participation in open, laparoscopic, and robotic cases. Case categories included alimentary tract, abdomen, endocrine, thoracic, pediatric, and trauma. A one-way analysis of variance (ANOVA) was used to analyze overall cases, as well as participation by case type, post-graduate year (PGY) level, resident role, and institution type. Statistical significance was defined as a p value < 0.05.

RESULTS

Operative case logs from 77 residents were analyzed with a total of 34,757 cases: 59.3% open, 39.6% laparoscopic, and 1.1% robotic. There was no significant change in open or laparoscopic case volumes. However, there was a 3.4% increase in robotic cases, from 2014 to 2020 (p = 0.01), specifically in foregut (4.0%, p = 0.01), intestinal (1.6%, p = 0.03), and hernia (8.3%, p = 0.003) procedures. Academic (2.8%, p = 0.01) and veterans' hospital (2.0%, p = 0.01) institutions saw a significant increase in their residents' robotic cases. The only resident role with a significant increase in robotic cases was first assistant (8.0%, p = 0.004). There was no significant difference across PGY levels by surgical approach.

CONCLUSIONS

This study highlights that the growth of robotic cases has not had a detrimental effect on the resident experience with open and laparoscopic cases. As robotic cases continually increase, the impact on laparoscopic and open case volumes must be monitored to ensure a well-balanced training experience.

Robot-assisted groin hernia repair is primarily performed by specialized surgeons: a scoping review

Surgical residents routinely participate in open and laparoscopic groin hernia repairs. The increasing popularity of robot-assisted groin hernia repair could lead to an educational loss for residents. We aimed to explore the involvement of surgical specialists and surgical residents, i.e., non-specialists, in robot-assisted groin hernia repair. The scoping review was reported according to PRISMA-ScR guideline. A protocol was uploaded at Open Science Framework, and a systematic search was conducted in four databases: PubMed, EMBASE, Cochrane CENTRAL, and Web of Science. Included studies had to report on robot-assisted groin hernia repairs. Data charting was conducted in duplicate. Of the 67 included studies, 85% of the studies described that the robot-assisted groin hernia repair was performed by a surgical specialist. The rest of the studies had no description of the primary operating surgeon. Only 13% of the included studies reported that a resident attended the robot-assisted groin hernia repair. Thus, robot-assisted groin hernia repair was mainly performed by surgical specialists, and robot-assisted groin hernia repair therefore seems to be underutilized to educate surgical residents.

Current Barriers in Robotic Surgery Training for General Surgery Residents

OBJECTIVE

To assess the current barriers in robotic surgery training for general surgery residents.

DESIGN

Multi-institutional web-based survey.

SETTING

9 academic medical centers with a general surgery residency.

PARTICIPANTS

General surgery residents of at least PGY-3 training level.

RESULTS

163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console.

CONCLUSIONS

General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.

Spin is present in the majority of articles evaluating robot-assisted groin hernia repair: a systematic review

BACKGROUND

The number of scientific articles published each year is increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers' interpretation of results so that they are viewed more favorable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown.

OBJECTIVES/AIM

To determine the frequency and extent of spin in studies assessing robot-assisted groin hernia repair.

METHODS

This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE, and Cochrane Central.

RESULTS

Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p < 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p < 0.05) compared with those who were not.

CONCLUSION

Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.