Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
7 Starting andDeveloping aRobotic Program
Adopting
71
Idenfity leaders
MD and OR
Staff
Specialty
specific
Fig. 7.2 Components of the adopting stage
Training
Online
Simulation
Beside assisting
Intraoperative
participation
Support
Instituitional
Colleagues
Finally, the surgeon champion will balance all conicts and discrepancies along the
way. If needed, the leader can appoint trainees to aid with the duties. It is worth noting that in some institutions this role can be targeted by a team rather than just an
individual. Once a leading entity has been appointed, a group of learners or apprentices can be selected. This faction is constituted by surgeons who want to be trained
in RS and have the availability to do so.
Training in RS is a multimodal endeavor that includes online platform courses,
simulator drills, bedside preparation, and intraoperative console experience [8–10].
Each stage targets a different skill set that is valuable to accomplish specic preset
milestones. Online modules are completed to become familiar with fundamental
concepts of RS such as parts of the console, types of robot equipment, positioning,
and energy settings, among others [11]. While some curriculums only use an online
platform as an overview of the upcoming education plan, others like the well-known
“Fundamentals of Robotic Surgery” employ it for multifaceted and comprehensive
training [8, 11]. Virtual RS curriculums range from simple to complex, to tailor to
the needs of the rising program.
After a basic understanding of the robotic equipment is acquired, the next step is
to participate in console-based simulation. It is well known that simulation-based
training has positive outcomes in the surgical education eld [12, 13]. This is exem-
plied by prospective studies demonstrating improvement in performance after
these sessions [12]. Regarding RS specically, simulation exercises upgrade technical uency, comfort, the notion of the operative eld, and pedal coordination
72
C. Franco-Mesa and Sarah Samreen
[14–16]. Numerous modules are available in robotic consoles spanning from basic
instrument manipulation to the recreation of an entire surgical procedure. For
instance, in general surgery RS curriculums, residents start online and simulation
drills during the rst years of training to be prepared for early intraoperative exposure [9, 10].
After the general concepts and technical skills have been grasped, the next phase
is bedside assisting. Although bedside assisting is generally performed by a nonphysician rst assistant, it is relevant to understand concepts such as patient positioning based on the operation, correct port placement, docking, robotic setup,
camera holding, nuances of energy devices, assistant ports, and specimen removal.
Additionally setting up robotic components, troubleshooting unexpected situations,
and targeting emergency scenarios from the bedside are crucial for safe practice [17].
The last aspect is intraoperative training. In this scenario, an experienced robotic
surgeon walks an apprentice through a case. Progressively the apprentice takes on parts
of the surgery until they can complete the procedure independently under supervision.
While training sessions with a single console are acceptable and many times, the rst
accessible method in a startup RS program, dual-console systems create an unparalleled opportunity for hands-on learning. Studies in RS comparing single- to dual-console teaching have reported that trainees have longer console time and more frequent
interactions with the preceptor when using a dual system [15]. To obtain even more
benets, using HIPAA-compliant video recordings of the procedure for dedicated postoperative debrieng sessions can enhance the overall learning experience [18].
Like any other program on the rise, support from other surgeons must be pursued. Reaching out and recruiting colleagues in the eld will guarantee a large
enough workforce to accomplish the educational goals established. Additionally, it
will be the seed of an environment of teamwork and acceptance of RS within the
practice’s cultural scenario.
Operationalizing
Operating room (OR) time is one of the largest expenses in healthcare, yet, it is also
the principal source of revenue for hospitals [19]. Given the variability of case duration and unpredictable events, developing an efcient yet exible OR schedule is an
essential task. This is no different in the setting of an RS program. To identify the
requirements (OR time, personnel, instruments, etc.) for every case, surgeons must
establish a pattern of action. In other words, every case should follow a basic conguration or workow. The more times the case is performed, the more familiar it
will become to the team. RS programs start by operationalizing simple cases like
nonrecurrent inguinal hernia or elective cholecystectomy for biliary colic and then
progress to more complex scenarios such as abdominal wall reconstruction or common biliary duct exploration. While the learning curve varies throughout procedures
and surgical centers, studies demonstrate that a reliable curve can be constructed
over time [20, 21]. Furthermore, after creating an array of operationalized cases
7 Starting andDeveloping aRobotic Program
Fig. 7.3 Components of
the operationalizing stage
73
Operationalizing
Robotics
committee
Robotics
Coordinator
Addresses
challenges
Data collection
Clinical
Financial
Operational
Cultural change
Familiarization
and
reproducibility
proctoring other physicians becomes an available option to expand the RS program
locally or at a larger scale (Fig.7.3).
Besides creating a pattern for every procedure, a key variable of operationalization is prioritizing safety and teamwork. One cannot take place without the other as
everyone has a different role to fulll. A hospital robotics steering committee that
oversees roles, promotes safety, and collects data from procedures is an essential
component of the RS program. Through tangible data such as performance indicators, the surgical outcomes of RS can regularly be evaluated. Even more, by developing a framework of key performance indices (KPIs), programs can review
liabilities and develop targeted solutions to enhance performance [22]. The permanence and growth of the upcoming RS programs are directly related to the clinical,
nancial, and operational KPIs. Data this signicant can be used to support different
types of decisions within the institution in the long run.
Like in any other rising discipline, a cultural environment of collaboration and
curiosity is needed for an RS program to ourish. The introduction and acceptance
of robotics can be tedious; however, with increasing uptake of robotic technology, it
is rapidly becoming a reality. Thus, the goal is to promote a cultural scenario where
the use of RS is normalized and regarded as a safe tool for patient care [23].
Standardizing
Standardization is the act of assembling a process throughout time in an organized,
efcient, reproducible, and harmonious manner. This practice has been considered
fundamental for global development for centuries [24, 25]. Within the medical eld,
standardization has been essential in areas such as evidence-based medicine, patient
safety, and healthcare outcomes [24, 25]. This is the case with the European consensus
74
C. Franco-Mesa and Sarah Samreen
on robotic mesorectal excision that was published in 2019 and aimed to provide baseline standards for training and technical success in this area of colorectal surgery [26].
The major purpose of standardization in robotic surgery is to reduce variation
and optimize efciency (Fig.7.4). For instance, employing predetermined instruments and accessory sets for the robot decreases the amount of time preparing the
operating room or looking for specic utensils while the procedure is carried out.
“Peel packs” (prepackaged sterile robotic instruments) allow for efciency and
establish a predictable sterile processing time and inventory management. Thus,
operative time is optimized benetting the patient, surgeon, staff, and everyone else
in the facility involved in operative services.
The standardization journey for an upcoming program is variable. Standardizing
on-time rst-case start and turnover times are essential parts of the standardization
process, along with block time allocation with accurate case scheduling. A study
from Stanford attempted to standardize the operative start time for cardiac cases after
making a thorough background check of their perioperative data [28]. They noticed
that adherence to the start time was associated with increased efciency, decreased
costs, and higher satisfaction [27]. Armstrong etal. described the use of video recordings of numerous microvascular anastomoses to break down key portions of the procedure that could be improved [28]. The videos were analyzed by a multidisciplinary
team that provided different perspectives and proposals [28]. While taping and
reviewing procedures is not obligatory for standardization, the ability to automatize
procedures based on visual documentation is a possibility. No matter what specic
strategy for homogenized RS practice is pursued, supporting the robotic scheduling,
Fig. 7.4 Components of
the standardizing stage
Efficiency
Instruments
Sterility process
Robotic case
scheduling
Staff availability
Standardizing
Assessing
outcomes
Clinical
Financial
Operational
Goals
Short term
Long term
7 Starting andDeveloping aRobotic Program
75
allowing block time for certain services, and optimizing turnover time will be benecial. In the long run, this practice promotes self- sustainability and chronicity with the
ability to overcome challenges posed throughout time.
By this point, the RS program is up and running. The success of the course will
depend on a well-developed plan for growth. Ideally, this should be designed in a
stepwise approach with short-, medium-, and long-term goals. Predicted difculties
should be factored in the proposal as well as alternative solutions. It is crucial to
collect data during every stage of the process. These will be useful to construct
future projection curves to tailor long-term goals accordingly. Teaching curriculums
must be incorporated in forthcoming plans as they will provide structured learning
instructions for upcoming surgeons and operative staff.
Lessons
Challenges arise with change and innovation. Building an RS program will come
with unparalleled benets, but also inherent struggles. The path itself is not linear
but rather convoluted with peaks and falls. By normalizing and expecting this type
of scenery, the unexpected becomes expected. One of the areas that will require time
to ourish is cultural change. For this, persistence and patience will be the best
allies in the long term. Finally, patient outcomes are the principal tool to determine
success; however, nancial outcomes matter and will be considered for critical
decision- making purposes.
Conclusion
Developing a robotic program is a challenging task. While numerous factors must
align to be successful, robotic technology provides numerous benets associated
with patient safety and surgical outcomes in standard and complex procedures.
Furthermore, this minimally invasive technique imminently protects the ergonomics of physicians securing a safe practice in the long run. Adopting, operationalizing, and standardizing are the operational pillars of a roadmap to a successful
robotic program. The inevitable development of technology challenges physicians
to renovate and modernize their surgical practice to guarantee optimal patient care.
Bibliography
1. Radojcić B, Jokić R, Grebeldinger S, Meljnikov I, Radojić N.History of minimally invasive
surgery. Med Pregl. 2009;62(11–12):597–602.
2. Yeung TM, Larkins KM, Warrier SK, Heriot AG.The rise of robotic colorectal surgery: better
for patients and better for surgeons. J Robotic Surg. 2024;18(1):69. https://doi.org/10.1007/
s11701- 024- 01822- z.
3. Alvarado CE, Worrell SG, Bachman KC, etal. Robotic approach has improved outcomes for
minimally invasive resection of mediastinal tumors. Ann Thorac Surg. 2022;113(6):1853–8.
https://doi.org/10.1016/j.athoracsur.2021.05.090.
76
4. Sheetz KH, Clain J, Dimick JB.Trends in the Adoption of Robotic Surgery for Common
Surgical Procedures. JAMA Netw Open. 2020;3(1):e1918911. https://doi.org/10.1001/
jamanetworkopen.2019.18911.
5. Alkhamesi NA, Davies WT, Pinto RF, Schlachta CM.Robot-assisted common bile duct exploration as an option for complex choledocholithiasis. Surg Endosc. 2013;27(1):263–6. https://
doi.org/10.1007/s00464- 012- 2431- 0.
6. Peters BS, Armijo PR, Krause C, Choudhury SA, Oleynikov D.Review of emerging surgical robotic technology. Surg Endosc. 2018;32(4):1636–55. https://doi.org/10.1007/
s00464- 018- 6079- 2.
7. Maykel J.Leadership in surgery. Clinics Colon Rectal Surg. 2013;26(04):254–8. https://doi.
org/10.1055/s- 0033- 1356727.
8. Greenberg AL, Syed SM, Alseidi A, O’Sullivan PS, Chern H.Robotic training for medical
students: feasibility of a pilot simulation curriculum. J Robotic Surg. 2022;17(3):1029–38.
https://doi.org/10.1007/s11701- 022- 01508- 4.
9. Azadi S, Green IC, Arnold A, Truong M, Potts J, Martino MA.Robotic surgery: the impact
of simulation and other innovative platforms on performance and training. J Minim Invasive
Gynecol. 2021;28(3):490–5. https://doi.org/10.1016/j.jmig.2020.12.001.
10. Howard KK, Makki H, Novotny NM, Mi M, Nguyen N.Value of robotic surgery simulation for training surgical residents and attendings: a systematic review protocol. BMJ Open.
2022;12(6):e059439. https://doi.org/10.1136/bmjopen- 2021- 059439.
11. Robotic Task Force SAGES, Chen R, Rodrigues Armijo P, Krause C, Siu KC, Oleynikov D.A
comprehensive review of robotic surgery curriculum and training for residents, fellows, and
postgraduate surgical education. Surg Endosc. 2020;34(1):361–7. https://doi.org/10.1007/
s00464- 019- 06775- 1.
12. De Montbrun S, MacRae H.Simulation in surgical education. Clinics Colon Rectal Surg.
2012;25(03):156–65. https://doi.org/10.1055/s- 0032- 1322553.
13. Sandeva MG, Tufkova S, Ketev K, Paskaleva D.Evaluating the effectiveness of simulation training in obstetrics and gynecology, pediatrics and emergency medicine. FM. 2019;61(4):605–11.
https://doi.org/10.3897/folmed.61.e47961.
14. Larkins KM, Mohan HM, Gray M, etal. Transferability of robotic console skills by early
robotic surgeons: a multi-platform crossover trial of simulation training. J Robotic Surg.
2022;17(3):859–67. https://doi.org/10.1007/s11701- 022- 01475- w.
15. Leon MG, Carrubba AR, DeStephano CC, Heckman MG, Craver EC, Dinh TA. Impact
of robotic single and dual console systems in the training of minimally invasive gynecology surgery (MIGS) fellows. J Robotic Surg. 2022;16(6):1273–80. https://doi.org/10.1007/
s11701- 022- 01369- x.
16. Wang VL, Pieper H, Gupta A, Chen X, Husain S, Meara M.Expectations versus reality: trainee
participation on the robotic console in academic surgery. Surg Endosc. 2021;35(8):4805–10.
https://doi.org/10.1007/s00464- 020- 07874- 0.
17. Britton CR, Francis I, Tay LJ, Krishnamoothy B.The role of the bedside assistant in robotassisted surgery: a critical synthesis. J Perioper Pract. 2022;32(9):208–25. https://doi.
org/10.1177/17504589221094136.
18. Cristofari H, Jung MK, Niclauss N, Toso C, Kloetzer L.Teaching and learning robotic surgery
at the dual console: a video-based qualitative analysis. J Robotic Surg. 2022;16(1):169–78.
https://doi.org/10.1007/s11701- 021- 01224- 5.
19. Denton B, Viapiano J, Vogl A.Optimization of surgery sequencing and scheduling decisions under uncertainty. Health Care Manag Sci. 2007;10(1):13–24. https://doi.org/10.1007/
s10729- 006- 9005- 4.
20. Nasseri Y, Stettler I, Shen W, etal. Learning curve in robotic colorectal surgery. J Robotic
Surg. 2021;15(3):489–95. https://doi.org/10.1007/s11701- 020- 01131- 1.
21. Soomro NA, Hashimoto DA, Porteous AJ, etal. Systematic review of learning curves in robotassisted surgery. BJS Open. 2020;4(1):27–44. https://doi.org/10.1002/bjs5.50235.
22. Abdel-Razik MSM, Rizk HI, Zein MM, Abdel-Megeid SMES, Abd El Fatah SAM.Promoting
the culture of key performance indicators (KPIs) among primary health care staff at health
C. Franco-Mesa and Sarah Samreen
7 Starting andDeveloping aRobotic Program
district level: an intervention study. Eval Program Plann. 2023;96:102188. https://doi.
org/10.1016/j.evalprogplan.2022.102188.
23. Jogerst KM, Coe TM, Petrusa E, etal. Multidisciplinary perceptions on robotic surgical training: the robot is a stimulus for surgical education change. Surg Endosc. 2023;37(4):2688–97.
https://doi.org/10.1007/s00464- 022- 09708- 7.
24. Paradis E, De Freitas C, Heisey R, etal. Getting standardization right. Can Fam Physician.
2021;67(5):323–5. https://doi.org/10.46747/cfp.6705323.
25. Lehmann CU, Miller MR. Standardization and the practice of medicine. J Perinatol.
2004;24(3):135–6. https://doi.org/10.1038/sj.jp.7211060.
26. Miskovic D, Ahmed J, Bissett-Amess R, etal. European consensus on the standardization of
robotic total mesorectal excision for rectal cancer. Colorectal Dis. 2019;21(3):270–6. https://
doi.org/10.1111/codi.14502.
27. Burton É, Medina M, Antonio H.Standardization of operative start times for non-emergent
cardiac surgical procedures. J Card Surg. 2022;37(10):3092–8. https://doi.org/10.1111/
jocs.16756.
28. Armstrong T, Yu D, Frischknecht A, Minter R, Andreatta P, Kasten S.Standardization of surgical procedures for identifying best practices and training. Work. 2012;41:4673–9. https://doi.
org/10.3233/WOR- 2012- 0108- 4673.
77
Robotic Training andPathway
KatherineFay andAnkitD.Patel
Introduction
The introduction of minimally invasive surgical (MIS) techniques has been
shown to greatly improve surgical outcomes, including lower rates of complications, decreased postoperative pain, and shorter hospital length of stay [1].
However, there are certain limitations inherent to laparoscopy, including reliance
on two- dimensional vision, decreased range of motion given the rigidity of
instruments, and ergonomic challenges experienced by the operating surgeon.
Through the robotic surgery platform, the advantages of MIS are maintained
with the added enhancement of three-dimensional vision, further instrument
articulation, abolition of tremor, and improved surgeon ergonomics allowing for
improved hand–eye coordination and overall surgical precision [2]. Although
there are demonstrated surgical benets and rapidly increasing utilization of the
platform, there is no universally adapted training paradigm for robotic surgery.
Available programs have signicant variation in didactic content and access to
technical skill sessions provided. Here, we discuss the key elements of a robotic
surgery program to train future and currently practicing surgeons, support continued skill development, and ensure patient safety and optimal outcomes through
credentialing and maintenance policies.
8
K. Fay (*)
Department of General Surgery, Grady Memorial Hospital, Atlanta, GA, USA
Department of General & Gastrointestinal Surgery, Emory University School of Medicine,
Atlanta, GA, USA
e-mail: kat.fay@emory.edu
A. D. Patel
Department of General & Gastrointestinal Surgery, Emory University School of Medicine,
Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_8
79
80
K. Fay and A. D. Patel
Implementation ofaCurriculum
Since its integration into modern medicine beginning in the 1980s, the utilization of
the robotic surgery platform has steadily increased in the United States across a
multitude of surgical disciplines [3–5]. One study showed that as of 2017 use of
robotic-assisted surgical techniques had grown exponentially compared to laparoscopic surgical techniques at a relative rate of 10–40-fold [6]. Increasing use has
driven the need for the creation of training pathways for currently practicing surgeons as well as the integration of robotic curricula into surgical residency training
programs. A survey of general surgery residents in 2015in the United States indicated that 96% of respondents were training at an institution where a surgical robotic
platform was available [7].
Unlike other areas of technical advancement in surgical practice, robotic surgery
is one of the few without a surgical society-backed designated curriculum. The
adoption of surgical laparoscopy drove the creation of the Fundamentals of
Laparoscopic Surgery (FLS) developed by the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) to ensure that all graduating surgical residents
possess the minimum skills to perform laparoscopic procedures safely. Certication
in this program has been endorsed by the American Board of Surgery (ABS), the
Canadian Association of General Surgeons (CAGS), and American Board of
Obstetrics and Gynecology (ACOG) and is a graduation requirement for surgical
trainees and necessary for board eligibility. Similarly, the Fundamentals of
Endoscopic Surgery (FES), an educational pathway that evaluates basic endoscopic
knowledge and skills, is also a requirement within surgical training and board
eligibility.
SAGES published a consensus document in 2007 outlining guidelines for the
initiation and maintenance of an effective robotic surgery program. Created by an
international multidisciplinary consensus group, the document focuses on training
and credentialing, clinical applications of robotic surgery, risks of surgery, cost–
benet analysis, and future research [8]. Additionally, the document comments on
the key elements of robotic training, credentialing, and program maintenance.
While these guidelines are broad and somewhat outdated, they do provide a backbone for future training programs. Recently, several leaders in resident education
published recommendations from a robotic surgery working group that we will
highlight in the sections below [9].
Curricula Components
The SAGES robotic surgery consensus document highlights combining web-based
didactics, virtual reality simulation, in-person course, and cadaveric/animal training
models when training new surgeons. When offered in concert, each component
allows for the enhancement of certain skill levels that aim to build competency,
develop procient technical skills, and allow for the maintenance of performance in
robotic surgery. Each training program then ultimately culminates in training on the
8 Robotic Training andPathway
robotic platform, including the development of bedside assistant and on-console
surgeon skills.
81
Web-Based Training
Web-based training modules provide signicant exibility to users new to the
robotic surgical platform. As the majority of new users are likely in surgical training, self-scheduled learning results in less logistical challenges during the acquisition of foundational knowledge. These courses focus on learning ideal patient
selection, instrumentation, patient and system positioning, port placement, and
basic troubleshooting. They also review some basics or pre-, intra-, and postoperative care. Expansion of these curricula to include support staff can also allow for
greater programmatic efciency and growth. Eventually, some of this training could
be converted to on-demand content or could be accessed in a virtual reality format.
Virtual Simulation
Virtual simulation training has also been shown to play an integral role in the development and maintenance of robotic surgical skills. A variety of simulators are available, including the Fundamentals of Robotic Surgery (FRS) Dome, the da Vinci
Skills Simulator (DVSS), and the dV-trainer. As the robotic surgery platform is utilized for more advanced cases, wider application is limited by the fact that many
institutions do not see the number of cases needed for prociency, even for experienced surgeons. The utilization of virtual reality simulation training aims to bridge
that gap more effectively and allow for wider application of the robotic platform.
Multiple studies support that trainees who participate in virtuality reality simulation
perform better on robotic task testing than those who do not [10, 11]. A more recent
review compared the more prominent available simulators and demonstrated the
ability of a VR training curriculum to improve skills and a prociency-based training platform being the most effective [12]. For most training programs, these skill
simulators will likely be the foundation of any curricula.
Bedside Skills
Once a trainee (either resident/fellow or new user) has indicated prociency in an
online program (dened by most as achievement of a minimum competency score
of >90% on written knowledge assessments as well as indicate prociency of skill
on simulators), as well as undergone a bedside teaching session emphasizing basic
techniques, they are graduated to in operating room training. While variable by
institution, prior to initiation of on-console training, most robotic programs mandate a certain number of bedside assist cases to ensure adequate docking, instrument
exchange, and troubleshooting knowledge of the platform. This component of