Introduction
Embarking on robotic surgery training can be a daunting task for the robot-naïve surgeon. Robotics has a steep learning curve, and a pathway to robotic surgery competency has not yet been standardized. Surgical colleges have not yet developed credentialing for robotic surgery training. There is no surgical college accredited curriculum for robotics. The result is that training in robotics has been haphazard and is fragmented among hospitals, medical institutions, and robot vendors. The robot vendors provide a guide for a minimum required standard of training but defer responsibility to the hospital for credentialing. Some academic medical centers have established their own robotic training pathways, some of which are to a level of high proficiency. These institutions currently operate in silos. The aim of this chapter is to describe the evolution of robotic surgery training since its inception in 2000, when the da Vinci Surgical System received FDA approval. We suggest here a blueprint for a standardized training pathway to achieve robotic surgery competency and proficiency in line with the Dreyfus model of skill acquisition. Programs are vulnerable to “shadow learning,” where the attending robotic surgeon is reluctant to hand over control to the trainee because the attending is still on their own learning curve. We define competency, equipping the trainee with the skills to make a surgeon fit for purpose, although they may still lack refinement ( Fig. 8.1 ). The pillars of robotic surgical education comprise theory, simulation, and live surgery overlaid by nontechnical skills. Robotic surgery training requires a multifaceted pathway, involving various simulation platforms and didactics. , Robotic surgery training will most likely transition from live animal and cadaver training to a digital and synthetic organ training system.
History of robotic surgery training
When soft tissue robotics began in 2000, training occurred in a Halstedian fashion, where learning was mostly on the live patient by the early robotic surgery adopters. These early adopters undertook a short course by Intuitive Surgical that included an introduction to the robot buttons and features, dry lab exercises for instrument manipulation, a live porcine surgery, a cadaver surgery, observation of a small number of live cases, and then, finally, three proctored live cases. Intuitive’s current recommended training pathway has not changed significantly in 20 years, other than to include virtual reality (VR) simulation. In some instances, the training requirements for robotics today may be less than when this technology was introduced.
Surgeons who have no access to a residency program that includes a structured robotic program need to rely on the robot vendor directed pathway that offers minimal exposure to robotics training prior to live operating room cases. The current recommended Intuitive pathway includes a brief online course of 3 hours, dry laboratory sessions conducted by the robot company training staff, VR simulation only if available and then at the surgeon’s expense, and porcine and cadaver models. Proctoring by a surgeon with robotic experience is suggested for early procedures; however, this is not mandatory. The validity of this training pathway is not standardized and cannot allow the trainee to achieve basic robotic surgery competency considering the long learning curves in robotic surgery reported to require 300 cases for some procedures to become an “expert.” ,
In Europe and Australasia, robotic surgeons often travel internationally to complete a year-long robotic surgery fellowship. They are immersed in a robotic program under close observation of experienced expert robotic surgeons. In the United States, academic hospitals with access to robots have integrated robotic training pathways into their residency programs. In this setting, sometimes learning occurs by passive observation with limited hands-on experience. Currently, there is no standardized surgical college accredited robotic surgery curriculum, and most hospitals have arbitrary criteria as to what constitutes adequate training. The quality of robotic training in fellowships and residency programs is variable. The European Association of Urology’s (EAU) Robotic Urology Section (ERUS) has recently endorsed a 6 month curriculum aimed at fellowship level for robotic radical prostatectomy that has been adopted by a limited number of hospitals. An ERUS robot-assisted partial nephrectomy curriculum has also been developed and completed by a single trainee. These curricula are confined to urology and dependent on animal and cadaver models that have significant financial, ethical, and logistical drawbacks. This training method involves observation of master surgeons in the operating room, with sequential progress from simple tasks, such as tissue retraction and handling, to more advanced tasks. Many facets of the apprenticeship model remain today that can be challenging in an environment of safe working hour restrictions. Advances in digital education have been adopted by some robotic training centers to deliver a more adaptive surgical curriculum that meets the individual needs of the training robotic surgeon. Emerging digital and synthetic organs present new opportunities for an enhanced robotic surgery curriculum.
Robotic surgery education
The pillars of robotic surgery education are theory, low- and high-fidelity simulation, and live surgery underpinned by nontechnical skills or human factor training ( Fig. 8.2 ). A review of these training elements is provided below.
Theory
Foundational knowledge for robotic surgery is found in textbooks and online courses. Prior to commencing hands-on training, the surgeon should have an overview of the system features of surgical robots, be familiar with the steps for robot setup, be aware of anesthetic considerations, know the principles of good robotic surgical technique at the console and the bedside, understand how to achieve robotic surgical competency, and recognize the importance of human factors in robotic surgical practice. Robot vendors provide a limited online course that introduces the robot components, buttons, and functions. A comprehensive multispecialty and multivendor online course containing the theory and principles of robotic surgery has been developed by expert surgeons at the International Medical Robotics Academy with accreditation from the Royal Australasian College of Surgeons.
Simulation
Simulation is an educational technique that allows interactive and immersive activity by recreating all or part of a clinical experience without exposing patients to the associated risks. Simulation training for robotics can be categorized into low-fidelity and high-fidelity simulation ( Fig. 8.3 ). The term “fidelity” refers to the extent to which the appearance, behavior, and physical properties of a simulation match the live operating experience.
Simple dry lab models
Low-fidelity dry lab simulation models include simple plastic abdominal trainers for port placement and docking and models for basic psychomotor exercises, such as suture pads and hollow tubes. These models are part-task trainers that can teach the basic psychomotor skills necessary to progress to more advanced simulation models.
VR simulation involves the manipulation of computer-simulated instruments in an artificial world. The validity of VR simulators to train a wide range of psychomotor skills through discrete tasks, procedural training, and team training is well established. , , VR is low fidelity and best suited to the early phase of training where the focus is on gaining the correct psychomotor skills. VR is particularly helpful for the acquisition of basic techniques for robotic dissection, retraction, cutting, suturing, camera control, and energy application. Currently, the computing power of VR simulation machines does not deliver an experience equivalent to the realistic tissue handling of animal, cadaver, or advanced synthetic organ models. , There are five major commercial simulation machines available. These are the ProMIS simulator, the Mimic dV trainer, the RobotiX Mentor, the RoSS, and the da Vinci skills simulator ( Fig. 8.4 ). The ProMIS simulator and da Vinci skills simulator are attached to a robot console. The other three simulators are standalone, enabling practice outside of the operating room. The high cost of VR simulation machines remains a major barrier to the widespread adoption of this technology for robotic surgery training.
The Mimic platform includes individual proficiency scoring, where performance is compared to robotic surgeons who have performed at least 75 live cases accessible on multiple digital devices on a cloud-based system. Baseline psychomotor skills can be measured objectively and compared across robotic surgery experience levels on a bell curve ( Fig. 8.5 ). Skill acquisition can be tracked, and simulation performance postcurriculum can be compared to baseline. A surgeon’s natural aptitude can be assessed using an “innate ability” curriculum. In studies of medical students, it was demonstrated that 6% will be rapid adapters, where they quickly perform VR exercises at a level equivalent to experienced robotic surgeons. , At the other end of the scale are an 11% who have low aptitude for robotics. In between is a large cohort of average performers. The Morristown protocol is a VR simulation curriculum that demonstrates skill transfer from VR to the live operating room among robotic gynecology surgeons.
Live animals
Live animals have been used for advanced robotic surgical training since its inception. These models can replicate realistic tissue properties and bleeding. Live animals, mostly pigs, have been used by robot vendors for port placement, docking, and advanced procedural skills despite limited evidence demonstrating their efficacy in robotic surgery education. , Live animals do not accurately represent human anatomy, usage poses major ethical concerns relating to animal rights, and they are expensive and difficult to access. The Australasian College of Surgeons has phased out live animal training from its formal curriculum. The American College of Surgeons has stated that “whenever feasible, alternatives to the use of live animals should be developed and employed.” Intuitive Surgical will likely shift toward “kind-hearted” surgery and replace the requirement for live animal surgery with synthetic organ training from 2022.
Cadavers
Cadavers have been long considered the optimal method of surgical simulation. , However, there is a lack of studies that demonstrate educational validity of cadavers for surgical training, and very few studies have examined their use for robotic surgery training. Qualitatively, surgical trainees and students report that they value the experience of training on cadavers. Cadavers are expensive and provide a single nonrepeatable training episode, and availability of specimens is scarce, particularly for rare or irregular pathologies. Cadaver and animal models mostly lack specific pathology needed for procedural simulation, especially for cancer surgery. Cadaveric and live animal models often require storage facilities that are expensive and often centralized, which requires surgeons to travel to gain access to these specialized labs. Additionally, animals and cadavers can carry a risk of spreading transferable diseases, including COVID-19. ,
Synthetic organs models
Advances in three-dimensional (3D) printing technology and materials engineering have enabled the fabrication of high-fidelity synthetic organ models that will supersede our reliance on training on animal and cadaver models. The diffusion of robotic surgery into all the different disciplines means that there will not be an ability to supply adequate numbers of cadavers for surgical training. When production of these high-fidelity models is scaled up, the relatively low cost will allow repetitive surgeries on these models until proficiency is reached. Recent synthetic model construction has focused on integrating models into full-procedural simulation and employing methods of educational validation to confirm their utility as surgical training tools.
The latest development in hyperrealistic synthetic organ models is demonstrated by the Simulation Innovation Laboratory at the University of Rochester. Rochester has refined a method for producing computer generated, 3D printed organ models using printed molds and polyvinyl alcohol (PVA) hydrogel and has already validated some of these models. Realistic models for simulation of robot-assisted kidney transplant ( Fig. 8.6 ), robot-assisted partial nephrectomy ( Fig. 8.7 ), and robot-assisted radical prostatectomy ( Fig. 8.8 ) have been validated for surgical training.
