and Victor Wilcox2
(1)
Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661A, Houston, TX 77030, USA
(2)
Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661A, Houston, TX 77030, USA
Abstract
This chapter is designed as a resource for anyone seeking to develop a curriculum for surgical trainees in robotic surgery. It is organized in the same fashion as a curriculum is developed covering the topics of needs assessment, goals and objectives, educational methods, outcome measures, and evaluation and feedback. This chapter outlines the currently available resources to provide cognitive and technical skills training, highlighting the advantages to each and the barriers to their implementation. It also provides examples of best practices for each part of the curriculum identified from the literature or through personal communication with experts in the field. The chapter focuses on training for use of the da Vinci® Surgical System, but the principles for training are the same for any robotic platform.
Introduction
This chapter is designed as a resource for anyone seeking to develop a curriculum for surgical residents and fellows in robotic surgery. It is organized in the same fashion as a curriculum is developed covering the topics of needs assessment, goals and objectives, didactic and skills educational methods, outcome measures, and evaluation and feedback. The chapter outlines the currently available resources to provide cognitive and technical skills training, highlighting the advantages to each and the barriers to their implementation. It also provides examples of current best practices for each part of the curriculum identified either in the literature or through personal communication with experts in the field. The chapter focuses on training for use of the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, California, USA), the only FDA-approved surgical robot available in the USA, but the principles for training are the same for any robotic platform.
Needs Assessment
The first step in curriculum design is to perform a thorough needs assessment. This requires determining the learning needs of the target audience, identifying gaps in their current learning, and setting priorities. In 2005, there were 25,000 robotic cases reported; that number grew to 355,000 in 2011 and is on pace to surpass 400,000 cases in 2012 (Fig. 31.1) [1]. Over 1,000 hospitals now boast a robotic surgery platform, and the robot is becoming commonplace in gynecological, urological, thoracic, and general surgery procedures. The robot holds particular importance to certain subspecialties such as urology where the public knowledge of and demand for robotically performed radical prostatectomies have led to an increasing centralization of cases in hospitals equipped with robots where 85 % of all of these procedures are currently performed in the USA [2]. As the use of the robot in surgery becomes ever more prominent, the need for residents and fellows to be trained on the system becomes greater. Adding to this clinical demand are the unique aspects of robotic surgery in regard to patient safety and team communication that are not part of other surgical procedures. These factors and the complexity of the robotic system indicate that robotic surgery training is ideally introduced during residency and fellowship to allow for a longitudinal training experience over a significant period of time. Despite this need, a minority of training programs offers a structured curriculum for robotic surgery. Additionally, a lack of accepted clinical measures of competency in robotic surgery has led to great variability in credentialing requirements for use of the robot at different hospitals. The end result is a failure to guarantee that any particular training curriculum will provide all the evidence of competency that an institution requires for the graduating resident or fellow to practice [3]. Clearly, the increasing volume of robotic surgery across multiple specialties, coupled with the unique aspects of robotic procedures, complexity of the platform, and variability in training opportunities is strong evidence that there is a need for more structured curricula introduced as early as possible into surgical residency and fellowships.
Fig. 31.1
Rapid rise in robotic surgical procedures with extrapolated estimates through 2012
Goals and Objectives
Once a formal needs analysis is performed, the next step in curriculum development is to determine the goals and objectives of the curriculum. Goals are general ideas of what the curriculum needs to accomplish such as “provide residents and fellows with a comprehensive robotic education to make them more proficient in robotic surgery.” Objectives are more specific action items often worded as “After completing this curriculum the learner will be able to…” Goals are determined based on the needs analysis and objectives created for each goal that are specific actionable items. For example, one goal is to teach residents and fellows to be proficient in robotic surgery. An objective to meet this goal might be that after completion of the curriculum, the resident will be able to describe the components of the da Vinci Si robotic system.
Expertise in a surgical domain requires both knowledge and technical skill. Interestingly, of all the curricula reviewed for this chapter, many had written overall goals and specific objectives for what was to be achieved technically, but few had specific cognitive objectives. In developing a meaningful curriculum with measurable outcomes, it is essential to pay particular attention to well-developed goals and objectives.
Knowledge
All medical device manufacturers are committed to the safe use of their products and take measured steps to achieve this by their users. Intuitive Surgical Inc., the manufacturer of the da Vinci Surgical System (dVSS) is no different. As a result, the company has developed the da Vinci Surgery Training Pathway and the da Vinci Residency/Fellowship Training Program. The Surgical Training Pathway is focused on practicing physicians who want to learn to perform robotic surgery, while the Residency/Fellowship program is focused on “senior” level residents (those in the last 2 years of training) and fellows across multiple specialties. Both programs utilize online modules and assessments developed specifically for each da Vinci platform (Si, Si-e, S, and Standard) coupled with live in-person hands-on training using the actual robotic system and either inanimate or animate models. The online modules for both are available for free through the da Vinci Surgery Online Community accessed through Intuitive’s website (http://www.intuitivesurgical.com) [4].
The da Vinci Residency/Fellowship Training Program is arranged into three steps: Step 1—preclinical phase, Step 2—clinical preparation phase, and Step 3—online modules and assessments. Step 1 is focused on residents and fellows who are not yet prepared to operate the dVSS clinically—either as a patient-side assistant or as a console surgeon. There are four components to this step (1) online dVSS courses and exams for each system, (2) hands-on dVSS overview, (3) procedure observation, and (4) literature review. The first component consists of professionally developed on-line video modules with a self-assessment quiz to be completed after viewing. There are four goals for this component (1) describe the features and benefits of the dVSS, (2) review the surgeon console components, (3) review the patient cart components, and (4) review the vision cart components. No objectives are listed to achieve these goals. It is anticipated to take approximately 2 h to review the material, and residents/fellows who complete the module and take the self-assessment quizzes will receive an online certificate of completion. There is no description of what is entailed in the second component of Step 1—hands-on dVSS overview. For the third component, procedure observation, it is suggested that this can be accomplished by viewing live cases or recorded cases from the da Vinci online video library. No goals or objectives are described for this component and no suggested cases. The fourth and final component of Step 1 is a literature review. Multiple robotic surgery articles are available through the Intuitive website, but no suggested articles, structure of review, or goals and objectives for this component are available.
Step 2 of the da Vinci Residency/Fellowship Training Program is focused on residents and fellows who are beginning their participation in dVSS surgery. It has six components (1) energy control lab for da Vinci Si users, (2) da Vinci port placement philosophy, (3) dVSS docking practicum, (4) dVSS skills training, (5) procedure observation, and (6) literature review. Components 1–4 are all done with an instructor using the real dVSS platform in an inanimate lab, and while instructions for how to set-up and conduct the labs are provided, there are no goals and objectives described. Components 5 and 6 are identical to that describe for components 3 and 4 in Step 1.
Step 3 of the da Vinci Residency/Fellowship Training Program entails online modules and assessments for each of the available dVSS models on the market. The components of each module and the goals of each component are shown in Table 31.1. There are extremely comprehensive descriptions of the dVSS system with professionally edited videos and images coupled with self-assessment quizzes within each module and a final comprehensive “Staff Assessment” test at the end. As a result, this material is frequently incorporated into curricula developed by individual training programs to satisfy the cognitive component.
Table 31.1
Components and goals for da Vinci online modules
Intuitive da Vinci online training modules | |
|---|---|
Module | Training goals |
da Vinci Si (or Si-e, S, Standard) system | |
Overview | • Provide an overview of the features and benefits of the dVSS • Review the surgeon console components • Review the patient cart components • Review the vision cart components |
OR setup and system connections | |
OR configuration | • Demonstrate how to arrange the system components into a basic OR configuration |
System connections | • Review the steps for properly connecting all the system cables |
Start-up | • Demonstrate the start-up process |
Shutdown | • Demonstrate the shutdown process |
Vision system | |
Components | • Introduce the components of the vision system – CORE – Camera assembly – CCU – Illuminator – Touch screen monitor |
Vision system controls | • Review vision system controls available on the touch screen monitor and camera head |
White balance | • Explain the white balancing procedure |
Endoscope calibration | • Review the steps for endoscope and camera calibration |
Draping | |
Patient cart | • Review the patient cart components that require draping • Demonstrate the steps required to drape the patient cart |
Camera assembly | • Provide an overview of the camera assembly components • Demonstrate the steps required to drape the camera |
Touch screen monitor | • Demonstrate the steps required to drape the touch screen monitor |
Docking | |
Port placement | • Review the basic da Vinci port placement philosophy • Discuss the accessories needed for port placement • Explain remote center technology |
Camera arm positioning | • Summarize the steps for setting up and aligning the camera arm to maximize range of motion |
Instrument arm positioning | • Summarize the steps for setting up and aligning the instrument arms to maximize range of motion |
Docking | • Review the steps for docking the patient cart • Explain the guidelines for minimizing trauma to the incision site • Provide tips for retaining correct position of the camera and instrument arms during the docking process |
Endoscope insertion and removal | • Review the correct procedure for inserting and removing the endoscope and camera assembly |
Instrument insertion and removal | • Review the procedure for inserting and removing the EndoWrist instruments manually • Demonstrate the correct procedure for removing and inserting the EndoWrist instruments using the guided tool exchange (GTE) |
Safety features | |
Fault modes and error handling | • Review recoverable and non-recoverable fault modes • Discuss basic safety features and error handling procedures • Explain the battery back-up feature • Discuss the process for contacting customer service • Review the process for accessing the events logs |
Emergency switches | • Review the function and purpose of the emergency stop button • Review the function and purpose of the emergency power off switches |
Energy control | • Review the system energy and control features |
Procedure conversions | • Review the procedure steps for converting to an open or laparoscopic procedure in an emergency situation |
Final OR staff assessment | |
Da Vinci Si OR staff assessment | • Quiz covering the material in all of the modules |
The most comprehensive industry agnostic curriculum is the Fundamentals of Robotic Surgery (FRS) Curriculum being developed under the direction of three co-principle investigators (Satava, Smith, and Patel) with funding from industry and government [5]. The FRS program has brought together experts from multiple surgical societies and in the fields of education and performance metrics to build a basic curriculum in robotically assisted surgery that could be adopted by multiple specialties. Since 2011 there have been four FRS conferences focused on identifying the essential components of knowledge and skill required to perform robotic surgery. The vision is to create didactic content coupled with hands-on skills practice and team training that lead to measurable competence. A high stakes written examination and hands-on skills test are also planned to serve as validated measures of knowledge and skill at the completion of the curriculum. The program is arranged into three phases—preoperative, intraoperative, and postoperative—and the goals and objectives of this curriculum are evolving. FRS is meant to serve as the core knowledge and skills required by any specialty to perform robotic surgery, with more advanced modules left to be developed by specific specialties (Fig. 31.2).
Fig. 31.2
The Sweet tree of curriculum templates
Another example of a curriculum with clear goals and objectives in the knowledge domain has been created at the Lehigh Valley Health Network under the direction of Dr. Mario Martino. This curriculum is available through the “The Medicine Network” website which serves as a central repository for curricula and resources for robotic training for medical students, residents, and fellows [6]. The goal of the Lehigh Valley Health Network robotic surgical training curriculum for residents is to train all OB-GYN and general surgery residents to be competent bedside assistants in complex robotic surgery. The curriculum has two phases—bedside training and console training. Within bedside training, there are five competencies with clearly identified goals and objectives in both knowledge and skill.
Technical Skill
Most curricula focus on the technical skills required to perform robotic surgery. For the da Vinci Residency/Fellowship Training Program, technical skills are rehearsed using the actual dVSS in either an inanimate or animate laboratory setting and under the guidance of a trained proctor. While the Program provides suggested “scripts” of what should be done in the lab and what measures should be recorded, there are no specific goals or objectives outlined.
The FRS Curriculum sought to develop a deconstructed task list essential for all specialties. Participating expert surgeons engaged in a 2-day workshop using the Delphi method where ideas from each institution’s curriculum were evaluated and then ranked by anonymous vote. The guiding principles in selecting tasks were that they be oriented around three dimensions, incorporate as many elements of real surgical skills as possible, be cost effective, easy to administer and reliably evaluate, utilize physical models that could be placed under any robotic platform, and preferably already have validating evidence supporting their use. After the first selection round, tasks were organized into a matrix and then another round of voting performed to assign importance. Tasks falling two standard deviations below the mean task score were eliminated. The resulting task list (Table 31.2) serves as a basis for training objectives for a core global curriculum.
Table 31.2
FRS task list in order of decreasing importance
Task | Description |
|---|---|
Situation awareness | Aware of status of team, equipment essential to the procedure, and patient status; maintains effective communication |
Eye–hand instrument coordination | Learn to accurately and efficiently manipulate the bedside instruments with economy of motion; pass objects between instruments |
Needle driving | Accurately and efficiently pass needle through targeted tissue without tearing, damaging adjacent structures, or dropping the needle |
Atraumatic handling | Manipulating tissue with graspers without causing avulsion or crush injuries; understanding of haptics |
Safety of operative field | Appropriate placement and positioning of instruments so as to avoid injury to tissues from instrument collision outside of the field of view |
Camera | Effectively maneuver the camera in a controlled manner maintaining focus, proper orientation and angle, and avoiding tissue contact |
Clutching | Maintaining full range of motion in an efficient, ergonomic manner without collision of console controls; efficient, accurate use of pedals |
Dissection, fine and blunt | Accurately utilizes instruments to bluntly or precisely dissect tissue in correct plains maintaining traction and countertraction and adequate exposure without injuring surrounding structures |
Closed loop communication | Maintain effective communication with team members using names, clear requests, and using callbacks as per TeamSTEPPS® |
Docking | Guides team in docking the robot efficiently with proper positioning and alignment, attaches arms to trocars, avoids moving OR table |
Knot tying | Accurately and efficiently ties secure knots with economy of motion and without causing tissue damage or ischemia |
Instrument exchange | Efficiently, accurately, and safely removes |
Cutting | Efficiently and accurately cuts the right structure without collateral damage or going past-point |
Energy sources | Applies energy appropriately without collateral damage |
Foreign body management | Safely removes all foreign bodies from the patient with the appropriate instruments, confirming removal and instrument counts |
Robotic Trocars | Safely inserts trocars with correct orientation and spatial orientation relative to the target; uses direct visualization after first trocar |
Suture handling | Efficiently, accurately, and safely places running and interrupted sutures to adequate appose tissues avoiding suture breakage or tissue damage |
Wrist articulation | Efficiently uses all degrees of freedom in full range of motion |
Ergonomic positioning | Maintains good posture with comfortable position of body and limbs during the entire procedure |
System settings | Can properly configure console settings for scope angle, magnification, and motion speed and scaling |
Multiple arm control | Can efficiently activate and employ the fourth arm in the procedure without collisions |
OR setup | Properly arranges bedside cart where most accessible and safe while maintaining sterile field |
Robot system errors | Understands and troubleshoots system errors to correct them when possible avoiding unnecessary conversion |
Undocking | Efficiently and safely removes robotic equipment and trocars and inspects port sites |
Transition to bedside assist | Safely and efficiently removes instruments and ports performing port site inspections |
The Lehigh Valley Health Network curriculum requires skills practice using the Fundamentals of Laparoscopic Surgery (FLS—http://www.flsprogram.org) as well as inanimate and simulator training on the robotic platform but does not provide details of this practice or outline goals and objectives.
Dulan et al. from the University of Texas Southwestern Medical Center have developed and published a comprehensive, proficiency-based curriculum [7]. While this curriculum uses the da Vinci Residency/Fellowship Training Program for its didactic content, it systematically created goals and objectives for developing technical skills. This process brought together six experienced experts from various disciplines to identify the skills necessary to perform robotic surgical procedures for any specialty. From this discussion, they developed a deconstructed task list that served as the basis for their objectives in the skills curriculum (Table 31.3).
Table 31.3
Deconstructed robotic surgery curriculum tasks list from UT southwestern
Task | Description |
|---|---|
Cognitive skills | |
Console setup | Setting up and adjusting console settings as needed during surgery |
Docking | Surgeon guides OR nurse in positioning bedside robot and attaches arms to trocars |
Robotic trocars | Appropriate port location strategies and placement technique |
Robotic positioning | Placing the bedside cart in the location where the operative field is most accessible |
Communication | Closed loop communication between console surgeon, bedside assistants and OR team |
Robot component names | Knowledge of robotic component terminology |
Instrument names | Knowledge of instrument terminology |
Technical skills | |
Energy sources | Activation and control of cautery or other energy sources |
Camera | Maneuvering the camera to obtain a suitable view |
Clutching | Maintaining comfortable range of motion for manual controls |
Instrument exchange | Changing out instruments used in the operation |
Fourth arm control | Activating the fourth arm through clutching and using it in the operation |
Basic eye–hand coordination | Using manual controls to accurately manipulate bedside instruments and perform tasks |
Wrist articulation | Understanding and using the full range of motion of the EndoWrist (Intuitive Surgical) |
Depth perception | Appreciating spatial relationships of instruments and tissue |
Instrument to instrument transfer | Passing objects between the instruments |
Atraumatic handling | Using graspers to hold tissue or surgical material without crushing or tearing |
Blunt dissection | Using instruments to separate tissues bluntly |
Fine dissection | Using instruments to perform precise dissection of delicate structures |
Retraction | Holding tension on an object to facilitate surgical manipulation |
Cutting | Using the scissors to cut at a precise location |
Interrupted suturing | Suturing single stitches with the robot |
Running suturing | Suturing continuous stitches with the robot |
Lyons et al. from the Methodist Institute for Technology, Innovation, and Education (MITIESM) have used a similar consensus conference of experts to deconstruct robotic surgery skills into a somewhat shorter list of tasks which then served as a basis for developing a proficiency-based skills curriculum using the da Vinci Skills Simulator (Table 31.4) [8].
Table 31.4
MITIE deconstructed task list for robotic surgery
Task | Description | |
|---|---|---|
1 | Pick and place | Pick up an object and set it down in a specific location |
2 | Two-handed transfer | Transfer an object from one hand to another in space |
3 | Wrist manipulation | Use wristed instruments to advantage |
4 | Camera control | Manipulate camera for optimal view |
5
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