Jeffry T Zern, MD. Christiana Care Health System
Introduction: Development of an objective, standardized training experience including simulation would allow advanced laparoscopic surgeons to become proficient with the da Vinci robotic platform and lead to improved patient outcomes.
Robotic surgery enables surgeons to perform highly complex procedures through minimally invasive modalities. Although this is an extension of basic surgical principles, a steep learning curve exists to master this technology. Training requirements were established using robotic simulators to ensure that all surgeons possessed a standard level of proficiency prior to performing surgery on patients. The MIMIC and the daVinci backpack simulators were used. They allow surgeons to practice robotic skills without affecting patient care. The simulator grades the surgeon on multiple parameters and requires skill advancement in order to obtain an expected score.
Methods and Procedures: An educational training curriculum included the following components:
1. Intuitive/daVinci on line learning modules.
2. Two specialty specific case observations.
3. Simulator drills–10 exercises to teach specific robotic tasks. A passing score of 90% for each of the10 drills was set to ensure a standard for proficiency. These were grouped regarding surgical tasks including:
A. EndoWrist manipulation and camera control
B. Third arm control
C. Needle control
D. Energy and dissection
4. Intuitive/daVinci guided animate porcine operative training, followed rapidly by first live proctored cases to avoid skill decay.
5. Three proctored cases.
6. Retrospective review of ten successful cases.
7. Requirement to complete 15 basic cases prior to advanced cases.
Results: Eight advanced laparoscopic surgeons participated, spending 6.4 to 8.1 hours performing simulation drills. The first 208 general surgical procedures performed at our institution used the daVinci Si robot and were evaluated for this study.
Overall results have been outstanding with no robotic specific complications to date. This compares to other surgical disciplines at our institution that started robotic surgery without the benefit of simulation training and had conversion and complication rates of over 8%.
Seven conversions occurred from robotic to laparoscopic modality due to anatomic issues, positioning of the robotic arms relative to target anatomy, inflammation of target tissues and unexpected findings which changed operative plans. Two patients were converted from robotic to open surgery, one due to the presence of gangrenous cholecystitis and the second due to anatomic issues, specifically obesity during a low anterior colon resection.
Robotic to laparoscopic conversion rate 3.4%
Robotic to open surgery conversion rate 0.96%
Robotic specific complications 0%
Conclusion: This project demonstrates that robotic surgeons who have trained through a curriculum including simulation are well prepared to begin robotic surgery. Surgeons operating with the daVinci robotic platform routinely are able to maintain their skills better than infrequent users and novices. Simulation drills could also be used to demonstrate competency if a surgeon has not used the robot for an extended period of time. Mastery of the daVinci robot will allow surgeons to provide safe and effective care for their patients.
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