Use the Third Arm: A Reliable and Relevant Way To Teach Robotics

Jeffrey R Watkins, MD, Houssam G Osman, MD, Rohan Jeyarajah, MD. Methodist Dallas Medical Center

Introduction – Transitioning from open to laparoscopic surgery involved trial and error as surgeons learned their boundaries of teaching in a remote environment. The transition to robotics has been more thoughtful, but not as intuitive to many. As faculty surgeons get trained in robotics, there is generally a year-long hiatus in trainee participation. We describe a method of robotic education involving the use of the third arm, allowing for faculty and trainee growth together.

Methods and Procedures – A tertiary care center with a surgical fellowship and residency was the backdrop for this trial program. The surgeon himself was recently trained and the aim was to gain personal robotic experience without compromising the trainees in the program. The third arm was used on every robotic case that was performed by this surgeon at the institution. These cases consisted of cholecystectomy, paraesophageal hernia, esophagectomy and Heller myotomy. The trainee was then transitioned from the third arm to arms one and two.

Results – Trainees all completed the online and simulated training modules prior to any console work. Thereafter, using the third arm on every case, the trainee was placed in the dual console positon. This was instead of the bedside laparoscopic assistant, which was felt to not provide robotic-specific experience. As the trainee showed competence in the assistant role, including finger-clutch and arm control proficiency, the surgeon handed over two operating arms and while himself taking the third arm. Using this technique of graduated responsibility and robotic-specific training, trainees were able to graduate to dual arm work quickly. Moreover, both the faculty and the trainee obtained robot-specific experience together.

Conclusions – The use of the third arm allows for a graduated progression in robotic training. The third arm allows for robot-specific training which we believe is superior and more relevant than bedside laparoscopic assistant position. This method allows for an expedient transition to dual-arm surgeon role for trainees, and a parallel learning curve for faculty and trainee. We would propose a multi-center trial to look at this mode of robotic training.

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