Vincent Obias (ed.)Robotic Colon and Rectal Surgery10.1007/978-3-319-43256-4_3

3. Training and Credentialing in Robotics

Ryan Broderick¹, Simone Langness¹ and Sonia Ramamoorthy¹

(1)

Department of Surgery, University of California, San Diego Health System, San Diego, CA, USA

Sonia Ramamoorthy

Background

Since the introduction of robotics in minimally invasive surgery in the 1990s, many new devices and advances in technique have been developed. In addition, access and exposure have been increasing, with currently more than 3266 da Vinci Surgical Systems (dVSS , Intuitive Surgical, Sunnyvale, CA) in hospitals worldwide accounting for 570,000 procedures in 2014 [1]. Overall, the use of robotics in minimally invasive surgery has reportedly produced significant improvement in many aspects of surgery, including decreased postoperative pain, decreased physiologic insult, faster recovery times, and improved cosmesis [2–4]. Compared to laparoscopic surgery, robotic surgery provides better visualization and dexterity in many situations. Patient demand, physician demand, and industry involvement have driven the advancement of both laparoscopic and robotic surgery. The trend toward minimally invasive techniques in general, and robotics in particular, has significantly altered the focus and characteristics of surgical training programs. Open surgical training, and the Fundamentals of Laparoscopic Surgery (FLS ) curriculum, is now required by governing bodies such as the Accreditation Council for Graduate Medical Education (ACGME) to obtain board certification and has been vetted as safe and effective surgical training [5–13]. With the rapid expansion of robotics in general surgery and surgical subspecialties, the education and certification materials are not as well developed nor as well regulated as earlier surgical techniques (e.g., laparoscopic surgery). Similar to laparoscopic surgery training, the future of robotic surgery training should feature objective metrics in a curriculum that can be broadly applied across training institutions and also allow for specific subspecialty training.

Current Credentialing and Privileges in Robotics

Credentialing by a certifying organization verifies that a surgeon meets objective standards for performance of clinical tasks or operations. Privileging is defined as the surgeon’s scope of practice based on performed competency. Despite having multiple master-slave robotic platforms in the past such as the Automated Endoscopic System for Optimal Positioning (AESOP; Computer Motion, Santa Barbara, CA), the Zeus Surgical System (Computer Motion), and the da Vinci Surgical System (dVSS), the only FDA-approved platform at this time is the da Vinci Surgical System. A steep learning curve is a well-documented hurdle in the early stages of surgical training in general as well as adoption of new surgical techniques, and robotic surgery training (specifically with the dVSS) is not an exception [14]. Training programs with the dVSS have been initiated in an attempt to decrease the risks for patients during initial attempts at robotic surgery and to assist in the credentialing process.

Current training for the dVSS consists of an introductory industry-sponsored training program. The training features 8 h of training on an animal (porcine) model as well as virtual reality (VR) simulator. Following the initial introductory course, far less regulation exists regarding specialty-specific training. Many hospitals have further opportunities for observation, and feedback is available through proctors; this however can be accompanied by costs to the participant or hospital if a suitable proctor is not readily available locally. Specialty-specific training appears to offer participants the most utility for robotic practice preparation. These courses are designed to give the new robotic surgeons tips and tricks that include efficiency with setup and OR team operations, avoiding common errors in patient selection and avoiding complications, and utilization of proper instrumentation [15].

Because training practices for the credentialing process are provided through the industry that provides and sells the systems, objective measures to ensure safety and proficiency cannot be guaranteed [16–18]. There is little data to show construct validity of the dVSS courses [15, 19, 20]. The device industry nevertheless is motivated by both market forces and FDA pressure to ensure safe and responsible utilization of their systems. In the case of robotics, the technology is evolving and rapid progress is being made not only in area of device development but in the development of training tools such as virtual simulation. Few can argue with that fact that this investment will have a lasting impact on surgical education for the future.

Robotic Training Development and Research

Significant challenges must be addressed to develop a standardized robotic surgery curriculum. First, the cost of robotic surgery is much higher than for most laparoscopic devices attributed to the initial purchase start-up cost and service contract, with significant time and expense dedicated to maintenance. Due to the high cost, a dVSS is more profitable when used for patient care than for training time and therefore may limit trainees’ access when systems are operational. Similar challenges were faced during the introduction of laparoscopic surgery, but it has been established by the Fundamentals of Laparoscopic Surgery (FLS ) that inanimate objects can be as a significant part of training, which improves cost-effectiveness [5–13].

Research has been initiated to develop more cost-effective, inanimate, and virtual reality training for robotic surgery [15, 18–33]. Using the validated FLS objective metrics, inanimate training in robotics consists of peg transfer, camera movements, and suturing techniques in addition to other defined skills specific to robotic surgery. Many groups have also begun validating their own inanimate and virtual reality systems for robotic training [31–33]. Both content and face validity have been proven with inanimate trainers [18, 21, 29–33]. Despite these results, a remaining hurdle for training, even with inanimate objects, is that the robot must be available and not in use for patient care. An additional hurdle is that the inanimate training modules have been criticized for not providing adequate anatomic representation, resulting in limited feedback on the intraoperative consequences for various actions, although research on cross method validity is beginning to take shape [32].

Virtual reality (VR)-based simulators have been pursued as the ideal model for robotic training. Available simulators in practice currently include: the Mimic dV-Trainer (MdVT) (Mimic Technologies, Seattle, WA), the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA), the Robotic Surgical Simulator (RoSS) (Simulated Surgical Systems, Williamsville, NY), the SEP Robot (SimSurgery, Oslo, Norway), and novel platforms for specific procedure training [33]. The goal of VR training is to provide realistic practice in a controlled setting without exposing patients to risk. As training exercises, VR simulators have been able to construct programs for specific operations and skills.

VR simulators are valuable training tools, especially for novice robotic training, with varying content and construct validity [19, 30, 32, 33]. Each system has degrees of face, content, and construct validity for their various analyzed skills but with limited procedure-based components of training [30]. Comparative studies of the available simulators have not been performed to provide information on which system may be most effective. Additionally, comparisons between VR-based training and animal labs are in early phases to determine if VR may replace or should be used in conjunction with animal and/or inanimate models or initial operations during the training phase [32].

Two newer areas for VR training are procedure-based modules with relevant anatomy and escalating complexity to engage the user. These procedure-based modules are currently under development for the robotic platform and may be incorporated into future VR trainers in the future.

The physical separation between operator and instructor required by the dVSS master-slave configuration decreases the ability of the instructing surgeon to teach safe and effective surgical techniques. Dual-console robots have been developed by dVSS with some subjective improvement in training and a more controlled environment for trainee and experienced robotic surgeons. An improvement in training with the dual console has not yet been confirmed with data, and the cost for obtaining and using dual-console robots is prohibitive for many health-care systems [29, 34]. Nevertheless, the dual console appears to facilitate robotic teaching as it makes use of the “drivers education” model with a “brake” for the trainers to take over if needed, thereby giving the trainer added security when handing over the console.

Research efforts from multiple groups in both VR-based and inanimate techniques have provided valuable information but have reported conflicting, competing, and redundant training and assessment tools [21, 24–26, 29–33]. Also, in addition to the technical skill set that must meet a minimum proficiency in all realms of surgery, including robotics, communication, teamwork, decision making, and judgment should be verified prior to the independent use of a robotic surgical system [21, 22]. Inanimate training, VR simulation , and proctored operations each have strengths and limitations as isolated training tools. Each of these methods can play a significant role in robotic training, credentialing, and privileging in the future [30–33].

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