NARUS 2018: How to Shorten the Learning Curve in the OR
The initial learning curve of robotic surgery is somewhere between 20-50 cases. This is followed by a second learning curve of around 100 cases. Proficiency is likely to occur somewhere after, but largely based on volume, overall surgical experience, and case selection. Didactic training is composed of the daVinci surgical online based curriculum, dry lab experience, article and video review, and pre- and post-training. Skills training is composed of simulated skills training (virtual reality simulators and dry labs), and dry lab based learning (docking, positioning, instrument insertion/removal, and troubleshooting).
The “Morristown” Protocol was developed by a group of experienced da Vinci system surgeons led by Dr. Patrick Culligan.1 The team’s curriculum was designed to help surgeons who are new to the da Vinci develop expert levels of proficiency when performing their first robotic supracervical hysterectomy. It requires approximately 20 hours of virtual reality simulation, designed for gynecologists without any robotic experience. The Morristown protocol includes the following virtual reality simulation robotic exercises: Peg board 2, Matchboard 2, suture sponge 2, tubes, ring walk 3, matchboard 3, camera targeting 2, energy dissection 1+2, and energy switching. At the end of the simulation training, the trainees complete a test prior to console work. This included a simple pre- and post- test on robotic parts and operations, and a skills based aptitude test – the Robotic Objective Structured Assessment of Technical Skills (R-OSATS).2
The robotic training network was established in 2010. It is a multi-institutional approach to improving and standardizing robotic training for residency programs. It includes a didactic curriculum, research review, simulation, and psychomotor testing. It includes a validated psychomotor exam that should be taken prior to live surgery. This exam encourages ongoing mentoring and feedback, and is designed as a way to teach and test the basic fundamentals for robotic surgery.
The new surgeon will need to be credentialed and later on, a strict maintenance protocol should be followed, with a minimum number of cases per year, further simulation and reviewing of videos will be required as well. The most important point that needs to be made here, is that experience equals quality and must be maintained. Greater skill is associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency.3
The topic of nursing learning curve was later discussed. This requires a 6 week orientation partnership, with the first 3 weeks comprised of online daVinchi modules, learning to drape and drive, and observation of various cases alongside senior staff nurse with vast robotic experience and motivation. The final three weeks are comprised of competency checklist and dry labs, troubleshooting in-services, in-service on various auxiliary systems used in robotics cases, and finally practice scrubbing in as the surgical tech role.
The most compatible nursing staff for robotic surgery should include staff members who are motivated, tech savvy, effective communicators, quick on their feet and mind. During the orientation and training, debriefing and feedbacks sessions should take place on a regular basis.
The last topic discussed was the training of the surgical assistant. A well-trained bedside assistant is just as important as the surgeon on the console. Factors affecting the learning curve include volume/repetition, complexity of cases, prior surgical experience, consistent team, and surgeon familiarity. It is important for the assistant to complete the daVinchi competency checklist and the online training first assist modules from the daVinchi community website. The next step is performing several dry labs focusing on patient, robot and port positioning, docking proficiency, insertion/exchange of instrumentation, troubleshooting scenarios, and fault management. Additionally, watching surgical videos, live cases, and understanding the anatomical relations and memorizing the steps of the operation are mandatory. After completion of all training steps, the assistant trainee should transition to proctored cases with experienced assistants for at least 5-10 cases, and then the trainee can start to perform independently. Once the assistant is completely independent, it is important to perform debrief sessions after each case with the surgeon. Continued practice will eventually lead to high proficiency, resulting in good surgical outcomes.
Presented By: Suzannah Sorin, NYU Langone Medical Center, NY, USA
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV
References
1. Culligan P, Gurshumov E, Lewis C, Priestley J, Komar J, Salamon C. Predictive validity of a training protocol using a robotic surgery simulator. Female pelvic medicine & reconstructive surgery 2014; 20(1): 48-51.
2. Siddiqui NY, Galloway ML, Geller EJ, et al. Validity and reliability of the robotic Objective Structured Assessment of Technical Skills. Obstetrics and gynecology 2014; 123(6): 1193-9.
3. Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. The New England journal of medicine 2013; 369(15): 1434-42.