Article on the pitfalls of robotic surgical training.

[DoctwoB]

Young doctors struggle to learn robotic surgery – so they are practicing in the shadows

Interesting article, much of which rings true to me. I do think that robotic surgical training is a very tricky subject, with a combination approach of simulation and graduated operative autonomy needed. Unfortunately in Urology we have very few simpler robot cases that are good for early trainees. Some do radical nephrectomies as a way to ease in, but then where will our pure laparoscopic training come from?

I will say that one aspect that is oft overlooked is the value of assisting. As a 1st and 2nd year, I probably bedside assisted for over 100 prostates (occasionally getting on the console to drop the bladder, etc.). In addition to the technical benefits (laparoscopic entry, basic lap skills, etc.) i think that just seeing these cases and the anatomy is important. A radical prostate previously was a senior or chief level cases, and good luck seeing what the hell is going on in the pelvis as a second scrub. Having started to do more open prostates or being the console surgeon for robos as a senior, I know the planes and anatomy cold in a way that I doubt I would have if I hadn’t done so much assisting.

With regards to simulation, I feel that it is necessary but not sufficient. It is a great intro to manipulating all the arms, camera movement, basic needle control, etc, but sucks when it comes to dissection or tissue handling. It is a reasonable prerequisite to sitting on the console but can’t replace console time. Part of the problem comes down to staffing. If an attending can sit at a dual console with a PA or junior resident at bedside, it is much easier for them to briefly show you something or help you out of trouble then give the controls back. If you don’t have help and the attending is at the bedside and have to break scrub to help, you’re probably not getting the controls back.

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[Jolie South]

In my residency, we got a lot of robot time (general surgery). I think it was a combination of things: comfortable attendings on the robot, several month minimally invasive rotation as a senior, and a dedicated scrub that could assist as needed. The best attendings would watch while you were at the console and make screen annotations to help. If needed, they could then take over the console at any point. I had zero simulator time. I do think the fact that we do so much laparoscopically earlier in residency helped with the transition to the robot.

 

[TypeADissection]

We thankfully get a lot of robot time here too. As long as we work our way through the training modules and spend hands-on time with the reps when they come learning how to use everything, the attendings are great about letting us do stuff. It helps that we also have those double consoles where the attendings can see what you're doing and take over if needed from their end. We start with gallbladders and umbilical hernias then move our way towards inguinals. Personally, I'm rather meh on the robot. It doesn't turn me on the way it does my other colleagues who will be doing general surgery and looking to incorporate it into their practice.

 

[doc05]

We thankfully get a lot of robot time here too. As long as we work our way through the training modules and spend hands-on time with the reps when they come learning how to use everything, the attendings are great about letting us do stuff. It helps that we also have those double consoles where the attendings can see what you're doing and take over if needed from their end. We start with gallbladders and umbilical hernias then move our way towards inguinals. Personally, I'm rather meh on the robot. It doesn't turn me on the way it does my other colleagues who will be doing general surgery and looking to incorporate it into their practice.

Gallbladders and umbilical hernias with a robot? Not exactly cost effective.

 

[rigid]

We thankfully get a lot of robot time here too. As long as we work our way through the training modules and spend hands-on time with the reps when they come learning how to use everything, the attendings are great about letting us do stuff. It helps that we also have those double consoles where the attendings can see what you're doing and take over if needed from their end. We start with gallbladders and umbilical hernias then move our way towards inguinals. Personally, I'm rather meh on the robot. It doesn't turn me on the way it does my other colleagues who will be doing general surgery and looking to incorporate it into their practice.

Pardon my ignorance as i've never used a robot, but wouldn't it take longer to set it up than to do it laparoscopically?

 

[DoctwoB]

Pardon my ignorance as i've never used a robot, but wouldn't it take longer to set it up than to do it laparoscopically?

Not really. Port placement is the same as lap and docking the robot takes just a couple minutes with an experienced team. It also then can speed up the dissection. It does add a bit to turnover time though, and of course to cost.

 

[TypeADissection]

Pardon my ignorance as i've never used a robot, but wouldn't it take longer to set it up than to do it laparoscopically?

It does add some time but a lap chole is such a standard operation that has very described steps that almost everyone does across the board. Thus making it an ideal operation to learn the robot.

 

[balaguru]

It's great that residents are now more commonly getting exposure to the robot in training. I graduated in 2013 and did not. I recently spoke to one of my old attendings and this has since changed. I agree that gallbladder and umbilical hernias are great cases for getting used to the instrumentation and learning how to trouble shoot. You can easily fall back to traditional lap if the exposure/dissection feels unsafe.

I have since gone back to traditional lap choles for mainly time efficiency reasons. I am sure it is cheaper too. But I see a benefit to using the robot for umbilical hernias in obese patients and other high risk cases. I do a preperitoneal repair with Progrip mesh and closure of the defect with vloc.

 

[AdmiralChz]

Port placement is the same as lap and docking the robot takes just a couple minutes with an experienced team.

Gosh can your Speedy Gonzales team come to my hospital? 3 institutions now and I don't think I've ever had a surgeon starting his or her dissection in the robot before 45 minutes after intubation, it's almost always an hour anecdotally. The faster surgeons will be closing the trochar sites for the gall bladder by that time. For robotic VATS, it's even worse.

That being said, there's a bit of a learning curve to the robot. After about a year that thoracic surgeon was able to do 3 robotic wedges a day (ending in late evening) in the same amount of time it first took him to do just one. Hospitals love putting this stuff up on billboards ("Now available: ROBOTIC SURGERY"), so getting proficient is important.

 

[armybound]

With regards to simulation, I feel that it is necessary but not sufficient. It is a great intro to manipulating all the arms, camera movement, basic needle control, etc, but sucks when it comes to dissection or tissue handling. It is a reasonable prerequisite to sitting on the console but can’t replace console time. Part of the problem comes down to staffing. If an attending can sit at a dual console with a PA or junior resident at bedside, it is much easier for them to briefly show you something or help you out of trouble then give the controls back. If you don’t have help and the attending is at the bedside and have to break scrub to help, you’re probably not getting the controls back.

Agree 110% on all points.

It's an interesting article. Something to think about for sure.

 

[vhawk]

My anecdotal offering: last week I was able to do a vessel preserving distal panc for a 3cm cystic neuroendocrine tumor using the robot. I am very sure I would not have been able to get this case done lap, and would have either converted or taken spleen, or at very least had to do Warshaw. I'm not sure how I would design an experiment to show this value and I certainly am not claiming this value justified the cost, but there are very clearly, to me and in my practice, cases where the robot gives me the ability and comfort to do things that would be much harder lap. Laparoscopic end to side roux an y hepaticpjejunostomy is a ****ing bitch. Robotic is a thrill.

 

[DoctwoB]

My anecdotal offering: last week I was able to do a vessel preserving distal panc for a 3cm cystic neuroendocrine tumor using the robot. I am very sure I would not have been able to get this case done lap, and would have either converted or taken spleen, or at very least had to do Warshaw. I'm not sure how I would design an experiment to show this value and I certainly am not claiming this value justified the cost, but there are very clearly, to me and in my practice, cases where the robot gives me the ability and comfort to do things that would be much harder lap. Laparoscopic end to side roux an y hepaticpjejunostomy is a ****ing bitch. Robotic is a thrill.

Oh the robot is a valuable tool without a doubt. A pure lap prostate or difficult partial nephrectomy is exceedingly technically difficult, not impossible, but few have the skills or patience. And while an open prostate isn’t particularly morbid with a small lower midline incision, partials have a big muscle splitting sub costal or flank incision when done open, so avoiding that is a huge plus.

 

[Buzz Me]

Gosh can your Speedy Gonzales team come to my hospital? 3 institutions now and I don't think I've ever had a surgeon starting his or her dissection in the robot before 45 minutes after intubation, it's almost always an hour anecdotally. The faster surgeons will be closing the trochar sites for the gall bladder by that time. For robotic VATS, it's even worse.

That being said, there's a bit of a learning curve to the robot. After about a year that thoracic surgeon was able to do 3 robotic wedges a day (ending in late evening) in the same amount of time it first took him to do just one. Hospitals love putting this stuff up on billboards ("Now available: ROBOTIC SURGERY"), so getting proficient is important.

Really? Usually it gets much better as the OR team becomes more familiar with the steps. From skin incision to console operation, we usually take less than five minutes in our cases. Back-to-back robotic lobectomies will usually be done by around 3-4 pm.

 

[Dares Dareson]

Wait so...how did the attendings who went through residency before robots existed learn to use the robot?

 

[Smurfette]

Wait so...how did the attendings who went through residency before robots existed learn to use the robot?

You go for training....they have simulators to practice on as well as courses to practice doing robotic procedures in a pig lab before working on humans. Generally if you're already in practice, you will then need to be proctored on a certain number of cases before being able to do robotic cases independently.

 

[balaguru]

You go for training....they have simulators to practice on as well as courses to practice doing robotic procedures in a pig lab before working on humans. Generally if you're already in practice, you will then need to be proctored on a certain number of cases before being able to do robotic cases independently.

I thought the DaVinci courses were well organized and executed. As an attending who had essentially no robot training in residency I was brought up to speed pretty quickly with these short courses. The robot is now my go to platform for hernia repairs.