Keywords

20.1 Introduction

Robot-assisted procedures have been increasingly adopted over the last two decades because of the advantages of three-dimensional vision, a shorter learning curve, increased dexterity and precision, and better ergonomics for the surgeon [1]. These advantages have led to robotic surgery becoming the prevalent approach of minimally invasive surgery worldwide, with approximately 4500 Da Vinci robotic systems (Intuitive Surgical Inc., Sunnyvale, CA, USA) in action in 2018 [2, 3], with robot-assisted radical prostatectomy (RARP) as the most commonly performed robotic procedure worldwide [4]. With respect to this, the implementation of robotic surgery in this field has led to equivalent oncological outcomes compared to open or laparoscopic surgery with the advantage of having superior peri-operative and functional outcomes [5].

However, “a fool with a tool, is still a fool.” The rapid increase of robotic systems has not yet been translated into an even greater increase in the training of robotic surgeons. Consequently, a significant proportion of surgeons start using robotics without being adequately trained according to validated training curricula, and therefore expose their patients to unnecessary risks of unfulfilled learning curves [6, 7]. This has resulted in increased adverse events [8].

The phenomenon of inadequate training is not unique to the implementation of robotic surgery, but could be applied to every field in medicine and could result in a significant number of medical errors and preventable complications. In the book “Why Hospitals Should Fly,” the author reported mortality comparisons between the aviation and healthcare industries over a 5-year period between 2001 and 2006, with zero deaths on commercial US flights compared to an estimated 250–500,000 deaths from medical errors in the US healthcare system at the same time [9, 10]. Nonetheless, the structure of training in aviation and robotic surgery has many similarities, and both parties control complex technology with their hands, that if managed inappropriately, could result in fatal consequences. This significant difference in outcomes could be explained by the different approaches to training. The increased standardization, with internationally agreed training standards, forms the basis of pilot training in the airline industry. Evaluation and regulation comprised of benchmarked high-stakes tests related to proficiency-based training, result in quality assurance [10, 11] and should also be the way forward in surgical robotic training since we live in an era of outcome-based surgery. The implementation of structured, standardized, and validated curricula in a non-clinical training environment will form the basis of this process [12]. In these times, it is not justifiable anymore, that living patients are being used as training objects.

20.2 Elements of Training Programs in Robotic Surgery

A structured training curriculum should include theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and a final evaluation [13].

20.2.1 E-learning Instruments

E-learning, and, more generally, video training, are essential tools for acquiring theoretical notions and technical skills. In surgical practice, it allows a proctor to guide his trainee using procedure-specific training videos. New e-learning processes are emerging to spread knowledge about a single procedure [14]. New online learning platforms have the ability to incorporate procedure-specific operative metrics to offer novice surgeons a stepwise approach in technical skill acquirement as part of proficiency-based training curriculum [15]. Furthermore, procedure-specific assessment tools could be used to perform a video-based assessment of a surgical performance [16]. Moreover, these e-learning processes are easily accessible and can be quickly updated [17]. Maertens et al. [18] have shown how e-learning can have higher or equal effectiveness compared with both no intervention and non-learning interventions. Angelo et al. also indicated that implementation of an e-curriculum as concept of a proficiency-based progression (PBP) training methodology led to a significantly lower amount of procedural errors [15]. However, the introduction of these new learning processes is far from simple and requires the introduction of new methods of digital learning assessment and a redefinition of educational roles [19]. To date, there are no e-learning platforms in the robotic surgical field that have undergone an adequate and complete validation process.

20.2.2 Preclinical Simulation-Based Training

Virtual reality simulators are already an integral part of most of the curricula in literature [20,21,22] and have been shown to improve surgical skills in an out-of-hospital setting [12, 23]. The main ones available on the market are: da Vinci Skills Simulator (dVSS) (Intuitive Surgical, Sunnyvale, Santa Clara County, CA, USA), the Robotic Surgical Simulator (RoSS) (Simulated Surgical Systems, Buffalo, NY, USA), SEP robot (SimSurgery, Norway), d-V-Trainer (Mimic Technologies Inc., Seattle, WA, USA), ProMIS (Haptica, Ireland), and RobotiX Mentor (3D Systems, Israel). The most widely used today is the dVSS [24]. However, the d-V-Trainer is considered the most validated [25].

Benchtop simulators are the main tools found inside the dry lab. They are inexpensive, easy to carry, and useful for improving surgical skills. But they are rarely attractive to learners, and are unable to simulate a real surgical setting [23]. They could be used in the simulation phase of robotic docking. Some studies in the literature have established a partial validation of dry lab simulators [26, 27].

Two main simulation models are available in the wet-lab: animals and human cadavers. The animal tissue is of low cost but needs particular facilities for its conservation. Entire deceased animals and living animals are among the best existing simulation models [28]. They allow one to distinguish the consistency of tissues, to replicate the real anatomy and to practice the on-patient operation in a reliable manner. However, this type of training involves very high costs, legal requirements, and availability for single use only [29, 30]. The human cadaveric model is the gold standard for anatomical training; however, it has the same problems as mentioned for the animal model.

During the preclinical simulation-based training, a real-life case observation in a training center by an experienced robotic surgeon is essential as this also includes the circumstances of an operation theater, the associated stress factors, and interhuman relationships.

20.2.3 Clinical Modular Training

It consists of performing supervised surgery in a modular fashion under the expert surgeon’s supervision. Progressive, proficiency-based training through surgical steps with increasing levels of complexity is performed. At the end of the clinical training, the trainee should perform a complete procedure that needs to be recorded and evaluated by certified independent examiners in a blind-review process using recognized assessment tools [31].

20.2.4 Full Immersion Simulation and High-Fidelity Operating Room Simulation

The success of the surgical robotic procedure depends not only on the surgeon’s technical skills, but also on his/her non-technical skills and the preparation of his/her surgical team [32]. Recognition that, besides technical skills, also cognitive (thinking) and non-technical skills (NTS) will contribute to the development of robotic surgery curricula. To develop these skills in a standardized way, the main methods used are the classroom lessons, the full immersion simulation, and high-fidelity operating room simulation [33, 34].

20.2.5 Tele-Mentoring

Although not very relevant at present, tele-mentoring offers several advantages, making it most likely to play a fundamental role in future training and curricula. The possibility that experts in the field can guide novice surgeons, even when being remotely from each other opens perspectives. Moreover, technological advancement and the introduction of the 5G network could, in the future, even allow proctors to take over the master controls in case of an emergency or trouble. Financial, legal, ethical, economic, and security issues still need to be addressed and solved before being able to integrate this ingredient into the training process adequately [35].

20.3 Critical Issues in the Development of a Robotic Training Program

20.3.1 Adequate Training Time to Perform Safe Surgery

The learning curve is the process during which a novice surgeon gains experience, ability, and skills until reaching a plateau of having optimal operative results. Importantly, the initial phase of the learning curve can be burdened by nonoptimal technical, functional, and oncological results [36, 37]. The duration of this learning curve is procedure dependent and is associated with the level of complexity of the specific task. Taking, for example, the learning curve for robotic-assisted radical prostatectomy (RARP), this was estimated by some authors to be between 12 and 250 procedures based on measurable variables, while others showed a substantial reduction of positive surgical margins (PSMs) after 200 and 1600 procedures [38, 39]. Bravi et al. [34] also showed that previous open surgical experience does not correlate with the risk of PSMs during RARP. Implementation of structured and validated training curricula should aim to overcome the learning curve with its suboptimal results, in a non-clinical training center in order not to expose patients to the inexperience of novice surgeons [40].

Over the last decades, there has been a transition of the duties of surgeons in training, with more emphasis on non-clinical bureaucracy work. Moreover, due to an increased number of surgical procedures to learn during training and due to restricted working hours, fewer surgeons are fully trained and able to operate independently at the end of their training [41]. This might affect the patient’s health. Consequently, additional training fellowships to acquire the necessary skills are needed. Validated training curricula with preset proficiency benchmarks should be able to overcome the limited time issues by optimizing the quality of the training [42]. Of note, the foreseen training course should have sufficient length to reach the preset benchmarks and quality standards. For this reason, for example, the initial training period planned for the European Association of Urology Robotic Training Curriculum was 3 months and was then updated to 6 months, to allow all participants a sufficient amount of time to acquire the necessary expertise [43,44,45,46].

20.3.2 Cost of Training

The need for equipment, simulators, dual consoles, wet-lab training materials and the use of facilities at recognized training centers makes robotic surgery training extremely expensive compared to open and laparoscopic surgery. It seems correlated with the length of the learning curve, quantifiable between 95,000 and 1,365,000 dollars [13, 47]. Implementation of validated training curricula and the transition of training outside of the hospital will increase the cost of training further. However, this aims to deliver surgeons who have completed their learning curve and therefore should lead to decreased peri-operative complications. Consequently, this could be translated into lower hospital costs [48].

20.4 Available Robotic Surgical Training Curricula

Table 20.1 shows that several training programs are available [53]. However, the majority are characterized by short training sessions that rely exclusively on preclinical simulation-based training (virtual-reality/dry-lab/wet-lab). Conversely, only a few are all-inclusive fellowship-style programs that include clinical modular training. Of these curricula, a few have been validated [11, 44, 45, 54].

Table 20.1 Summary of validated training curricula
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20.4.1 Validated Robotic Surgical Training Curricula (Table 20.1)

  1. 1.

    Fundamental skills of robotic surgery (FSRS): this curriculum was created by the Roswell Cancer Institute in Buffalo, CA, USA, and consists of 4 modules, further subdivided into 16 tasks executed with the aid of the RoSS simulator. Studies have shown the validity of the FSRS curriculum in improving the robotic surgical skills of trainees. It has also been validated for construct validity [11]. The robot-assisted surgical training (RAST), developed by the same center, combines the FSRS with other forms of hands-on training, such as HoST training and wet-lab. Evidence suggests that it has an educational impact on trainees [54].

  2. 2.

    Proficiency-based robotic curriculum: that was developed by the University of Texas Southwestern Medical Center. It consists of an online free tutorial offered by Intuitive Surgical, followed by an interactive hands-on training session on the standard da Vinci system, and finally, the execution of nine inanimate exercises of increasing difficulty. The content, face, and construct validity of this curriculum has been established [49, 55].

  3. 3.

    Basic skills training curriculum (BSTC): It was developed by the University of Toronto and consists of a 4-week training, featuring didactic lectures, theoretical module, 2 hours of hands-on training and exercises at dVSS organized with weekly intervals. This curriculum has been validated and has shown to improve robotic surgical skills [11, 56].

  4. 4.

    The European Association of Urology Robotic Urology Section (ERUS) training curriculum (Fig. 20.1): this represents the first structured and validated curriculum in urology. It is built for training on a specific procedure, the RARP. The first version, published in 2015, was followed by a more recent one with a lengthening of the training period from 3 to 6 months. This change is intended to allow even the less experienced trainees to have enough time to continue and finish the full training path [44, 45]. The curriculum initially includes a theoretical study of the robotic platform and the index procedure through e-learning, followed by live case observation and bedside assistance in the host center. At this point, there is a week of intensive hands-on training with virtual simulators, dry-lab, and wet-lab, associated with in-depth theoretical knowledge of technical and nontechnical skills. A recent study by Larcher et al. [57] shows how the use of virtual simulators in the ERUS curriculum preclinical phase improves surgical performance, according to objective measurement indexes. Moreover, in this study, the average total score and the average improvement score that the trainee should reach to move to the next phase are quantified [57]. Subsequently, the curriculum includes a period of modular clinical training, under the supervision of an expert robotic surgeon, and finally, the surgeon will have to record an unedited video of a complete procedure that will be blindly evaluated using adequate scores [31]. Some studies showed that the fulfillment of the ERUS curriculum leads to an early improvement of results [58, 59].

  5. 5.

    The ERUS curriculum for robot-assisted partial nephrectomy (Fig. 20.2): Based on the ERUS curriculum for radical prostatectomy, the same scientific society has developed a training program to prepare surgeons to perform robotic-assisted partial nephrectomy (RAPN). This curriculum consists of the first part of theoretical preparation. Second, a week of intensive training with virtual simulators, dry-lab and wet-lab, followed by the third phase of modular clinical training, in which the procedure is divided into 10 steps which the trainee must reproduce. At the end, there is the final evaluation based on the assessment of an unedited video by an expert surgeon in the blind modality. In the pilot validation phase, this curriculum showed no deterioration in the clinical results of the interventions [51].

  6. 6.

    The ERUS curriculum for robot-assisted radical cystectomy (Fig. 20.3): Similarly to the ccERUS for RARP, ERUS also developed a structured training program for robot-assisted radical cystectomy (RARC). The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-day simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 months at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case [52].

Fig. 20.1
figure 1

Structure of the European Association of Urology robotic training curriculum

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Fig. 20.2
figure 2

Structure of the European Association of Urology Robotic Urology Section curriculum for robot-assisted partial nephrectomy defined by the modified Delphi consensus process. RAPN = robot-assisted partial nephrectomy; US = ultrasound

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Fig. 20.3
figure 3

Structure of the European Association of Urology Robotic Urology Section curriculum for robot-assisted radical cystectomy (RARC) defined by the modified Delphi consensus process

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It is noteworthy that, except for the ERUS training curriculum and the RAPN and RARC curricula, the other validated curricula do not follow the virtual reality simulation phase with dry and wet lab and a modular clinical training phase monitored by an experienced surgeon. This phase appears essential in order to transfer, in a protected and safe setting for the patient, the skills learned on training models into a clinical setting.

An important limitation in these validated curricula is the lack of objective, quantitative assessment tools. The above-mentioned curricula generally use qualitative assessment tools which are prone to high interobserver disagreements and subjective scoring. The development of an objective, quantitative scoring method would make the scoring and comparison of scores more reliable. A possible answer is the use of proficiency-based progression curricula with the implementation of validated, binary performance operative metrics to guide trainees during training and objectively scoring of their operative skills [60].

20.5 Assessment Tools to Evaluate Robotic Skills

Objective and standardized tools that can assess acquired skills are key to developing curricula that can accredit surgeons as being able to perform a specific robotic procedure. At the moment, there are different tools to evaluate the trainees. However, as stated above, it seems increasingly necessary to develop new, simple, objective, standardized, useful, and easy-to-use instruments. The most used tools are:

20.5.1 Global Assessment Tools

  1. 1.

    Robotic objective structured assessment of technical skills (ROSATS) : It is the most commonly used assessment scale in robotic surgery, and it is derived from the objective structured assessment of technical skills (OSATS) in surgery. However, it is a subjective evaluation. In ROSATS, four skill categories are assessed: depth perception and accuracy, force and tissue handling, dexterity, and efficiency. The score assigned for each category is from 1 to 5 [61].

  2. 2.

    Global evaluative assessment of robotic skills (GEARS) (Fig. 20.4): It is developed from a score for the evaluation of laparoscopic intraoperative skills, the global operative assessment of laparoscopic skills (GOALS). Therefore, this instrument was not explicitly developed for robotic surgery but was adapted for this technique. Six domains are assessed by this tool: Depth perception, bimanual dexterity, efficiency, force sensitivity, autonomy, and robotic control. The score assigned for each category is from 1 to 5. Studies showed that this score is a valid, reliable, reproducible measure to evaluate intraoperative robotic surgical skills and is also associated with functional outcomes in RARP [26, 62].

  3. 3.

    Structured assessment of robotic microsurgery skills (SARMS): This is a validated tool. It was adapted to robotic surgery starting from the original structured assessment of microsurgery skills (SAMS) [63].

  4. 4.

    Assessment of robotic console skills (ARCS): It is a validated instrument, consisting of six domains used to verify the adequate acquisition of skills in the use of the robotic console [64].

  5. 5.

    Generic dedicated scoring criteria (GDSC): This is a validated tool used to evaluate the video of a complete procedure performed by the trainees at the end of the ERUS curriculum. The parameters evaluated are instrument use, tissue handling, and errors made. The score assigned for each category is from 1 to 5 [45].

Fig. 20.4
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Global evaluative assessment of robotic skills (GEARS)

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20.5.2 Procedure-specific Assessment Tools

Recently, tools aiming to evaluate specific interventions or steps have been developed. These tools can evaluate both the acquisition of technical skills and the mastery of the procedure, assessing the safety and autonomy of the surgeon in performing the specific intervention. However, to date, no studies have assessed their correlation with clinical outcomes [62]. Specifically, for RARP, we can identify the RARP assessment score, the Robotic Anastomosis Competency Evaluation (RACE), and the Prostatectomy Assessment and Competency Evaluation (PACE) [65,66,67]. For RAPN, we can identify the RAPN assessment score and “Scoring for Partial Nephrectomy” (SPaN) [68]. For pelvic lymphadenectomy, we can identify the Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE) [69]. Finally, for cystectomy, we can identify Cystectomy Assessment and Surgical Evaluation (CASE) [70].

20.5.3 Automated Assessment Tools

These tools automatically acquire data during the execution of the exercise by the trainee. They have the advantage of providing an objective, quantifiable assessment, without loss of time by the evaluator. However, further development of this evaluation method is necessary in order to apply it continuously and on a large scale [62].

20.6 Future Perspectives

To date, the structured and modular training model has appeared to be the most convincing. However, the future seems directed toward a new training methodology: proficiency-based progression (PBP) training. The PBP has not yet been applied to robotic surgery, but prospective studies, randomized in other surgical areas, have shown how the application of this approach improves trainees’ skillsets by 40–70% compared to the level reached using conventional or traditional training [60, 71]. The application of this training model to robotic surgery might be crucial and result in better preparation of the surgeon for the operating room.

20.7 Conclusion

This recent literature analysis suggests that there is an urgent need to develop and validate new structured training curricula for robotic surgery. This allows them to improve the skills of the surgeons and of their team and to prevent patients from being used as a training module, optimizing their safety. Objective and repeatable evaluation systems and metrics might be used to assess the skills of the trainee and allow the attestation of the skills acquired. The road taken with structured curricula seems to be profitable because it takes into account the various theoretical and practical aspects that must be acquired by the robotic surgeon before fully accessing the clinical setting.

Further refinements in the curricula and some validation studies and reports demonstrating improvement in clinical outcomes since the first phase of learning curves seem to be necessary. However, the tendency to move training out of the operating room should be pursued.

Key Points

  • A validated, centralized, and standardized program of robotic surgery training, for each specific procedure is fundamental to guarantee patient safety.

  • A structured training curriculum should include theoretical training (e-learning, case observation), preclinical simulation-based training (virtual reality simulation, dry and wet lab), clinical modular training, and a final evaluation.

  • At the moment, there are different tools to evaluate the trainees. However, it seems increasingly necessary to develop new, simple, objective, standardized, useful, and easy instruments to use.

  • The future seems directed toward a new training methodology: the proficiency-based progression (PBP) training. The application of this training model to robotic surgery might be crucial and result in better preparation of the surgeon for the operating room.