Since Intuitive Surgical released its first robotic-assisted surgical device in 2000, surgical robots have offered the benefits associated with minimally invasive surgery, like quicker recovery time and less potential for infection, in addition to improved visibility, more precise tissue handling and less surgeon fatigue. It has even been a draw for patients interested in the science-fiction like technology.
Unfortunately, lawsuits and accident reports have made one thing very clear – these tools only benefit patients and practices if the surgeon using it has been trained properly. Training programs are continually updated to reflect studies and industry trends, and incorporate different technologies to serve its students.
There are two general ways to access hands-on training – through a residency or fellowship program or through various day-long training courses, usually on animal or cadaver models.
Residency or Fellowship Program
Dr. Daniel D. Eun is the chief of robotic surgery and director of minimally invasive robotic urological oncology at Temple University Hospital and associate professor of urology at the Lewis Katz School of Medicine at Temple University in Philadelphia. As he trains residents and introduces established surgeons to robotic surgery techniques, he says the two key aspects to effective training are providing surgeons:
- Enhanced visualization for trainees through 3D technology to maximize understanding of the anatomy and operative technique
- Consistent and intensive feedback in the operating room
When Eun started his surgical robotics training at Vattikuti Urology Institute, he said one of the aspects that made that program cutting-edge was his mentor’s use of 3D visualization. Before each case, he and the other fellows calibrated two stacked projectors on the wall and passed out 3D glasses. In the early 2000s, Eun reflected that 3D visualization had hardly come to fruition, but that by seeing the procedure done in 3D, just as the surgeon saw it, helped them to better understand complex anatomy and learn the nuances of the procedures. When trainees see the anatomy, layers and microlayers of tissue and how the instruments and sutures interact with the tissue, he says they understand the procedure better.
As an associate professor, he uses 3D visualization while he trains residents, fellows and visiting surgeons, not just because they can see and understand the cases, but because of some of the liability issues associated with letting other doctors operate on his patient. By seeing him do the procedures in the same clarity he sees them, Eun said they can maximize their experience while observing or assisting. “I think that now people are starting to appreciate it and want that for their programs,” he said.
In addition to specialties such as urology, more general surgeons are starting to perform robotic surgery as new instrument choices become available, since most interested, established urology surgeons have already adopted the procedure. Over the last several years, Eun has worked with surgeons from other subspecialties who have said they have benefited from being trained with 3D too. “I hope that more of the educational programs in the future will not just embrace high resolution, but embrace 3D technology in their operating rooms,” Eun said.
While 3D training helps surgeons understand the anatomy, Eun said trainees also needed consistent feedback so they can self-reflect and understand the limit of their skill. “Ultimately, every surgeon has a certain level of skill and talent. Sometimes they are natural and will pick it up faster, and others, no matter how much training they do, will do poorly,” he said. Surgeons need to be honest with themselves during training and once they are certified. “You have to really step out of yourself, look at your situation and see if what you are doing is really good and reasonable for the patient,” he said. “That is a hard thing for surgeons to do.”
If these shortfalls are noticed in training, Eun said the program will sit down with the trainee to discuss the issue and possible alternatives. Once surgeons are certified and practicing, it is harder to stop them from putting patients in danger. Thankfully, Eun says most surgeons stay focused on helping patients, and will seek training if they notice their skills lapsing or choose another path if outcomes are not desirable.
In addition to procedure training programs, there are also device training programs structured by suppliers, like Intuitive Surgical, that surgeons attend when the facility plans to purchase a surgical robot. Myriam Curet, M.D., chief medical officer at Intuitive Surgical, says the company has invested in a multi-component training system with an emphasis on hands-on feedback and individualized learning. “I think everyone has a vested interest in this,” she said, explaining the supplier, surgeon, facility and patient all benefit from positive outcomes.
For instance, the Intuitive Surgical training program introduces surgeons to the da Vinci robot through simulations, trains them on systems and safety through a computer-based module, introduces them to cases through operations and video and eventually evaluates the surgeon’s skill through a testing simulator. Throughout most of the hands-on training process, surgeons are partnered with a training specialist who offers feedback and technical tips. These specialists go through a rigorous training themselves and sometimes have surgical backgrounds. Surgeons are then observed as they operate on patients by a proctor. Ultimately, the surgeon’s hospital grants surgical privileges, not the device manufacturer.
Curet says most facilities review the surgeon’s skillset on an annual basis, looking at case numbers, outcomes and patient types, and may reinforce their skills with additional practice, if deemed necessary.
When it comes down to it, this curriculum is structured and thorough, but surgeons need to be honest with themselves on their skillset before scrubbing into cases, she said. “While robust, our multi-component program is only one aspect of the overall training picture to ensure proficiency and skill for robotic-assisted surgeons.”