Background
When introducing new equipment like robotic surgical systems, it is essential to ensure that surgeons have the basic skills before operating on patients. The objective was to investigate ...the validity evidence for a competency-based test for basic robotic surgical skills using the Versius® trainer.
Methods
We recruited medical students, residents, and surgeons which were classified based on data on clinical experience with the Versius system as either novices (0 min), intermediates (1–1000 min), or experienced (> 1000 min). All participants completed three rounds of eight basic exercises on the Versius trainer, where the first was used for familiarization and the final two for data analysis. The simulator automatically recorded data. Validity evidence was summarized using Messick’s framework, and the contrasting groups’ standard-setting method was used to define pass/fail levels.
Results
40 participants completed the three rounds of exercises. The discriminatory abilities of all parameters were tested, and five exercises including relevant parameters were selected to be part of the final test. 26 of 30 parameters could differentiate between novices and experienced surgeons but none of the parameters could discriminate between the intermediate and experienced surgeons. Test–retest reliability analysis using Pearson’s r or Spearman’s rho showed only 13 of 30 parameters had moderate or higher reliability. Non-compensatory pass/fail levels were defined for each exercise and showed that all novices failed all the exercises and that most experienced surgeons either passed or nearly passed all five exercises.
Conclusion
We identified relevant parameters for five exercises that could be used to assess basic robotic skills for the Versius robotic system and defined a credible pass/fail level. This is the first step in developing a proficiency-based training program for the Versius system.
Background
The introduction of robotic technology has revolutionized radical prostatectomy surgery. However, the potential benefits of robotic techniques may have trade-offs in increased mental ...demand for the surgeon and the physical demand for the assisting surgeon. This study employed an innovative motion tracking tool along with validated workload questionnaire to assess the ergonomics and workload for both assisting and console surgeons intraoperatively.
Methods
Fifteen RARP cases were collected in this study. Cases were performed by 10 different participants, six primarily performed console tasks and four primarily performed assisting tasks. Participants had a median 12 (min—3, max—25) years of surgical experience. Both console and assisting surgeons performed robotic prostatectomy cases while wearing inertial measurement units (IMUs) that continuously track neck, shoulder, and torso motion without interfering with the sterile environment. Postoperatively, participants completed a workload questionnaire (SURG-TLX) and a body part discomfort questionnaire.
Results
Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Postoperative pain was reported highest for the right shoulder and neck. Mental demands were 41 % higher for surgeons at the console than assisting (
p
< 0.05), while physical demands were not significantly different. Assisting surgeons worked in demanding neck postures for 58 % of the procedure compared to 24 % for the console surgeon (
p
< 0.01). Surgeons at the console were primarily static and showed 2–5 times fewer movements than assisting surgeons (
p
< 0.01).
Conclusions
Postures were more ergonomic during console tasks than when assisting by the bedside; however, the console may constrain postures leading to static loads that have been associated with musculoskeletal symptoms for the neck, torso, and shoulders. The IMU sensors were effective at quantifying ergonomics in robotic prostatectomies, and these methods and findings have broad applications to other robotic procedures.
To investigate the reliability with which healthcare professionals with different levels of expertise are able to impart the exact location of prostate cancer (PCA) after (A) reading written magnetic ...resonance imaging (MRI) reports, (B) attending MRI presentations in multidisciplinary team meetings (MDT), and (C) examining 3D printed prostate models, which represents a new technology to describe the location of PCA lesions.
We used three different PCA cases to assess the three information tools. Construct validation was performed using two healthcare groups with different levels of expertise: (1) Nine expert urologists in PCA, and (2) nine medical students. After each information tool, the study participants plotted the tumor location in a 2-dimensional prostate diagram. A scoring system was established to evaluate the drawings in terms of accuracy of plotting tumor position. Data are shown as median scores with interquartile range.
Within the expert group, no significant difference was seen in the overall scoring results between the information tools (p = 0.34). Medical students performed significantly worse with MDT information (p = 0.03). Experts performed better in all three information tools compared to students, resulting in a significantly 25% higher overall total score (25.022.3-26.7 vs. 20.015.0-24.0, p<0.001). The difference was largest after MDT information, with experts showing a 49% better scoring (p<0.001), and second largest with the 3D printed models, showing a 17% better scoring of the experts (p = 0.07). No difference was found in the written MRI report scoring results between experts and students.
3D printed models provided better orientation guide to medical students compared to MDT MRI presentations. This indicates that the 3D printed models might be easier to understand than the current gold standard MDT conferences. Therefore, 3D models may play an increasingly important role in providing guidance for orientation for less experienced individuals, such as surgical trainees.
Objective
To present the results of the first series of patients treated with robot‐assisted radical prostatectomy (RARP) with the use of the Versius® Surgical System (CMR Surgical Ltd., Cambridge, ...UK). RARP has demonstrated better perioperative outcomes compared to open RP. However, RARP remains limited by platform availability and cost‐effectiveness issues. The increasing competition from new robotic surgical platforms may further drive utilisation of the robotic approach.
Patients and Methods
Data were collected prospectively for our first 18 consecutive patients with localised prostate cancer who underwent RARP at our centre over a 3‐month period. We recorded parameters, including patient demographics and perioperative outcomes. We also report our optimised set‐up with regard to trocar placement, bedside unit placement, and overall composition of the operating room for this procedure. Describing the incremental modifications carried out to achieve reductions in set‐up and operating times to optimise utilisation of the Versius system.
Results
The median (interquartile range IQR) set‐up time was 8.5 (7–10) min. The median (IQR) console time was 201 (170–242) min. The median (IQR) operative time was 213 (186–266) min. The median (IQR) total surgery time was 226 (201–277) min. Bilateral pelvic lymphadenectomy median (IQR) time was 19 (17–20) min. There were no complications and/or limitations related to the use of the Versius system including need for conversion. There were no relevant intra‐ or postoperative complications at the 1‐month follow‐up related to the use of the Versius system. Patients were discharged after a median (IQR) of 4 (3.75–5) days, and the transurethral catheter was removed after a mean (range) of 8 (7–14) days. Continence at 2 months was achieved in 72.2% of the patients.
Conclusions
Performing RARP using the Versius system is feasible, safe, and easily reproducible. Our set‐up enables a rapid docking approach and efficient completion of the surgery.
Purpose To systematically review the literature to identify all studies reporting outcomes of arthroscopically repaired isolated subscapularis tears, to (1) report outcomes across all repair ...techniques, (2) compare outcomes by arthroscopic technique, and (3) highlight the frequency and management of associated long head of biceps pathology, and the influence of these concomitant procedures on outcomes following arthroscopic subscapularis repair. Methods A systematic literature review was conducted using the MEDLINE, Embase, and Scopus databases with the following term: (“isolated repair” AND “arthroscopic subscapularis tear”). Only studies evaluating the techniques and outcomes of isolated subscapularis repair were included. Data were extracted, including patient characteristics, surgical technique, and outcomes. Descriptive analysis was provided for the available literature. Results Eight studies were included in this review. Uniformly, improvements in patient-reported outcome scores were substantial after arthroscopic subscapularis repair. Constant Total scores improved in each individual study from preoperative to postoperative (range, Δ18.8-Δ49.8 points), as did Strength (range, Δ1.3-Δ13.7 points), Pain (range, Δ7.6-Δ8.9 points), Range of Motion (range, Δ7.3-Δ13.3 points), and Activities of Daily Living (range, Δ8.7-Δ10.2 points) subscores. Significant improvements were seen in most individual studies for belly-press (Δ21.6 N or Δ1.9 out of 5) and lift-off strength (Δ24.3 N or Δ1.7-Δ1.9 out of 5), range of motion in forward flexion (29.1°-37.0°), external rotation (10.3°-16.0°), and internal rotation. Complications were relatively infrequent overall, with 5 studies reporting no complications, and the remaining 3 studies with rerupture rates between 4.8% and 11.8%. Studies that used only double-row repair reported fewer complications (0% vs 5%-10%) and better outcome scores than single-row repair, similar to those studies that uniformly performed biceps tenodesis compared with no biceps intervention. Conclusions This descriptive study highlights that arthroscopic subscapularis repair appears to be a reasonable option for the treatment of isolated tears of the subscapularis to obtain successful functional and patient-reported clinical outcomes. Its findings also pose the question of whether future prospective, comparative studies will find double-row surgical fixation and concomitant biceps tenodesis surgery to be superior to single-row fixation and leaving the biceps alone. Level of Evidence Level IV, systematic review of Level IV studies.
Enhanced Recovery After Surgery (ERAS) is a perioperative approach to managing surgical patients. The impact of ERAS on radical cystectomy (RC) outcomes remains understudied.
To review the literature ...regarding ERAS protocols and RC outcomes. The primary outcome was hospital length of stay (LOS).
A systematic review of the articles published from 1970 through 2018 was conducted. Individual patient data (IPD) were requested and a meta-analysis was performed.
A total of 4197 articles were retrieved and 22 (reporting 4048 patients) were selected for the review. LOS followed by 30-d and that followed by 90-d complications were the most common endpoints. ERAS use was associated with reduced morbidity, quicker bowel recovery, and shorter LOS, without affecting mortality. IPD were obtained for 2077 patients from 11 studies. In multivariable models, LOS was associated with ERAS use (regression coefficient: –4.54 95% confidence interval {CI}: –5.79 to –3.28 d with ERAS p < 0.001) and Charlson Comorbidity Index (+1.64 1.38–1.90 d for each point increase, p < 0.001), and varied between hospitals (from –1.59 –3.03 to –0.14 to +4.55 1.89–7.21 d, p < 0.03). Individual ERAS components associated with shorter LOS included no nasogastric (NG) tube (–8.70 –11.9 to –5.53 d, p < 0.001) and local anesthesia blocks compared with regional anesthesia (–3.29 –6.31 to –0.27 d, p = 0.03).
ERAS protocols were associated with reduced LOS and postoperative complication rate. Avoidance of NG tubes and use of local anesthesia blocks were significantly associated with reduced LOS. These findings reflect different components of recovery, which ERAS can optimize and further support documentation of the use of ERAS components when reporting RC outcomes.
Use of enhanced recovery in patients undergoing surgery to remove the bladder is associated with fewer surgical complications and a shorter hospital stay. Avoidance of nasogastric tubes and use of local anesthesia after the operation were associated with a shorter length of stay.
In this systematic review, we found the inclusion of Enhanced Recovery After Surgery (ERAS) components when reporting radical cystectomy outcomes and found that only 0.5% studies control for ERAS when reporting outcomes. In the individual patient data meta-analysis, elimination of bowel preparation and nasogastric tube, and use of regional anesthesia were significantly associated with decreased hospital length of stay. These findings reflect different components of recovery that ERAS can optimize and further support documentation of the use of ERAS components when reporting radical cystectomy outcomes.
Objective
To develop and seek consensus from procedure experts on the metrics that best characterise a reference robot‐assisted radical prostatectomy (RARP) and determine if the metrics distinguished ...between the objectively assessed RARP performance of experienced and novice urologists, as identifying objective performance metrics for surgical training in robotic surgery is imperative for patient safety.
Materials and methods
In Study 1, the metrics, i.e. 12 phases of the procedure, 81 steps, 245 errors and 110 critical errors for a reference RARP were developed and then presented to an international Delphi panel of 19 experienced urologists. In Study 2, 12 very experienced surgeons (VES) who had performed >500 RARPs and 12 novice urology surgeons performed a RARP, which was video recorded and assessed by two experienced urologists blinded as to subject and group. Percentage agreement between experienced urologists for the Delphi meeting and Mann–Whitney U‐ and Kruskal–Wallis tests were used for construct validation of the newly identified RARP metrics.
Results
At the Delphi panel, consensus was reached on the appropriateness of the metrics for a reference RARP. In Study 2, the results showed that the VES performed ~4% more procedure steps and made 72% fewer procedure errors than the novices (P = 0.027). Phases VIIa and VIIb (i.e. neurovascular bundle dissection) best discriminated between the VES and novices. Limitations: VES whose performance was in the bottom half of their group demonstrated considerable error variability and made five‐times as many errors as the other half of the group (P = 0.006).
Conclusions
The international Delphi panel reached high‐level consensus on the RARP metrics that reliably distinguished between the objectively scored procedure performance of VES and novices. Reliable and valid performance metrics of RARP are imperative for effective and quality assured surgical training.
There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, ...providing evaluation statuses to guide research and inform implementation into training curricula.
A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.
Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.
Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.
Introduction
Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in ...the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.
Methods
A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.
Results
Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.
Conclusions
Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the ‘continuum of training’ by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.
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