The Training and Assessment of Surgical Skills in Robot Assisted Surgery Alexander Jacobus Wilhelmus Beulens
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The training and assessment of surgical skills in robot assisted surgery Alexander Jacobus Wilhelmus Beulens
The training and assessment of surgical Skills in Robot assisted surgery ISBN: 978-94-6458-880-4 Copyright 2023 by Alexander Beulens, Son en Breugel, The Netherlands Printing: Ridderprint, the Netherlands Cover design: Daan Janssen © 2023 Dutch Works. Image depicted on cover: Da Vinci X Surgical System © 2023 Intuitive Surgical Operations, Inc. The publication of this thesis was generously supported by: Wetenschapsfonds Catharina ziekenhuis, Stichting Opleiden Medici, SBOH, Dutch Society for Simulation in Healthcare (DSSH), and Vrije Universiteit Amsterdam
VRIJE UNIVERSITEIT THE TRAINING AND ASSESSMENT OF SURGICAL SKILLS IN ROBOT ASSISTED SURGERY ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. J.J.G. Geurts, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op vrijdag 30 juni 2023 om 13.45 uur in een bijeenkomst van de universiteit, De Boelelaan 1105 door Alexander Jacobus Wilhelmus Beulens geboren te Goes
promotoren: prof.dr. C. Wagner prof.dr. C. Bangma copromotoren: prof.dr. H.G. van der Poel dr. W. Brinkman promotiecommissie: prof.dr. H.P. Beerlage prof.dr. J.J. Jakimowicz dr. B.M.A. Schout prof.dr. J.P. Ruurda prof.dr. P.H.N. de With prof.dr. R.J.A. van Moorselaar
adviseurs: dr. A.J.M. Hendrikx dr. E.L. Koldewijn prof.dr. J. J. G. van Merriënboer dr. J. P. van Basten paranimfen: Dr L.A.M. van Lieshout Drs. R.C.W. Gielgens
Chapter 1 Introduction and Outline of the Thesis 9 Section I What are the best methods 27 Chapter 2 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons 29 Journal of Robotic Surgery, Volume 13, pages 435 to 447, 2019 Chapter 3 Training novice robot surgeons: Proctoring provides same results as simulator-generated guidance 55 Journal of Robotic Surgery, Volume 15, pages 397 to 428, 2020 Chapter 4 Robot assisted surgical skills training for residents in Urology 109 Journal of Robotic Surgery, Volume 15, pages 497 to 510, 2020 Chapter 5 Five Years of the CC-ERUS Fellowship: A Survey of the Experiences and Post-fellowship Work of the Fellows 143 European Urology Open Science, Volume 19, pages 45 to 47, 2020 Section II How can the performance of robotic surgeon’s best be assessed? 155 Chapter 6 Linking surgical skills to postoperative outcomes: a Delphi study on the robot-assisted radical prostatectomy 157 Journal of Robotic Surgery, Volume 13, pages 675 to 687, 2019 Chapter 7 A prospective observational multicentre study concerning non-technical skills in robot assisted radical cystectomy versus open radical cystectomy. 185 European Urology Open Science, Volume 19, pages 37 to 44, 2020 Chapter 8 Robot-Assisted Radical Prostatectomy: A survery on the influence of postoperative results analysis and surgical video review on postoperative complications and functional results 205 European Urology Open Science, [Submitted] Contents
Section III What is the relation between a surgeon’s performance and a patient’s postoperative outcomes? 225 Chapter 9 Identifying surgical factors predicting postoperative urinary continence in robot-assisted radical prostatectomy 227 Journal of Robotic Surgery, [Submitted] Chapter 10 Identifying surgical factors predicting postoperative potency in robot-assisted radical prostatectomy 251 European Urology Open Science, [Submitted] Chapter 11 Identifying the relationship between postoperative urinary continence and residual urethra stump measurements in robot assisted radical prostatectomy patients 277 The International Journal of Medical Robotics and Computer Assisted Surgery, Volume 17, Issue 2, e2196, 2020 Chapter 12 Analysis of the video motion tracking system ‘Kinovea’ to assess surgical movements during robot-assisted radical prostatectomy. 299 The International Journal of Medical Robotics and Computer Assisted Surgery, Volume 16, Issue 2, e2090, 2020 Section IV General Discussion, Conclusions, Future Perspectives, and Summary 325 Chapter 13 General discussion, conclusions, and future perspectives 327 Summary 347 Nederlandse samenvatting 361 Section V Appendix 377 List of abbreviations 379 List of publications 385 PHD Portfolio 393 Dankwoord 401 About the author 411
Chapter 1 Introduction and Outline of the Thesis
11 Introduction and Outline of the Thesis Introduction Healthcare is constantly moving towards the improvement of quality of care and safety for patients. Increasing attention is being paid to the relocation of complex treatments, such as robot assisted surgery, to high-volume centres as it is expected to improve the quality of care and increases patient safety due to the increased exposure of surgeon and staff.1–3 In the Netherlands, a move to large high-volume centres is seen in some specialties including Urology.4 This change is influenced by recent studies linking hospital volumes to surgical outcome.1–3 With the increasing call for the formation of high-volume centres in order to improve quality of care the question remains whether the higher number of surgeries per hospital or the quality of the surgeon influences outcome. There are large variations in postoperative complication rates amongst surgeons with similar surgical volumes per centre or even in the same centre.5,6 The qualification and certification of surgical skills are still in a preliminary phase within all surgical specialties, also in urology. The skills of a surgeon assessed by surgical video analysis has been correlated to the prevalence of major complications (i.e. readmissions) in the past.7 This initial study has sparked a new field of research into surgical skills and the use of surgical videos analysis.8–10 In more recent studies, surgical skills have been associated with functional outcome.2,6,11 Systematic evaluation of surgical skills, both technical and non-technical, is thought possible through video analysis methods. A description of the surgical steps in the procedure is needed in order to use the surgical videos for the assessment of surgical skills, and detect possible errors for the association with adverse outcomes. Problem statement With the increasing number of procedures and the increasing technical difficulty of procedures, the current challenge for both novice and expert surgeons is to learn how to analyse past performances and subsequently use this as a lesson for the future. We therefore describe surgical skills needed for robot assisted surgery and its shortcomings, next the educational and training status of novice and experienced robotic surgeons, and resume with a list of research questions related to the overall problem of how to test robotic skills and the impact of those tests. The methodology of testing and evaluation are shortly introduced at the end of the introduction.
12 Chapter 1 Surgical Skills in Robot Assisted Surgery Although laparoscopic surgery has it benefits, it also has its technical challenges. Examples of these challenges are such as a limited range of motion of the instruments and related loss of dexterity, fixed instrument tips, and an inadequate visual field associated with an unstable camera view.12,13 In order to improve these limitations, new methods of minimal invasive surgery were investigated. This resulted in the development of so-called robot assisted surgery. The introduction of this technique could potentially overcome some of the drawbacks of laparoscopic surgery through the improvement of ergonomics and enhanced dexterity with tremor filtration. Even for those surgeons transferring from laparoscopy, slow learning curves were described based on operating time, complication rates and surgical margins.14,15 The effect of a surgeons’ skills during these robots assisted surgeries on the outcome of the surgery has sparsely been investigated. In many clinics in the United States and Europe, the Robot Assisted Radical Prostatectomy (RARP) has replaced the open radical prostatectomy and laparoscopic radical prostatectomy. The RARP is a complex and highly specialized operation in which the surgical robot is used to remove the prostate. Multiple ports are placed in the abdomen to facilitate robotic access to the prostate. Since the removal of the prostate leads to the separation of the bladder neck and the urethra a new bladder neck/urethra anastomosis is created. The combination of the removal of the prostate with the new anastomosis can lead to severe post-operative incontinence. Due to the relative position of the neurovascular bundle to the prostate, erectile dysfunction is another common post-operative complication.16–18 Since the RARP is a video recorded procedure and one of the most performed procedures in urology, the RARP seems an optimal procedure to develop and validate competency assessment. This process could be used as an example for other operations within and outside the field of urology. Even though the RARP surgery could be used for competency assessment it remains unclear how this surgical skills analysis using surgical videos should be performed. It remains unclear if video analysis is a valid measuring tool to assess the competency of expert surgeons. The additional questions are “who should assess the video’s?” since it is a time-consuming method of analysis and “how do you define the competency of a surgeon?” since multiple assessment methods have been developed using different levels of detail.
13 Introduction and Outline of the Thesis Basic Proficiency Requirements for Robot assisted surgery In 2010, the Dutch health care inspectorate (Inspectie Gezondheidszorg en Jeugd, IGJ) published a report stating ‘insufficient carefulness at the introduction of surgical robots. In this report, the IGJ expressed their concern over the lack of clearly stated criteria for starting robot–assisted laparoscopy. It is increasingly accepted by the medical community to safeguard a minimal competency level for residents. The majority of robot assisted surgeons in the Netherlands agree that the basics in robotic surgery should be incorporated in a structured training program to guarantee the quality of the surgeon and the safety of the patient.19 The lack of structured training program and defined skills-criteria results in a training programme developed by the novice surgeons based on their perceived lack of knowledge.20,21 This, by the novice developed, training programme could result in a hiatus of knowledge due to overconfidence biases, an over-assessment of skills compared to the objective assessment of skills by an external observer.22 The lack of defined skills-criteria resulted in a study by the Netherlands institute for health services research (NIVEL), commissioned by the Dutch Ministry of Health, Welfare and Sport, in collaboration with a number of experts in which the ‘Basic proficiency requirements for the safe use of robotic surgery’ were investigated.23. The existence of these Basic Proficiency Requirements enables the specific development of training curricula for novice surgeons and the structured evaluation surgical skills in both novice and expert surgeons. The Basic Proficiency Requirements are a first step towards defining surgical skills and in enabling surgical skills assessment for both novice and expert surgeons. The question remains how these Basic Proficiency Requirements can be integrated into existing training programs and competency assessment methods. Surgical Skills in novice surgeons Different methods of training in robot assisted surgery have been researched.24–28 These results have been developed into multiple training curricula, some of which are implemented by the European Association of Urology Robotic Urology Section (ERUS) robotic urology fellowship curriculum, Fundamental Skills of Robotic Surgery (FSRS), Fundamentals of Robotic Surgery (FRS) and the Basic Skills Training Curriculum (BSTC). Although these curricula need thorough validation these are promising steps in the development of standardized robot surgery curricula.29 A well described and often cited modular training pathway for the laparoscopic prostatectomy is described by Stolzenburg et al.(2005).30 This training pathway neverthe-
14 Chapter 1 less does not describe an assessment method. Apart from the general intra-operative checklist, such as the Objective structured assessment of technical skills (OSATS) 31 limited assessment tools specific for radical prostatectomy are developed. Recently, the validation of the RARP Assessment Score and Learning Curve Assessment was published.24 This multi-institutional (Europe, Australia, and United States) observational prospective study identified the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. It remains unclear if the combination of standardized robot surgery curriculum with structured feedback using competency assessment methods influence the surgical skills of novice robot assisted surgeons and on the long-term influence postoperative outcome of patients. Surgical Skills in Expert surgeons The safety of the patient is not only guaranteed by a proper initial training, there is also an increasing demand for the implementation of clinical assessments of surgeons. Only limited initiatives have been installed to implement clinical assessment of surgeons using surgical videos.32,33 In order to optimize video assessment, it is primarily important to study the performance of the surgeon and focus on critical steps. In general surgery, several studies have been published describing assessment of intra-operative performance.34–36 Multiple standardized surgical skills assessment tools have been developed which could be used to investigate whether the differences in surgical skills in experts influence postoperative outcomes of the patients.34,37–39 Surgical skills analysis using surgical videos Analysis of past performance is a mandatory component of continues learning in many industries, yet still in its infancy in surgical assessment. Systematic evaluation of surgical skills, both technical and non-technical, is possible through video analysis methods, since laparoscopy and robot assisted surgery offer intraoperative video recordings. Post-operative outcomes in surgery could be related to surgical performance7,40, review of intraoperative videos allows for detailed analysis and improvement of skills and systems that contribute to patient safety. A detailed description of the surgery is needed in order to use the surgical videos for the assessment of surgical skills and the detection of adverse outcomes. In the past, multiple groups have devised a schedule defining the individual steps of the RARP.30,37,41 These schedules mostly are used to train new robot surgeons or to evaluate the skill of current robot surgeons but no specific schedule has been
15 Introduction and Outline of the Thesis developed to investigate the link between surgeons’ skills in the RARP as assessed on video and post-operative adverse outcomes. Other research has shown that it is possible to relate surgical skills in general to post-operative adverse outcomes.7,40,42 Little research has been done to evaluate the skills of robot surgeons and define which parts of the intervention could be related to adverse outcomes, post-operative complications, erectly dysfunction, incontinence and lower urinary tract symptoms. A recent study into the combination of video data with the movement of the surgical robot with the dVlogger system led to greater insight into the performance of the surgeons and could accurately identify novices and experts.8 These types of surgical skills analysis could increase our understanding of the origins of complications and help to investigate whether the differences in surgical skills influence postoperative outcome. Non-technical skills analysis Although the analysis of technical surgical skills in robot assisted surgery can lead to major improvements of postoperative outcomes40, the possible influence of Non-Technical-Skills (NTS) on postoperative outcomes also merits attention. The NTS needed for a successful robot assisted surgery probably differ from the NTS needed for open surgery. The introduction of the surgical robot has profoundly altered the traditional set-up of the operating room, since the scrub nurse and the surgeon are no longer on opposite sides of the patient. In robot assisted surgery, the surgeon is located in a separate control console for most of the surgical procedure, and thus direct communication with the team members could be hampered. It is conceivable that loss of non-verbal communication can influence the workflow and therefore the quality of the performance including patients’ safety. Two systematic reviews have been published concerning studies of NTS in minimal invasive surgery (i.e. conventional laparoscopy and robot assisted surgery).43,44 A wide variety in assessments of NTS was used which makes comparison of tools difficult.43,44 Even though several general assessment methods have been developed for both the entire team45–47 and individual team members48–50 the question remains whether these
16 Chapter 1 tools can accurately assess NTS in complex robot assisted surgeries such as robot assisted radical cystectomy. With the introduction of the Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS)51, adaptation to the robot assisted surgical setting has started. The question remains whether the introduction of robot assisted surgery leads to a change in NTS which could influence the outcome of the surgery. Research questions In this thesis the following general research question is answered: 1. What are the best methods to educate surgeons in robotic surgery? and 2. How can the performance of robotic surgeon’s best be assessed? 3. What is the relation between a surgeon’s performance and a patient’s postoperative outcomes These questions will be answered by answering the following research questions in 11 chapters (figure 1). 1. Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills? 2. What is the influence of structured skills training and structured feedback on the surgical skills of novice robot assisted surgeons? 3. What are the effects of structured robotic surgery skills training and structured feedback? 4. Which technical and non-technical skills factors in robot assisted surgery (competence, teamwork, dedicated OR team, patient factors, environmental factors) influence clinical and patient-related outcomes? 5. Is video analysis a valid measuring tool to assess the competence of surgeons? 6. Is it possible to find differences between surgeries that are relevant to the outcome of the intervention by analysing video material?
17 Introduction and Outline of the Thesis Methodology In this thesis we focus on the training of new surgical skills in novice surgeons and the implementation of surgical skills analysis in novice and expert surgeons. Different forms of surgical skill analyses were investigated in both novice surgeons (surgical skills simulation) and expert surgeons (surgical video analysis). to determine which form of analysis is more functional in either group. The surgical skills simulation was used to gain insight into the effects of different forms of guidance and training on the technical skills of novice surgeons. Surgical video analysis in expert surgeons was used to identify if surgical skills could be related to postoperative outcome in robot assisted radical prostatectomy patients. Multiple surveys and a Delphi process were used in the studies represented in this thesis to gain insight into the effects of surgical skills training in novice surgeons and the opinions of urologist who perform robot assisted surgery on the origins of complications and the use of postoperative results analysis.
18 Chapter 1 Figure 1: Thesis overview
19 Introduction and Outline of the Thesis Outline of the thesis The first section of the thesis focusses on surgical training. In this section four chapters will focus on the different aspects of surgical training and evaluation of the shortterm and long-term effects of surgical training. In this section research questions one, two and three will be answered in multiple chapters (figure 1). In Chapter 2 we investigate research question 1 ‘Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills?’ by investigating the ability of novice robot surgeons to assess their own robot assisted surgery skills and knowledge of robot assisted surgery. We compare the results of the surgical skills simulation exercises to the self-assessment of their own dexterity skills after a oneday robot assisted surgery training. Chapter 3 investigates research question 2 ‘What is the influence of structured skills training and structured feedback on the surgical skills of novice robot assisted surgeons?’ in order to evaluate the effectiveness of a simulation based surgical skills training in the vesico-urethral anastomosis of the Robot Assisted Radical Prostatectomy (RARP) in novice robot surgeons. In order to evaluate the effects of expert proctoring or simulation-based training by the simulator on technical skills and participant satisfaction. In Chapter 4 research question 2 ‘What is the influence of structured skills training and structured feedback on the surgical skills of novice robot assisted surgeons?’ and research question 3 ‘What are the effects of structured robotic surgery skills training and structured feedback?’are investigated. In this chapter, the results of a snap shot survey amongst Dutch residents and recently graduated urologist are combined with the results of residents who participated in an advanced course in Robot Assisted Surgery. This chapter provides valuable insight into the current state of robot assisted surgery training and the requirements set by the educators before the residents are allowed to take their first steps in robot assisted surgery. In addition, the short-term and long-term effect of structured robot assisted surgery training on novice robot surgeons was reviewed. Chapter 5 focusses on research question 3 ‘What are the effects of structured robotic surgery skills training and structured feedback?’. In this chapter, we evaluate the long-term effects of a robot assisted surgery fellowship. The evaluation consisted of a questionnaire amongst the participants of a robot assisted surgery fellowship in order to investigate the long-term influence of this fellowship on the surgeons work and their patient’s outcome.
20 Chapter 1 The second section of the thesis focusses on the assessment of the performance of robotic surgeons. In this section research questions will be answered in multiple chapters (figure 1). Chapter 6 focusses on research question 6 ‘Is it possible to find differences between surgeries that are relevant to the outcome of the intervention by analysing video material?’, it describes which aspects of the RARP are of influence in the origin of postoperative outcome according to the opinion of RARP experts. The results of this Delphi process were used to develop an assessment template which can be used in the technical skills assessment of RARP surgery. Chapter 7 describes the research protocol for a prospective observational multicenter study concerning non-technical skills in robot assisted radical cystectomy versus open radical cystectomy. This study was designed to evaluate the differences in NTS between open and robot assisted surgery. In Chapter 8 we review the opinions of surgeons who perform Robot Assisted Radical Prostatectomy on the influence of postoperative results analysis and surgical video review. This study gives insight into the use of surgical video review in daily practice which provides insight for further research. The third section of the thesis focusses on the relation between a surgeon’s performance and a patient’s postoperative outcomes. In this section research questions will be answered in multiple chapters (figure 1). In Chapter 9 and Chapter 10 research question 4 ‘Which technical and non-technical skills factors in robot assisted surgery (competence, teamwork, dedicated OR team, patient factors, environmental factors) influence clinical and patient-related outcomes?’, research question 5 ‘Is video analysis a valid measuring tool to assess the competence of surgeons?’ and research question 6 ‘Is it possible to find differences between surgeries that are relevant to the outcome of the intervention by analysing video material?’ are answered in order to identify which factors of RARP using different methods of surgical video assessment influence postoperative outcome. Different methods of surgical video analysis, including assessment by expert surgeons, were used to identify differences in surgical skill and relating them to the postoperative outcome of the patient.
21 Introduction and Outline of the Thesis In Chapter 11 we investigate research question 4 ‘Which technical and non-technical skills factors in robot assisted surgery (competence, teamwork, dedicated OR team, patient factors, environmental factors) influence clinical and patient-related outcomes?’, research question 5 ‘Is video analysis a valid measuring tool to assess the competence of surgeons?’ and research question 6 ‘Is it possible to find differences between surgeries that are relevant to the outcome of the intervention by analysing video material?’ by evaluating the use of a video motion tracking system to assess surgical movements during robot-assisted radical prostatectomy. The results of this surgical movements analyses were compared to the postoperative outcome of the patients to asses if this type of analysis could be used to predict postoperative outcome. Chapter 12 studies research question 4 ‘Which technical and non-technical skills factors in robot assisted surgery (competence, teamwork, dedicated OR team, patient factors, environmental factors) influence clinical and patient-related outcomes?’, research question 5 ‘Is video analysis a valid measuring tool to assess the competence of surgeons?’ and research question 6 ‘Is it possible to find differences between surgeries that are relevant to the outcome of the intervention by analysing video material?’ by investigating the relationship between postoperative urinary continence and residual urethra stump measurements in robot assisted radical prostatectomy patients. This chapter describes the comparison of intra-operative measurements of the urethra stump to postoperative outcome of the patients. Finally, the findings of the preceding chapters will be summarized and discussed in Chapter 13. Moreover, this chapter will report our recommendations, practical implications, and suggestions for further research.
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Section I What are the best methods to educate surgeons in robot assisted surgery?
Chapter 2 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons A.J.W. Beulens W.M. Brinkman P.J. Porte R.P. Meijer J.J.G. van Merriënboer H.G. Van der Poel C. Wagner Journal of Robotic Surgery Volume 13, Issue 3, pages 435 to 447, 2019
31 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons Abstract Introduction To fulfil the need for a basic level of competence in robotic surgery the NIVEL (Netherlands Institute for Healthcare Research) developed the ‘Basic proficiency requirements for the safe use of robotic surgery’ (BPR). Based on the BPR a 1-day robotic surgery training was organised to answer the following research questions: (1) Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills? (2) Is it possible to include the teaching of all BPRs in a 1-day training? Materials and methods Based on the BPR, a robot surgery course was developed for residents and specialists (surgery, gynaecology and urology). In preparation, the participants completed an online e-module. The 1-day training consisted of a practical part on robot set-up, a theoretical section, and hands-on exercises on virtual reality robot simulators. Multiple online questionnaire was filled out by the participants at the end of the training to evaluate the perceived educational value of the course and to self-assess the degree to which BPRs were reached. Results 20 participants completed the training during the conference of the Dutch Association for Endoscopic Surgery (NVEC) in 2017. Participants indicated nearly all competency requirements were mastered at the end of the training. The competency requirements not mastered were, however, critical requirements for the safe use of the surgical robot. Skill simulation results show a majority of participants are unable to reach a proficient simulation score in basic skill simulation exercises. Conclusion Results show novice robot surgeons are too positive in the self-assessment of their own dexterity skills after a 1-day training. Self-assessment revealed uncertainty of the obtained knowledge level on requirements for the safe use of the surgical robot. Basic courses on robotic training should inform trainees about their results to enhance learning and inform them of their competence levels.
33 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons Introduction Over the past years, much has changed for robot surgeons. Where the first robot surgeons received a short mandatory training in the basics of robotic surgery by the manufacturer, the next generation of robot surgeons has the possible advantage of a supervisor at their hospital to train them in their specific field of robotic surgery. Not all of these new robot surgeons do have access to the manufacturers basic training program since they are not necessarily new consumers of a robotic system. This could result in a gap in the training of residents and fellows since training of the basics of robotic surgery is currently not routinely implemented in their curricula. In 2010, the Dutch Health Care Inspectorate (IGZ) published a report stating ‘insufficient carefulness at the introduction of surgical robots’. In this report, the IGZ expressed its concern regarding robot-assisted laparoscopy. This report stated that in most hospitals, the criteria for novice robot-assisted laparoscopy were either vague or completely lacking.2,3 The lack of structured training, defined skill-criteria, and a systematic training needs analysis results in a personal training programme developed by the novice surgeons based on their own perceived lack of knowledge.4,5 This could result in a hiatus of knowledge due to overconfidence biases, an over-assessment of their own skill compared to the objective assessment of skill by an external observer6. To clarify criteria for starting robot-assisted surgery, the Netherlands Institute for Health Services Research (NIVEL) developed the ‘Basic proficiency requirements for the safe use of robotic surgery (BPR).7 As it was developed in co-operation with a surgeon, urologist, and a gynaecologist, these requirements transcend each of these individual disciplines and provide a guide to ensure each surgeon using a surgical robot has the required minimum of knowledge and skill to start preforming robot-assisted surgery.7 In earlier research, we investigated whether the current specialists think a basic training in robot surgery should be developed to guarantee a basic level of skills for all new robot surgeons.1 The majority of robot professionals in the Netherlands agree that the basics in robotic surgery should be learned in a structured training program to guarantee the quality of the surgeon and the safety of the patient. Since basic robot training could be similar for the different specialties such as general surgery, gynaecology, and urology a multidisciplinary basic robotic skills training could be a feasible and effective training method. To safeguard the quality the programme can be developed using the proficiency criteria defined by the NIVEL.1 Although several authors have investigated the development of a basic training in robotic surgery, no actual accepted basic robot surgery training has been implemented yet.8,9
34 Chapter 2 In this study, we aim to answer the following research questions (1) Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills? (2) Is it possible to include the teaching of all BPRs in a 1-day training? We will answer both questions by evaluating the outcomes of a 1-day multidisciplinary robot surgery training.
35 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons Methods Participants As part of the Dutch Association for Endoscopic Surgery (NVEC) conference of March 2017 in Amsterdam a multidisciplinary robot surgery training was organized. The training was given 1 day before the conference. Specialists and residents from urology, general surgery and gynaecology were invited to participate in the training. A total of 20 participants pre-registered for this training. Materials For this training different types of materials were used to instruct the participants. Prior to the training all participants were invited to complete a specific e-learning module (http://www.davincisurgerycommunity.com), to become more familiar with the Intuitive Surgical da Vinci Xi robotic system. During the training three types of virtual reality simulators (The MIMIC dV-Trainer, Intuitive surgical da Vinci skills simulator, and the 3D Systems RobotiX Mentor) were used to test the participants’ dexterity skills on the robot surgery system. An Intuitive Surgical da Vinci Xi system was used during a hands-on draping and docking trainQuestionnaire 1: Pre-training questionnaire, demographic data 1. What is your profession? A. Specialist B. residents 2. What is your specialism A. Surgery B. Gynecology C. Urology 3. How much experience do you have with the da Vinci Robot? A. Assist during surgery and practice on a simulator B. only assisting during surgery C. only practice on a simulator D. surgery on a real patient E. No experience with the da Vinci Robot 4. How many hours did you practice with the simulator or robot exercises? A. <10 hours B. 10-20 hours C. 20-30 hours D >30 hours 5. How many hours did you operate on a real patient with the da Vinci Robot? A. 0 hours B. 1-10 hours C. 10-20 hours E. 20-30 hours D. >30 hours
36 Chapter 2 ing, and an interactive presentation was given by an experienced (robot)-anaesthetist. During the training multiple questionnaires were filled out by the participant. An online Pre-training questionnaire on demographics and prior robot surgery or robot surgery simulation experience (questionnaire 1). An online BPR questionnaire based on the BPRs developed by NIVEL (see “Questionnaire 2”). The questionnaire consisted of 37 questions on the participants self-assessed competence of the basic proficiency requirements. This questionnaire was used to assess if the participants were prone to accurately assess their own dexterity skills compared to the objective assessment of simulator skill (overconfidence bias). The questionnaires were developed by a group of urologists and the overall perceived educational value of the training was examined. Questionnaire 2: questionnaire on basic requirements based on the basic proficiency requirements for the safe use of robotic surgery as developed by the NIVEL 1. Do you know the advantages and limitations of using the surgical robot? A. Yes B. No 2. Do you know how the arms are put in position? A. Yes B. No 3. Do you know how the trocars can be connected to the arms? A. Yes B. No 4. Do you know the possibilities and degrees of freedom of the arms? A. Yes B. No 5. Do you know the functionalities of the tower? A. Yes B. No 6. Do you know the functionalities of the robot? A. Yes B. No 7. Do you know the functionalities of the console? A. Yes B. No 8. Do you know how to solve collisions between the arms of the robot? A. Yes B. No 9. Do you know how the check of the poor can be taken over from the console? A. Yes B. No
37 The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons Questionnaire 2: continued 10. Do you know how to act if the instruments do not move / respond properly? A. Yes B. No 11. Do you know how the laparoscopic instruments can be inserted correctly under vision? A. Yes B. No 12. Do you know why the instruments need to be searched out of vision with the Camera? A. Yes B. No 13. Do you know what the various icons on the screen mean? A. Yes B. No 14. Do you know how the robot can be safely moved? A. Yes B. No 15. Do you know how the robot can be safely connected? A. Yes B. No 16. Do you know how all articulating instruments can be checked? A. Yes B. No 17. Do you know how the robot is positioned? A. Yes B. No 18. Do you know how the robot is docked? A. Yes B. No 19. Do you know how instruments can be Placed and exchanged? A. Yes B. No 20. Do you know how the number of lives of the instruments can be controlled? A. Yes B. No 21. Do you know how you can take into account in advance that the table cannot be moved after docking? A. Yes B. No 22. Do you know how to position the patient in a safe way? A. Yes B. No 23. Do you know how the patient can be fixed? A. Yes B. No 24.Do you know how the face of patients is protected during the procedure? A. Yes B. No
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