Antonio Gangemi1*, Theresa Dunham2, Federico Gheza1, Gianmarco Contino1, Pier Cristoforo Giulianotti1
1University of Illinois at Chicago, Division of General, Minimally Invasive, Robotic Surgery, Department of Surgery, USA
2University of Illinois at Chicago, College of Medicine, USA
Received: 29 April, 2016; Accepted: 11 May, 2016; Published: 12 May, 2016
Dr. Antonio Gangemi, University of Illinois at Chicago, Division of General, Minimally Invasive, Robotic Surgery, Department of Surgery, 840 S. Wood Street, Code 958, Suite 435E, Chicago, 60612, , USA, Tel: 312-355-2494; Fax: 312-355-3722; E-mail:
Gangemi A, Dunham T, Gheza F, Contino G, Giulianotti PC (2016) Robotic Training in General Surgery Residency: How Early Can We Begin?. J Surg Surgical Res 2(1): 021-024.10.17352/2455-2968.000025
© 2015 Gangemi A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Robotic surgery training curriculum; Surgical residency robotic simulation education; Virtual reality robotic surgery
Background: The increasing demand for robotics in general surgery has prompted academic institutions to train general surgery residents toward the acquisition of basic robotic skills. Our current robotic training curriculum begins in the PGY-3 year and is based on the use of surgical simulators in a risk-free environment, in which each resident must show proficiency prior to advancing to training on an animate model as PGY-4. Our unpublished data on the curriculum indicates that PGY-3s required additional remediation training on the robotic simulator, suggesting room for improvement in our teaching paradigm . Because of resident duty hour restrictions, we could not provide remediation by simply increasing the number of training sessions. We therefore decided to investigate an alternative strategy of shifting the training to an earlier time point in general surgical residency during PGY-1 and PGY-2 years. To explore the feasibility of a new curriculum, we undertook a pilot study to investigate the willingness of residents in their PGY-1 and PGY-2 years to begin robotic training on the robotic simulator, the dV-Trainer (dV-T). We also wanted to see if even minimal early exposure to the dV-T would help overcome residents’ initial diffidence in using the daVinci Surgical System (DaVss).
Methods: Ten general surgery residents (seven PGY-1s and three PGY-2s) with no prior exposure to robotic training were randomly distributed into MIMIC (MIM G) and daVinci (DaV G) groups. The MIM G subjects answered a post-exposure questionnaire about their overall experience with the robotic training. The five MIM G subjects performed five basic skills exercises on the dV-T simulator prior to executing the same exercises on the DaVss, while the five DaV G subjects performed the same exercises only on the DaVss. Two blinded robotic proctors scored each subject’s performance on the DaVss.
Results: All MIM G subjects found their overall experience constructive and viewed the dV-T as useful in preparing them to complete subsequent tasks on the DaVss. The MIM G subjects also performed better than the DaV G (p= 0.32) subjects in operation of the da-Vss, although statistical significance could not be achieved. Given the small sample size, statistical significant was unlikely.
Conclusions: The subjective perception of the dV-T experience was strongly positive, as the residents enjoyed the experience and seemed to be open to the possibility of introducing some robotic training with the robotic simulator earlier in their career. We attribute the fact that MIM G residents performed better with the DaVss than the DaV G residents to the value of minimal exposure to dV-T as a way to overcome the discomfort of using the DaVss for the first time.
The use of robotics in medicine has increased from 25,000 per year in 2005 to 450,000 per year in 2012 . In particular, surgical robots accounted for over 60% of the largest share in 2014, due to the increasing demand for minimally invasive surgeries and the growing use of surgical robotic equipment in hospitals . In fact, the global market for robotic systems is expected to reach 17.9 billion USD by the year 2022, with an estimated growth rate of 12.7% from 2014 to 2020 . Expanding upon the experience of a group of general surgeons who had previously pioneered the development and implementation of robotic surgery in their field, the use of this technology in general surgery is now catching up to other robotic sub-specialties . A growing number of general surgery procedures, ranging from bariatric procedures to colon resections, are being performed robotically [3,4]. Naturally, the trend of more robotic general surgery cases is accompanied by a requirement for more robotically trained general surgeons. This increasing need for robotic training poses multiple challenges, such as limited hands-on teaching during live surgery, the expense of animal model robotic training, and the resource- and time-consuming need to train not only surgical residents and fellows, but also seasoned and experienced laparoscopic attending physicians.
The robotic platform is complex, unique and requires dedicated training. The use of surgical simulators in a training environment is ideal because there are no risks imposed upon patients. We use the dV-Trainer (dV-T) surgical simulator for the training of our residents because its user interface, content, and construct validity have been demonstrated by multiple studies and it closely recreates a tridimensional field [5-7].
At our institution, we have implemented a standardized robotic training surgical curriculum in which general surgery PGY-3 residents complete five one-hour training sessions and one final examination prior to advancing to training on an animate model, in which they must complete six one-hour training labs and one final examination. In our curriculum, dV-T training does not commence until the PGY-3 year under the assumption that robotics training is a complex activity that requires at least some degree of prior experience with minimally-invasive surgical techniques. We felt that PGY-1 and PGY-2 residents, who are are just beginning their careers as general surgery trainees, might perceive such additional training as overwhelming,
However, we found that all PGY-3 residents required at least one remediation session before achieving basic robotic competency in the stimulated environment, delaying their advancement to the use of the DaVss on the porcine model . However, due to the 80-hour week duty restrictions in general surgery residency, we struggled to add more training sessions throughout the academic year. Instead, we considered the possibility that PGY-3 may not necessarily be the optimal time to introduce robotics and training and we pursued an alternative strategy of shifting robotics training to an earlier time point in residency. We implemented a pilot study examining PGY-1 and PGY-2 residents’ willingness to participate in robotic training with the dV-T simulator. By comparing robotic surgery performance parameters between trainees who participated in simulator training to those who did not, we examined the quantitative and qualitative impact of the simulation training at an early stage of surgical residency on these individuals’ subsequent performance on and perception of the DaVss.
Methods and Materials
In our proposed early introduction to robotics, PGY-1 and PGY-2 residents performed five basic skills exercises on the dV-T and/or the DaVss, depending on the study group. The five exercises included overview of controls with special emphasis on the use of robotic gimbals, camera and clutch pedals, camera targeting, pick and place, and ring and rope walk.
The research activities conducted at our surgical skills laboratory involving training and surgical simulation are covered with approval from our Institutional Review Board.
We recruited ten general surgery residents, seven PGY-1s and three PGY-2s, without prior experience in robotic surgery, and randomly distributed them into two groups. Five subjects were assigned to the MIMIC group (MIM G); these subjects performed the five exercises that comprised the curriculum on the dV-T simulator, and subsequently executed the same tasks in the daVss dry lab. The other five subjects were assigned to the daVinci group (DaV G); these subjects performed the five exercises on the DaVss without prior exposure to the dV-T simulator.
The MIM G residents were queried about their perception of their dV-T experience. They completed a six-question Self-Assessment Questionnaire about MIMC Experience, in which each question was answered on a five-point analog scale (Figure 1).
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