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BackgroundRPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138(7):777–784, 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329–4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique.MethodsThe current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative “tips and tricks” to facilitate the learning/teaching/evaluation process.ResultsEach of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique.ConclusionsEducational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.

Background Multiple surgical virtual reality (VR) simulators are currently available; however, there is lack of comparison between performance after practice on these simulators compared to bench top models. Utilizing the Intuitive Data recorder (IDR) and Objective performance indicators (OPI), we aim to objectively assess robotic surgical skills using a dry lab model. We hypothesize that practicing surgical skills will improve OPIs and that those who practice on the dry lab model will have a greater improvement in their OPIs compared to those who practice with Fundamentals of Robotic Surgery (FRS) SimNow VR. Methods The IDR was used to record kinematics as each participant went through five basic surgery tasks on a dry lab benchtop model to record baseline performance. Participants were then randomized to practice on the dry lab model or the corresponding SimNow Virtual reality (VR) tasks. The participants repeated the tasks again on the benchtop model. Statistical analysis was performed using paired samples t tests, independent samples t tests, and ANOVA tests. Results Twenty-seven surgeons participated in our study ranging from interns to attendings. Randomization to VR vs benchtop practice resulted in 11 and 13 participants in each group. For the rollercoaster, backhand suturing, railroad, and knot tying tasks, a significant improvement in kinematic profiles was observed. Bimanual dexterity, angular motion, and smoothness metrics improved most consistently across the tasks after practice. Kinematic profiles between those practicing on VR versus benchtop had no significant differences. Conclusions This study shows that OPIs can be used to benchmark surgical trainees. VR appears to be non-inferior to dry lab model for practice for trainees. We identified patterns in OPI improvement that can be tailored to specific skills depending on the trainees needs. Our study is the first step in developing a standardized training and assessment tool to assess competency in robotic surgery training.

BackgroundRobot-assisted surgery is used worldwide, allowing surgeons to perform complex surgeries with increased precision and flexibility. It offers technical benefits compared to traditional laparoscopic surgery due to its utilization of both 3D vision and articulated instruments. The objective was to investigate the isolated effect of 3D- versus 2D monitors when working with articulated instruments in robot-assisted surgery.MethodsSurgical novices (medical students, n = 31) were randomized to simulation-based training with either the 3D vision switched on or off. Both groups completed each of the four exercises six times over two sessions on the Medtronic Hugo™ RAS system simulator. The outcome was the simulator performance parameters and a visual discomfort questionnaire.ResultsFor the efficiency parameters, we found that both groups improved over time (p < 0.001) and that the intervention group (3D) consistently outperformed the control (2D) group (p < 0.001). On the other hand, we didn’t find any significant difference in the error metrics, such as drops (p-values between 0.07 and 0.57) and instrument collisions (p-values between 0.09 and 0.26). Regarding Visual Discomfort, it was significantly more difficult for the 3D group to focus (p = 0.001).Conclusion3D monitors for an open robotic console improve efficiency and speed compared to 2D monitors in a simulated setting when working with articulated instruments.

Background New surgeons experience heavy workload during robot-assisted surgery partially because they must use vision to compensate for the lack of haptic feedback. We hypothesize that providing realistic haptic feedback during dry-lab simulation training may accelerate learning and reduce workload during subsequent surgery on patients. Methods We conducted a single-blinded study with 12 general surgery residents (third and seventh post-graduate year, PGY) randomized into haptic and control groups. Participants performed five simulated bariatric surgeries on a custom inanimate simulator followed by live robot-assisted sleeve gastrectomies (RASGs) using da Vinci robots. The haptic group received naturalistic haptic feedback of instrument vibrations during their first four simulated procedures. Participants completed pre-/post-procedure STAI and post-procedure NASA-TLX questionnaires in both simulation and the operating room (OR). Results Higher PGY level (simulation: p  < 0.001, OR p  = 0.004), shorter operative time (simulation: p  < 0.001, OR p  = 0.003), and lower pre-procedure STAI (simulation: p  = 0.003, OR p  < 0.001) were significantly associated with lower self-reported overall workload in both operative settings; PGY-7 s reported about 10% lower workload than PGY-3 s. The haptic group had significantly lower overall covariate-adjusted NASA-TLX during the fourth ( p  = 0.03) and fifth ( p  = 0.04) simulated procedures and across all OR procedures ( p  = 0.047), though not for only the first three OR procedures. Haptic feedback reduced physical demand (simulation: p  < 0.001, OR p  = 0.001) and increased perceived performance (simulation: p  = 0.031, OR p  < 0.001) in both settings. Conclusion Haptic feedback of instrument vibrations provided during robotic surgical simulation reduces trainee workload during both simulation and live OR cases. The implications of workload reduction and its potential effects on patient safety warrant further investigation.

BackgroundRobotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking.MethodsThis was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences.ResultsOverall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2–8.0] vs 3.8 [2.3–12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training.ConclusionSurgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

BackgroundRobotic surgery is a valid option for minimally invasive surgery in most surgical specialties. However, the need to master laparoscopy is questionable before starting specific training in robotic surgery. We compared the development of basic robotic surgery skills between individuals randomized to train in conventional, laparoscopic, or robotic skills.MethodsWe conducted a single-centered, single-blinded randomized trial. Medical students were randomly assigned to 20 h of conventional, laparoscopic, or robotic surgical training. Students with previous surgical experience were excluded. Participants were evaluated pre- and post-training on the dV-Trainer robotic surgical simulator with the following exercises: Camera Targeting 1, Peg Board 1, Ring and Rail 1, and Ring and Rail 2.ResultsSixty-six students were randomly assigned to each training group. Eight individuals did not complete the study (2 in the conventional group, 3 in the laparoscopic group, and 3 in the robotic group). All groups demonstrated significant improvement in the composite score and in each task following the training period (p < 0.001). No differences were seen between the conventional and laparoscopic groups in the composite score or individual tasks. The robotic group showed greater improvement in number of errors, economy of motion, workspace utilization, and time for completion compared to the other groups. The laparoscopic group showed improved camera manipulation skills compared to the conventional group, while the conventional group showed improved errors and economy of motion compared to the laparoscopic group.ConclusionThere was no difference in the acquisition of basic robotic surgical skills between individuals trained in basic conventional or laparoscopic surgical skills. We believe surgeons mastery in laparoscopy is not needed before initiating robotic surgical training. However, basic principles of laparoscopy remain applicable to robotic surgery. Future studies should compare transferability of conventional and laparoscopic training to robotic skills in the operating room.

Bacground The aim of this study was to assess the learning curve of a novel seven-axis robot-assisted total hip arthroplasty (RaTHA) system. Methods A total of 59 patients who underwent unilateral total hip arthroplasty at our institution from June 2022 to September 2022 were prospectively included in the study. In this randomized controlled clinical trial, robot-assisted THA (RaTHA) and Conventional THA (CoTHA) were performed using cumulative sum (CUSUM) analysis to evaluate the learning curve of the RaTHA system. The demographic data, preopera1tive clinical data, duration of operation, postoperative Harris Hip Score (HHS), postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, and duration of operation between the learning stage and the proficiency stage of the RaTHA group were compared between the two groups. Results The average duration of operation of the RaTHA group was increased by 34.73 min compared with the CoTHA group (104.26 ± 19.33 vs. 69.53 ± 18.38 min, p  < 0.01). The learning curve of the RaTHA system can be divided into learning stage and proficiency stage, and the former consists of the first 13 cases by CUSUM analysis. In the RaTHA group, the duration of operation decreased by 29.75 min in the proficiency stage compared to the learning stage (121.12 ± 12.84 vs.91.37 ± 12.92, p  < 0.01). Conclusions This study demonstrated that the surgical team required a learning curve of 13 cases to become proficient using the RaTHA system. The duration of operation, total blood loss, and drainage gradually shortened (decreased) with the learning curve stage, and the differences were statistically significant. Trial registration Number: ChiCTR2200061630, Date: 29/06/2022.

BackgroundCurrently, only a limited number of remote assistance modalities are utilized in the basic phase of robotic surgery training to facilitate the rapid acquisition of robotic surgery skills by surgeons. This study aimed to investigate the benefits of real-time remote surgical robotic skill training based on a multi-channel video recording and playback system.MethodsWe randomly divided 40 medical students without prior expertise in the use of surgical robots into two groups to assess the performance of trainees on a robotic simulator (Mimic dV-Trainer). The remote group received remote training, while the control group received live one-on-one guidance. We compared the learning curves of the two groups based on simulator scores. Furthermore, the NASA task load index (NASA-TLX) scale was used to measure the fatigue load of the trainers.ResultsWe observed no significant differences in the demographics or initial baseline skill levels between the two groups. Participants in the remote group achieved higher total scores in the Match Board 2 and Thread the Rings 1 exercises compared to the control group. In addition, trainers in the remote group reported lower subjective fatigue load than in the control group.ConclusionsThe remote approach to surgical robotics skills training based on the Remote Teaching System for Robotic Surgery (ReTeRoS) is both feasible and has the potential for large-scale training.

BackgroundVirtual reality is a frequently chosen method for learning the basics of robotic surgery. However, it is unclear whether tissue handling is adequately trained in VR training compared to training on a real robotic system.MethodsIn this randomized controlled trial, participants were split into two groups for “Fundamentals of Robotic Surgery (FRS)” training on either a DaVinci VR simulator (VR group) or a DaVinci robotic system (Robot group). All participants completed four tasks on the DaVinci robotic system before training (Baseline test), after proficiency in three FRS tasks (Midterm test), and after proficiency in all FRS tasks (Final test). Primary endpoints were forces applied across tests.ResultsThis trial included 87 robotic novices, of which 43 and 44 participants received FRS training in VR group and Robot group, respectively. The Baseline test showed no significant differences in force application between the groups indicating a sufficient randomization. In the Midterm and Final test, the force application was not different between groups. Both groups displayed sufficient learning curves with significant improvement of force application. However, the Robot group needed significantly less repetitions in the three FRS tasks Ring tower (Robot: 2.48 vs. VR: 5.45; p < 0.001), Knot Tying (Robot: 5.34 vs. VR: 8.13; p = 0.006), and Vessel Energy Dissection (Robot: 2 vs. VR: 2.38; p = 0.001) until reaching proficiency.ConclusionRobotic tissue handling skills improve significantly and comparably after both VR training and training on a real robotic system, but training on a VR simulator might be less efficient.

PurposeIn this study, we investigate the effect of trainee involvement on surgical performance, as measured by automated performance metrics (APMs), and outcomes after robot-assisted radical prostatectomy (RARP).MethodsWe compared APMs (instrument tracking, EndoWrist® articulation, and system events data) and clinical outcomes for cases with varying resident involvement. Four of 12 standardized RARP steps were designated critical (“cardinal”) steps. Comparison 1: cases where the attending surgeon performed all four cardinal steps (Group A) and cases where a trainee was involved in at least one cardinal step (Group B). Comparison 2, where Group A is split into Groups C and D: cases where attending performs the whole case (Group C) vs. cases where a trainee performed at least one non-cardinal step (Group D). Mann–Whitney U and Chi-squared tests were used for comparisons.ResultsComparison 1 showed significant differences in APM profiles including camera movement time, third instrument usage, dominant instrument moving time, velocity, articulation, as well as non-dominant instrument moving time and articulation (all favoring Group A p < 0.05). There was a significant difference in re-admission rates (10.9% in Group A vs 0% in Group B, p < 0.02), but not for post-operative outcomes. Comparison 2 demonstrated a significant difference in dominant instrument articulation (p < 0.05) but not in post-operative outcomes.ConclusionsTrainee involvement in RARP is safe. The degree of trainee involvement does not significantly affect major clinical outcomes. APM profiles are less efficient when trainees perform at least one cardinal step but not during non-cardinal steps.