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Building a surgical robotics program

      Abstract

      Building a strong institutional robotics program requires commitment from administrative and clinical departments. Here we present issues to be considered when developing such a program, including development of a pathway for introduction of the technology into patient care, team recruitment, creation of an objective-based curriculum, multispecialty training, and proper patient selection.
      With the introduction and propagation of laparoscopic surgical techniques, during the late 1980s and early 1990s, a shift in thinking occurred for many surgeons. General surgeons followed both gynecologic and orthopedic surgeons in their quest to replicate excellent surgical technique through small port incisions. The first successes were criticized by many surgeons because of increased operative times and difficulty with these early procedures. Improvements in instrumentation and visualization resolved many of these problems. Surgeons soon had long instruments and angled endoscopes. Laparoscopic approaches soon replaced open cholecystectomies, done through a Kocher incision, and fundoplication procedures, performed through an upper midline incision. More complex laparoscopic common bile duct explorations became possible through further improvements in instrumentation and technology. The driving forces behind this revolution were surgeons and their patients. Positive outcomes soon were recognized widely and included shortened hospitalization, faster recovery, less postoperative pain, and improved cosmesis.

      Robots in cardiac surgery: an evolutionary trek

      Cardiac surgery evolved during the 1980s with new operations, such as internal mammary artery conduit usage and mitral valve repairs; however, cardiopulmonary support and the size of the incision remained unchanged. In the early 1990s, further advances in cardiac anesthesiology, cardiopulmonary bypass techniques, and critical care helped to propel cardiac surgery forward. However, heart surgery still was done through a large median sternotomy incision, requiring sternal division and spreading. This seemed ironic, given the delicacy of both coronary and congenital heart surgery as well as the precision required for a cardiac surgeon to be successful. Moreover, almost all cardiac procedures were done via cardiopulmonary bypass. Surgeons, patients, and referring cardiologists accepted that patients probably would require blood product transfusions, overnight intubation in the intensive care unit, and hospitalization for 7 to 10 days [
      • Litynski G.S.
      Profiles in laparoscopy: Mouret, Dubois, and Perissat: the laparoscopic breakthrough in Europe (1987–1988).
      ,
      • Reddick E.J.
      • Olsen D.O.
      Laparoscopic laser cholecystectomy: a comparison with minilap cholecystectomy.
      ,
      • Soper N.J.
      • Brunt L.M.
      • Kerbl K.
      Medical progress: laparoscopic general surgery.
      ].
      The adoption of minimally invasive techniques was very slow in cardiac surgery, even though many thoracic surgeons started performing thoracoscopic surgery routinely. As many cardiac surgical educators believed that less invasive techniques forfeited quality, most training programs did not emphasize these methods. Minimally invasive coronary artery bypass grafting was approached first, and even though there was slow adoption and great success, the minimally invasive direct coronary artery bypass (MIDCAB) procedure eventually faded. This was due in part to patient discomfort, related to rib and costal cartilage displacement, but mostly because of decreased referrals from improved percutaneous coronary intervention stent results with single-vessel disease. However, the MIDCAB experience had a positive influence on many cardiac surgeons' impressions of less invasive operations. Some began experimenting with secondary visualization techniques, using 2-dimensional endoscopic cameras to view abnormalities inside heart chambers on video monitors. Improvements in visualization and instrumentation allowed rapid advancement toward video-assisted mitral valve repairs and replacements [
      • Chitwood Jr, W.R.
      State of the art review: videoscopic minimally invasive mitral valve surgery: trekking to a totally endoscopic operation.
      ]. At first a human assistant provided control of endoscopic cameras. Nevertheless, because of hand tremor, instrument collisions, and poor assistant command translation, fine reconstructive valve operations still were very difficult. This often led to surgical inaccuracies and increased procedure times. Robotic camera assistance and, thus, control finally became available with the introduction of Automated Endoscopic System for Optimal Positioning (AESOP; formerly Computer Motion Inc., Goleta, CA; now operated by Intuitive Surgical, Inc., Sunnyvale, CA) to the cardiac surgeons' armamentarium. AESOP allowed surgeons to control the visual field by voice activation. At last, a steady, reproducible image was possible. In robotically assisted video-assisted procedures, shorter operative and faster recovery times became possible, and fewer blood product transfusions were necessary [
      • Falk V.
      • Autschbach R.
      • Krakor R.
      • et al.
      Computer-enhanced mitral valve surgery: toward a total endoscopic procedure.
      ,
      • Reichenspurner H.
      • Boehm D.H.
      • Welz A.
      • et al.
      Three-dimensional video and robot-assisted port-access mitral valve surgery.
      ,
      • Vanermen H.
      • Wellens F.
      • De Geest R.
      • et al.
      Video-assisted Port-Access mitral valve surgery: from debut to routine surgery. Will Trocar-Port-Access cardiac surgery ultimately lead to robotic cardiac surgery?.
      ].
      Development and perfection of the da Vinci Surgical System (Intuitive Surgical) introduced the first real possibility of accurate minimally invasive closed-chest cardiac surgery. This was the first device that had both sufficient visualization and mechanical flexibility to perform complex operations. Loulmet's group reported the first use of this device in mitral and coronary surgery [
      • Loulmet D.
      • Carpentier A.
      • d'Attelis N.
      • et al.
      Endoscopic coronary artery bypass grafting with aid of computer-assisted instruments.
      ]. Our group was the first to expand the use of da Vinci into a large patient series. The first complete robotic mitral repair in the United States was performed in May 2000 [
      • Chitwood Jr, W.R.
      • Nifong L.W.
      • Elbeery J.E.
      • et al.
      Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da Vinci™ surgical system.
      ]. This quadrangular resection of the posterior leaflet with band annuloplasty was part of the initial US Food and Drug Administration (FDA) trial. Since then we have performed 160 mitral repairs and replacements with 1 operative death and 2 mortalities after ≥30 days.

      Robotic surgical program development

      In developing our robotic surgery program, we have had both exhilarating and disappointing experiences. We have trained many surgeons worldwide and served as preceptors when they returned to their institutions. Our program has focused on training general and cardiac surgeons, as well as gynecologists and urologists. We have helped to develop programs to the point that many of them are now teaching others. In each successful program, there has been a constant theme of teamwork and commitment. We suggest following a definitive plan using an objective-based curriculum when learning the required techniques. Clearly, these operations are a team activity and each member must play his or her part as an expert.

      Planning and leadership

      Before beginning actual training, one should review the literature and analyze it critically to feel comfortable with advocating this approach for patients. If the surgeon truly does not believe that these operations will really benefit patients, traditional methods should be retained. Moreover, it is important to educate the operating room nursing staff as to the difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. It is helpful to communicate with a colleague involved directly in the field to help answer questions and provide guidance.
      Hospital administrators and surgeons must define the reasons for developing a robotic surgical program. The real reason for using this new technology in minimally invasive surgery must be evaluated. The surgeon-team leader must determine whether he or she has a real interest in developing a minimally invasive/robotics program, or whether it will just be a marketing tool for the hospital system. Institutional commitments become much more solid when a surgeon organizes the program. The main goal should be to facilitate endoscopic operations. However, hospitals often use surgical robotics to increase patient volume while facilitating patient recovery. In other instances, the institution purchases the system and then encourages use by the surgical teams. The latter situation requires more work to develop an understanding between hospital administrators and surgical teams. The potential is greatest when the surgical team and hospital administration can work together for patient care and institutional advancement.
      In academic institutions, there is much greater opportunity for collaborative work. The intellectual process associated with a robotics program can promote grant-writing and scientific publishing. Regularly scheduled interest group meetings for faculty, staff, trainees, and students are important to maintain a timeline. New programs may be developed within these working interest groups, and realistic timelines should be strictly enforced. This is a potentially great source for resident training, offering many areas for research projects. It is important for new robotics programs to provide educational programs within the community. We refer to this type of work as “outreach,” and believe it is important to enlist community support and provide education locally.
      It is important to formulate an early plan with mentors, the departmental chairperson, or a trusted colleague. This helps solidify support and offers constructive comments in preparation for development of a structured business plan. In developing a business plan and timeline, it is important to collect the necessary data, including the potential increase in referrals as well as savings from reduced hospital lengths of stay and faster recovery. During this phase, it is important not to forget the cost of the yearly service contract for the robotics system as well as instruments and disposables for each case. When negotiating with hospital administrators, it is most important to show them that robotics will add a dimension that will benefit the hospital through patient care. In addition to potential benefits to patients, programmatic growth potential and institutional recognition should be emphasized.

      Training the robotic surgical team

      Team training is the most important early step. A carefully planned protocol or objective-based curriculum should be followed for the best results. In the beginning of robotic cardiac surgery, the FDA mandated that comprehensive training had to be provided for all institutional teams and surgeons planning to use the da Vinci Surgical System. Our institution initiated this type of training in 2000 to provide a uniform start for early adopters of this technology. Surgical teams are composed of the console surgeon, the patient-side surgeon or assistant, a scrub nurse, and a circulating nurse. Cardiac teams trained to date also have included a senior perfusionist and an anesthesiologist. Training should be designed to expand upon prior clinical experiences and training. However, to master surgical telemanipulation as applied to specific operations and become a facile patient-side assistant, a completely new set of skills must be acquired.
      The curriculum for each surgical team focuses more on sterile draping, operating room arrangement, instrument care, and device maintenance. Teams begin with system training that includes setup, draping, and both electrical and mechanical troubleshooting. Teams then return to their home institutions and begin doing robotic operations to reinforce the objectives learned. After mastering these objectives, they return for advanced procedure-specific training. Training programs now exist for all disciplines of surgery, including general, cardiac, and thoracic surgery as well as urologic and gynecologic surgery [
      • Chitwood Jr, W.R.
      • Nifong L.S.
      • Chapman W.H.H.
      • et al.
      Robotic surgical training in an academic institution.
      ]. Curriculum advancement levels include case observation, didactic sessions, inanimate laboratories, and fresh cadaver training. In cardiac surgery, inanimate models are used to emulate human thoracic geometry for port and camera placement. Intact animal hearts provide pliable valvular and annular tissues for suturing. Fresh cadavers supply the complexities associated with human musculoskeletal characteristics and organ tissues. The final link is provided through live case observation of a mitral valve repair done using da Vinci. Since August 2000, >200 surgical teams have completed the East Carolina University (Greenville, NC) training curriculum (Table 1). This includes both system training and advanced procedure-specific training.
      Table 1Robotic surgical training: objective-based curriculum levels
      I. System training
       A. Didactic overview
        1. Understand robotic vision and electronics
        2. Understand robotic instrumentation
       B. Inanimate laboratory
        1. Master robotic operative cart (draping and setup)
        2. Master operative console
        3. Master instrument and camera control
       C. Animal laboratory
        1. Console surgeon
         a. Suturing
         b. Tissue cutting
        2. Patient-side assistant
         a. Instrument exchanges
         b. Camera cleaning
         c. Clip-application
         d. Retraction
         e. Trocar positioning
       D. Cadaver laboratory
        1. Master trocar positioning
        2. Apply above to human anatomy
        3. Apply above to variable body habitus
      II. Advanced procedure-specific training
       A. Operative observation
        1. Observe interaction with adjunctive surgical technology
        2. Discuss training objectives with trainer and team
         a. Patient positioning
         b. Procedure steps
         c. Port placement
         d. Pearls and pitfalls
       B. Didactic review
       C. Inanimate models
        1. Practice procedure steps
        2. Apply all of the above
       D. Cadaver laboratory
        1. Master all of the above
        2. Apply to variable body habitus

      Summary

      The most important characteristics in developing a robotic program are intellectual curiosity, introspective honesty, and commitment. These traits must be present throughout the institution, from top to bottom, including the department chairperson or group leader. Most important is a high level of commitment by surgeons involved in the program. We encourage multispecialty training because one team can benefit greatly from another and provide expanded personnel resources. Meticulous intraoperative time-motion data collection allows teams to track their progress. It must be remembered that successful programs develop slowly and iteratively. Every advancement requires critical analysis and quality review by team leaders. It is important never to move to the next step without mastering the previous one. With these few maxims in mind, most modern hospitals can field a robotics team and program with excellent patient care results.

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