A practical guide to development of a successful robotic abdominal surgery program: The path to implementation

Summary

The authors describe current situation in robotic assisted operations. The most important aspects of establishing a successful robotic program are patience and flexibility. The improved patient satisfaction, return to function, and decreased perioperative pain for patients and surgeons will be seen, but the road is long and requires careful navigation.

Key Words:
robot − abdominal surgery – program − development

INTRODUCTION

A structured plan with specific key elements is required for establishment of a successful and safe robotic surgery program. In this manuscript we outline key components for developing a robotic program, highlighting advantages and possible challenges encountered.

Robotic surgery, largely through use of the da Vinci platform (Intuitive Surgical, Sunnyvale, CA), has been widely disseminated since its debut [1]. Many operations, including technically advanced procedures such as hepatectomy and pancreatectomy, are now performed safely with this minimally invasive technique [2−4]. Education of the surgical team as well as patients undergoing an operation using this technique is imperative [5].

With introduction of new technology to perform an operation, patient safety is of utmost importance during the initial learning curve, meaning the period of time required to gain proficiency with new technology. The majority of hospitals in the United States now require surgeons to be credentialed to perform surgery robotically. Credentialing typically involves completion of a several day course to become a bedside assistant and primary robotic surgeon, followed by a number of cases proctored with a trained robotic surgeon. The presence of a representative from the robotic company is helpful during the initial operations to help with resolution of any obstacles encountered.

Although a minimum number of proctored operations are required for hospital credentialing, this minimum number is not sufficient to indicate technical kompetence [6]. Adequate training and mentorship are vital for the safe introduction of robotic surgery into the surgical community. Much literature has been published on the number of cases required to achieve technical proficiency for both laparoscopic and recently for robotic operations [7]. The number of operations needed to surpass the learning curve depends highly upon the surgeon’s past experience with minimally invasive techniques. Interestingly, in some respects, robotic surgery may be more easily adopted than laparoscopy secondary to wristed instruments that mimic a human had. However, the lack of haptic feedback remains a significant obstacle to overcome, particularly in more complex operations. [8].

Several surgical sub-specialty societies have published recommendations regarding the introduction of new technology, highlighting the use of simulators, mentorship of a robotically trained and experienced surgeon, as well as a rigorous and honest self-assessment to include detailed review of adverse events and personal data collection [9].

Key elements in establishing and maintaining a successful robotic program

The first step in the establishment of a new program is definition of an economic plan to include currently available institutional resources, the setup and maintenance costs of necessary equipment, and training of not only surgeons, but also operating room and nursing staff. The assessment of cost is dependent highly on the frequency of future use of the robotic system [10]. Calculation of case volume that will be required to surpass the initial learning curve and subsequent maintenance of a robust robotics program is also critical as proficiency and ultimate success cannot be achieved without adequate case volume [6,11]. Some reports have defined 3−5 robotic cases per week as necessary during the program initiation to assure achievement of proficiency and eventually reduce operative time [6].

The next step should be a clear definition of which operations will be performed robotically initially. [12]. This provides the ability to facilitate lead surgeon proficiency, operating room team development and adequate case volumes to promote positive development. Additionally, modifications of the current operating rooms to incorporate space for the robotic console, the robot and other ancillary equipment are likely required. Purchasing of robotic platforms, equipment and instruments is dependent on the specific institution and availability, but should be part of the initial step of planning [13].

Many programs that have had success in development of a strong program have identified a lead surgeon that dedicates the time and effort to become proficient and an expert in the robotic platform, a champion so to speak [6,12]. The lead surgeon takes the obligatory steps of overcoming the learning curve and observes one or more institutions with an established program to understand their experience and process of program development. With visitation of a robotic program, the lead surgeon can establish a relationship with a mentor who will then in turn visit and proctor initial operations. The lead surgeon can then educate other surgical sub-specialties and increase number of operations that are done with the robotic platform, promoting cost-efficiency. Robotic platform manufacturers offer a training and mentorship program that can aid in forming and establishing these relationships. da Vinci also offers training programs in which surgeons can learn the important maneuvers of suturing with the robot and performing other specific tasks. Many sub-specialty specific programs are also offered.

Another step to program development is creating a consistent team that will be dedicated to the robotic operating room. The team required to perform a robotic operation includes two surgeons (one console surgeon and the other as a bedside assistant), anesthesia personnel, a scrub technician and a circulating nurse. When setting up the operating room, it is important to remember that the operating surgeon is not directly at the bedside, which can impair communication. Thus, the location of the robotic console becomes important. Additionally, the console camera offers the luxury of 3-dimensional imaging, not available typically to the bedside assistants, again emphasizing the importance of communication and trust between the surgeon at the console and those at the bedside.

A final step of program development is data tracking and evaluation at regular intervals, followed by appropriate adjustments. Variables helpful for tracking include but are not limited to: time taken for various steps of an operation such as port placement and key points of dissection, length of console time, estimated blood loss, length of hospital stay, major and minor morbidities, and rates of conversion to open procedure. During the initial phases of robotic program development, these numbers should be reviewed regularly and with great attention to detail. If needed, a surgeon can set time limits to each step of an operation and if those limits are exceeded then choose to convert to open.

Training of residents and fellows

The robotic platform is now routinely used to perform minimally invasive surgery in certain centers, and, its adoption particularly in general surgery continues to spread. A structured curriculum to expose surgeons in training (residents and fellows) to robotic surgery should be employed at centers utilizing the robot. This curriculum can be tailored to each institution and their specific needs. For example, a junior resident completes the online robotic modules (provided by the platform company) that teach the basics of the platform (how to dock, familiarity with the console etc) and a literature review of publications and robotic surgical videos [6]. The junior resident then has an orientation to the robot and a simulator. When he/she becomes a mid-level resident, they scrub as the bedside assistant. The mid-level resident would also complete specific modules on the simulator and potentially a dry laboratory to introduce surgical techniques such as suturing [14]. We believe that it is crucial for the surgeon in training to have an extensive experience as the bedside assistant, as this is the only means to full exposure to the challenges of the robot. This allows for developing the ability to trouble shoot collisions, learn port placement and observe the lead surgeon operating at the console. As the trainee’s skill improves, the more senior resident advances to limited work on the console with gradual advancement as their skill set allows. Certain training programs have also employed training modules on the robotic simulator that are required to be completed with pre-determined proficiency (graded by the simulator tracking movements and collisions) prior to advancing to operating on the console. Friendly competitions amongst trainees to beat senior surgeon times on the simulator can foster great motivation and may increase trainee participation.

Benefits and downfalls of the robotic platform

Robotic surgery was in part developed to overcome some of the limitations of traditional laparoscopic surgery, which utilizes rigid instrumentation and is not always ergonomically optimal for the operating surgeon [15]. Robotic instruments articulate at the wrist and thus mimic the dexterity of open surgery with human hands. The articulated instruments allow for suturing and working at a variety of angles, which may not be possible with rigid instruments of laparoscopy. The operating surgeon works at the console in a sitting and more ergonomic position, with hopes to maintain the physical longevity of the surgeon. The camera and retractors are controlled by the operating surgeon, obviating the need for an assistant to manage the camera as in laparoscopy. The 3-dimensional projection of the images in part overcomes the lack of depth perception.

Overall, the learning curve for minimally invasive technique using a robotic platform is thought to be shorter than the learning curve of laparoscopic surgery because the robotic instruments resemble the human hand with the ability to articulate. For this reason, it may be easier for an expert surgeon in a particular field to transition to robotic surgery compared to laparoscopy, if they have had little experience with minimally invasive techniques. However, this is not to say that the learning curve is shorter for all complex operations using the robotic platform. In fact, for pancreaticoduodenectomy, the learning numbers for robotic surgery are documented to be double those for laparoskopy [8,16]. This finding has largely been attributed to the lack of haptic feedback - the use of the sense of touch. The lack of the touch sensation is an aspect of robotic surgery that the surgeon must overcome mentally. Retraining of the surgeon’s mind to rely on visual sensations rather than the innate sense of touch is a necessary step the robotic surgeon must take. Skilled robotic surgeons describe a sort of “visual haptics” that develops over time.

While the lack of haptic feedback persists, the newer generation robotic platforms are designed to make operating in multiple quadrants more feasible, which was previously a disadvantage to robotic surgery. The new generation robot (the da Vinci Xi) allows for complete change in operating fields, either from right to left, or upper to lower abdomen without additional ports or repositioning of the robot. There is now an operating room table with the capacity to move with the robot docked, something that was not possible with the older generations [17].

The component of robotic surgery that is most strikingly different from open or traditional laparoscopic surgery is the separation of the surgeon from the patient during the operation. The surgeon operates on the console, typically 2−5 meters away from the patient. This can lead to anxiety when hemorrhage or other operative complications are encountered, and can lead to a delay in conversion to open [18]. In order to convert the operation from robotic to open emergently, the lead surgeon has to scrub into the field, and the robot has to be undocked and removed from the field before a laparotomy can be performed. Pressure can be held during this time by an assistant through a laparoscopic assistant port or a gel port, thus highlighting the need for a skilled assistant, particularly during the early learning curve phase.

It is not uncommon, even in experienced hands, to have technical malfunction of placement of instruments, energy devices, robotic arms, camera and the details of the surgeon konsole [19−21]. These malfunctions not only increase the amount of operating time, but also contribute to the stress of the surgeon and staff. Therefore, it is vital for the lead surgeon to be extremely familiar and knowledgeable with the robotic equipment and trouble-shooting of system. All team members must be trained and familiar with the instrumentation, giving them the ability to trouble-shoot in these events. An example of malfunction is a robotic arm/instrument jammed during bleeding encountered during a hepatectomy. Time is spent with the robotic arm, and the hemorrhage worsens. Several publications have reported a low rate of malfunction (2.4−4.5%), though some have resulted in conversion to open or conversion to laparoskopy [19]. These percentages may be underreported and likely occur more frequently during the learning curve.

Other disadvantages include the need for a skilled assistant (another skilled surgeon, especially during the adaptation phase) to assist through laparoscopic ports, suction, change instruments, and for certain cases apply energy devices, staplers and clips that may not be available as robotic instruments [18]. The learning curve period is as much for the operating room staff and bedside assistants as it is for the senior surgeon. When possible, it helps to have team members in place with prior robotic experience.

Length of operative time

Longer operative times have been shown for robotic surgery when compared to laparoscopy due to set up time of the system, docking of the robot and changing instruments [18]. An example of significantly time consuming changing of instrument is the robotic clip applier as placing a clip robotically requires the robotic arm to be exchanged for each individual clip. Additionally, due to the cost of the robotic instruments, only one clip applier is used and the surgeon has to wait for the arm to be removed, the clip to be loaded and the arm to be replaced. We recommend using two laparoscopic assistant ports if needed to improve time efficiency in the beginning. For example, a laparoscopic clip applier can be used by the assistant and is much more efficient than multiple exchanges required to place the clip robotically. The range of new instrumentation is expanding regularly and now there are vessels sealers, suctions and staplers available as robotic instruments. While these will eventually eliminate the need for laparoscopic assistant ports, we do recommend the use of assistant ports during the learning curve phase with a gradual reduction as the surgeon attains proficiency.

The pearls of port placement

Robotic arm collisions are likely the most difficult problem to overcome, once they occur. The collision may occur between the robotic arms themselves, between the robotic arms and parts of the patient’s body, and the robotic arms with the laparoscopic assistant ports. This is less common with the newer robotic platforms available. Nevertheless, robotic port placement requires careful planning and study of the patient’s pre-operative imaging, and knowledge of their unique anatomy in the context of a particular surgical plan. Each individual patient’s body habitus can influence collisions – as an example, patients with a narrow and short torso will require the robotic ports to be placed more inferiorly, and ultimately may collide with the anterior superior iliac spine or the patient’s thigh. Early in the experience, it may be helpful to measure the distance from the working space of interest (for example spleen) to the umbilicus using the sagittal views on CT imaging. This will allow the surgeon to minimize placing the ports too high on the abdomen, which is a common mistake in the early experience. The distance and alignment of the trocars depends on the generation of robot being used. For the older generation robot, da Vinci Si (Intuitive Surgical, Sunnyvale, CA), the ports need to be 8−10 cm apart, usually in a curvilinear line. The design of the Xi allows for port placement 5−8 cm apart, in a straight line. Planning of the laparoscopic assistant port is imperative and is often best placed inferior and lateral to the robotic ports.

Planning of the camera port also depends on which system is being used. One of the improvements of the Xi system is an 8 mm camera that can be used with any of the robotic ports. This differs from the Si system in that the camera required a 12 mm port and thus disallowed movement of the camera after initial port placement. This was a practical complaint of many early robotic surgeons that resulted in evolution of technology by da Vinci. As mentioned prior, the da Vinci Xi has evolved to a mobile tower that houses the robotic arms, such that the entire system can be shifted to a separate quadrant without moving the patient or the robot [22]. Additionally, this platform offers “targeting” to area of operative interest such that the robotic arms are automatically aligned in the most effective position based on the operative target. While these mark big steps forward, improvements continue to be made.

Preparation for a robotic operation

A well thought-out plan for conduction of each robotic operation is vital for success. This begins with appropriate patient selection. A common mistake that surgeons make early in the learning curve is inappropriate patient selection that is biased by the desire for case volumes. A better approach is patience and waiting for the appropriate candidate, with gradual but safe growth. Once the appropriate patient is selected, a thorough evaluation and knowledge of their anatomy by detailed examination of their cross-sectional imaging in all views (sagittal, coronal, axial) is important. This includes trocar placement planning and forethought of the number of ports, trocar alignment that is best suited for the patient’s unique body habitus and planning of the assistant ports.

Next, a clear conversion plan is crucial. This begins with an understanding between the team members of reasons to convert and amount of time to conversion. The two reasons to convert are in cases of emergencies such as hemorrhage or patient decompensation, or failure to progress. The decision to convert based on an emergency is a much more straightforward decision. Conversion based on lack of progress is much more difficult, especially when the surgeon is motivated to complete the operation robotically. Thus, we recommend a pre-planned allotted length of time in which an operation will be converted. For example, a surgeon may chose a two hour allotted time from the skin incision to planned conversion in order to prevent excessive operative times. Once the decision has been made regarding when to covert to an open operation, a clear plan of execution is developed. In cases of hemorrhage, the assistant may hold pressure from the laparoscopic ports while the other assistant un-docks the robot. This is one of the many reasons that the assistant must have access to the laparoscopic ports as placing an additional port in the case of an emergency and the robot in the way can be difficult. The surgeon at the console is still the leader in the room and must remain calm. All robotic instruments should be in the open position, not holding any tissue, prior to being removed. Once instruments are removed, un-docking of the robot must be done quickly and efficiently as it is necessary to make an open incision. Each team member should have an assigned role established in advance prior to the start of the operation. Open instruments, suction, long sutures, and staplers should already be available prior to the start of the operation. Direct closed-loop communication between all team members is essential.

CONCLUSION

The most important aspects of establishing a successful robotic program are patience and flexibility. It is critical to resist the urge to soldier onward to continue an operation robotically despite lack of progress. This places the patient at risk of severe harm. It can be easy for any surgeon to fail to convert the operation to an open laparotomy in a timely fashion due to motivation to complete the surgery robotically, especially in the early phases. However, one should always bear in mind that it takes dedication, time and patience to have a successful robotic program with excellent patient outcomes, and it is expected to have a number of conversions during the adaptation phase. In the end, improved patient satisfaction, return to function, and decreased perioperative pain for patients and surgeons will be seen, but the road is long and requires careful navigation.

Conflict of Interests

The authors declare that they have not conflict of interest in connection with the emergence of and that the article was not published in any other journal.

Yuman Fong, M.D.

Chair, Department of Surgery

Sangiacomo Chair in Surgical Oncology

Department of Surgery

City of Hope National Medical Center

1500 Duarte Road

Duarte, CA 91010

e-mail: yfong@coh.org