Overview

The rapid and widespread adoption of robotics in surgery has changed the minimally invasive

surgical landscape within the last decade. Such rapid adoption and dissemination of this technology

has largely resulted from the perceived benefits of improved ergonomics, dexterity, safety, and

ease of surgery. Each year, an increasing number of general surgery cases are being performed

with robotic assistance. As more hospitals continue to adopt this platform, it is becoming increasingly

essential that general surgeons become properly trained in robotic technology. As the clinical

applicability and implementation of robotic surgery moves forward, it is imperative that a structured

curriculum which encompasses the acquisition of basic robotic skills and procedural

tasks be made available to surgical trainees. This robotic surgery curriculum has been developed to

guide robotic surgery training throughout the General Surgery Residency. A general overview of

the curriculum can be seen in Figure 1.

Learning

Objectives

1. Describe the individual components of the da Vinci System including the surgeon console,

patient cart, and vision cart.

2. Learn the basics of electrosurgery including: how electrical currents are harnessed in

electrosurgery, how generators and energy instruments work, and best practices for

electrosurgery.

3. Become familiar with the various types and functions of available Endowrist® instruments.

4. Develop proficiency in core da Vinci technical skills through virtual reality simulation exercises

and hands-on experience in a dry laboratory environment.

5. Become proficient in tasks required to beside assist robotic surgery cases including: port

placement, docking the patient cart, and instrument insertion and exchange.

6. Develop proficiency in the skills necessary to perform live da Vinci Surgery cases including:

mastery of the instruments, handling of tissue, and appropriate decision making and

judgement.

Cognitive Component

I Technical Component

I

*Denotes mandatory requirement.

Time Requirements of Mandatory Components:

• da Vinci eModules (2.5 hours)

• Case Observation (Varies)

• Required Reading (30 mins)

• da Vinci Virtual Reality Modules (5 hours)

Cognitive component must be completed prior

to starting technical component.

Figure 1 : Overview of robotic surgery curriculum

Robotic Surgery Training Pathway

Case Observation*

Required Readings*

Hands-On

(10 Cases)

Console Surgeon Training

dV Xi EndoWrist® Stapler Assessment

dV Xi EndoWrist® Vessel Sealer Assessment

C O G N I T I V E C O M P O N E N T

da Vlinci eLearning and Assessment

Residents must complete the appropriate eLearning for the both the da Vinci Si and Xi consoles to be

granted simulator privileges. Course topics include basic system terminology, functions and safety

features (Table 1 ).

e-Modules for da Vinci Si and Xi

da Vinci Si Modules da Vinci Xi Modules

Table 1: Required eLearning Modules

Upon completion, trainees must pass the corresponding assessments with a score of 80% or better. All

trainees must forward their certificate of completion to the Surgical Educator. Certificates must be

received two weeks prior to the trainee's scheduled In-Service Training session. All completion

certificates will be uploaded to New Innovations to enable faculty to verify completion.

Access www.davincisurgerycommunity.com to create a user account. See Appendix A for additional

details regarding user account setup and e-Module enrollment.

Case Observation

Residents must observe three robotic cases and submit appropriate documentation signed by the

attending physician (see Appendix B).

Required Reading

Residents are encouraged to review the following selected articles published on robotic-assisted surgery

which focus on its application to General Surgery.

Barbash, G.I.,Glied, S.A. (2010). New Technology and Health Care Costs-the Case for Robotic

Assisted Surgery. New England Journal of Medicine 363(8):701-704.

Buchs,N.C.,Addeo, P.,Bianco, F.M.,Gorodner,V.,Ayloo, S.M., Elli, E.F.,et al. (2012).

Perioperative Risk Assessment in Robotic General Surgery: Lessons Learned from 884 Cases at a

Single Institution. Arch Surg 147(8):701-708.

Maeso,S., Reza, M., Mayol,J .A ., Blasco,J.A.,Guerra, M.,Andradas, E.,et al. (2010). Efficacy of

the Da Vinci Surgical System in Abdomi nal Surgery Compared with that of Laparoscopy: A

Systematic Review and Meta-analysis. Annals of Surgery 252(2):254-262.

dV Si for Residents and Fellows

dV Si EndoWrist® Stapler 45™

Assessments:

Si Comprehensive Assessment

dV Si EndoWrist® Stapler Assessment

dV Si EndoWrist® Vessel Sealer Assessment

T E C H N I C A L C O M P O N E N T

da Vinci Virtual Reality Simulation Modules

The technical skills component requires that trainees first demonstrate proficiency in da Vinci surgery

skills through completion of a series of virtual reality modules on the da Vinci Surgical Skills Simulator.

For instructions on gaining access to the simulation modules, refer to Appendix C.

The main menu of the simulator console contains 8 different modules comprised of a series of exercises.

Exercises within the 8 da Vinci modules have been assigned to four levels (i.e., Introductory, Beginner,

Intermediate, and Advanced) based on increasing difficulty of exercises (Table 2).

Getting Started

Complete the Introductory Module: Trainees must first complete the Surgeon Console Overview for

instructions on how to operate the da Vinci console prior to completion of the skills modules.

Baseline Testing

Trainees are required to complete baseline testing on the Beginner Module. This requires that the

sequence of 11exercises in the Beginner level module be completed in one sitting with no prior

practice.

Module Mastery

Exercises within the Beginner, Intermediate and Advanced modules must then be completed in a

mastery based learning fashion. This necessitates that exercises within the Beginner, Intermediate, and

Advanced modules be completed one-by-one, in sequence, until a score of 85% with "green checks"

in all fields (i.e. time, economy of motion, instrument collisions, instrument force, vision of

instruments, master of work-space range, drops, etc.) is achieved-indicating mastery of all areas

tested. For emphasis, trainees must start with the "Camera Targeting 111 exercise within the Beginner

Module and master the exercise before advancing to the next exercise (i.e. Scaling). However, trainees

are permitted to advance to the next exercise of the curriculum before mastery of a given exercise is

achieved if they have attempted a task >10 times. Despite being able to initially advance through the

remaining exercises, trainees must revisit exercises they found challenging and achieve a score of

85% or greater to complete this portion of the technical skills curriculum.

Record of Performance

The da Vinci console will record your performance. It is imperative that trainees complete modules

under their designated login only. Completion of modules under the default username will not provide

the necessary documentation to fulfill curricular requirements.

For a record of your module scores, please contact the Surgical Educator.

Introductory Module

Console Module Exercise

Surgeon Console Overview Using the Simulator

Ergonomic Adjustment

Understanding Icons l Overview of Controls 1 Error Messages l

Beginner Module

Console Module Exercise

Camera & Clutching Camera Targeting 1

Scaling I Ring Walk 1 1

EndoWrist® Manipulation Pick and Place 1 I·

Peg Board 1 1 1 ·

EndoWrist® Manipulation 2 Matchboard 1 I

Ring and Rail 1 1 1 ,

Energy & Dissection Energy Switching 1 j

Energy Dissection 1 l Needle Driving Suture Sponge 1 ·1

Dots and Needles 1 J

Intermediate Module

Console Module Exercise

Camera & Clutching Camera Targeting 2 I Ring Walk 2 1

Energy & Dissection Energy Switching 2 I Energy Dissection 2 J

EndoWrist® Manipulation 1 Peg Board 2 1 EndoWrist® Manipulation 2 Matchboard 2

Ring and Rail 2

Needle Targeting Needle Targeting .I

Thread the Rings 1

Needle Driving Suture Sponge 2

Dots and Needles 2

Advanced Module

Console Module Exercise

Camera & Clutching Ring Walk 3 1 Energy & Dissection Energy Dissection 3 I

EndoWrist® Manipulation 2 Matchboard 3 l Needle Driving Suture Sponge 3 l

Tubes ·1

Suturing Skills Vertical Defect Suturing ·1

Horizontal Defect Suturing I

Continuous Suturing

Suturing Practice

- Interrupted Suturing

Table 2: da Vinci Virtual Reality Simulator Modules

da Vinci Overview In-Service Training

Trainees must complete a live In-Service Training led by a da Vinci surgeon or lead educator. This

course offers learners hands-on experience using the da Vinci system and requires a time

commitment of 4 hours and details the content found in Table 3.

I'

I

I

l

I

I

I 1

\ 1'

Table 3: da Vinci In-Service Training Content

Successful Implementation of a da Vinci Surgery Session

Leadership structure within the da Vinci operating room

Communication between the OR staff and surgeon I

Task assignment

Standardization of the da Vinci System location

System Component Overview

Vision Cart Value 1 Surgeon Console Value

Patient Cart Value

Docking the Patient Cart

Cannulas & Trocars

Basic Port Placement

Patient Positioning

Patient Cart Overview: Positioning, Driving, and Docking J

EndoWrist ® Instrument Overview Components and Features

Insertion and Removal

' Guided Tool Change

Instrument Arm Status

End0Wrist • Instrument Best Practices I

Surgeon Console Overview Components and Features I Touchpad I Stereoviewer Display I Master Controllers

Footswitch Panel I Surgeon Console Activities I Dual Console Activities

Emergency Procedures Fault Modes

Event Logs

Disable Patient Cart Arm or Master Controller

' Emergency Stop

' Instrument Release Kit 1

Conversion to Open or Laparoscopic Surgery

. Hard-Cycle Power

Troubleshooting

Powering Off and Storing the System

c====J

Bedside Assist Training

Bedside Assist Case Completion

Subsequent to the da Vinci In-Service Training, the resident must log 10 cases in the primary role of

bedside assistant, focusing on establishing proficiency in each of the following areas:

• Port placement

• Docking the patient cart

• Instrument insertion and exchange

• Assisting during the procedure

Case Logging

These cases should be logged using the da Vinci Case Tracker. See Appendix D for additional

instructions on electronic case logging.

Performance Evaluation

Residents must seek feedback from the attending physician regarding their performance.

Console Surgeon Training

Console Case Completion

Upon completion of bedside training, residents must complete at total of 20 cases in the primary role of

console surgeon. Residents will be granted the opportunity to participate as the console surgeon when

the attending physician deems the resident to be sufficiently proficient in robotic surgical techniques.

The resident will initially perform specific tasks as directed by the attending physician and will advance

toward completion of more difficult portions of procedures. Resident participation and progression is at

the sole discretion of the attending physician.

Case Logging

Trainees should log console cases using the online da Vinci Case Tracker. Residents are required to

complete more than 50% of the case in order to count the case. See Appendix D for additional

instructions on electronic case logging.

Performance Evaluation

Residents must seek feedback from the attending physician for qualifying robotics procedures.

During the Chief Year, the resident should be able to demonstrate overall competency and perform both

bedside and console surgeon tasks. An attending physician will be required to complete a post­

procedure evaluation for 5 cases (see Appendix E). A minimum of 5 cases completed as a console

surgeon must include a post-case review with the attending surgeon. The resident must be deemed as

competent on the console for all of these cases. These cases must be performed with at least 2

different attendings and must be performed during the final year of residency.

c====J

Hands-On Dry Laboratory Simulation

Trainees are required to participate in a hands-on dry laboratory prior to sitting at the console to

operate. This high-fidelity simulation requires trainees to interact with physical models while operating

the actual da Vinci Surgical System Console. The nine exercises used in this inanimate skills module are

designed to hone basic robotic surgical skills including: instrument handling, suturing (simple

interrupted and running), knot-tying (surgeon's and square knots), camera driving and navigation, and

clutching (Figure 2). Trainees are required to complete baseline testing for the nine tasks prior to

progressing through the module.

Figure 2: The nine exercises of the inanimate skills module.

2.Clutch/Camera Movement 3.Rubber Band Transfer

4. Suture (Simple Interrupted) 5.Clutch & Camera Peg Transfer 6.Rubber Band Transfer

7.Running/Cutting Rubber Band

Ongoing Training

The following activities are suggested to further develop and maintain proficiency in da Vinci Surgery

skills and practices.

Console Practice

Residents are required to log 60 minutes on the simulator bi-weekly when on the MIS Service.

Video Library Review

• The Clinical Robotic Surgery Association (CRSA) has a video gallery showing robotic surgeries in

various categories including: bariatric, colorectal, oncology, etc. Membership is free for

residents and fellows. Visit http://www. clini calrobotics.com to create an account and view

videos.

• The da Vinci Surgery Community has many videos of general surgery robotic cases. Log in to the

community (www.davincisurgerycommunity.com).

• Alternatively, da Vinci training videos are available through the Fundamentals of Robotics Surgery

(FRS) Curriculum. Log in to the program (www.frsurgery.com).

APPENDIX A

Joining the da Vinci Online Community

Visit: www.davincisurgerycommunity.com

Click on "Join the Community"

Input your information to establish a login. Make certain to indicate that you are a "Resident or

Fellow" so that your interface displays properly.

Enrollment in eModules

In the upper right corner of the interface, click the small white arrow

which will display the following options:

-My Profile

-My Training

-My Bibliography

-My Cases

Select "My Training" and on the following screen select "Add New

Training" which will allow you to Search Online Training (see

Figure 3).

You are required to complete modules for both the da Vinci Si and

Xi.

To add the appropriate modules, input the following parameters

select the System (Si or Xi) and the appropriate software. Software

parameters for the Si and Xi are P9 and P6, respectively.

Enroll in the modules as shown in Figure 4.

Figure 4: Required Training Modules for Si and Xi

My Training

Figure 3:Search

Online Training

APPENDIX B

Robotic Surgery Case Observation

PGY: _

You must document observation of 3 cases. Submit completed forms to the Surgical Educator.

Case 1

Date:

Procedure:

Attending Physician Signature:

Case 2

Date:

Procedure:

Attending Physician Signature:

Case 3

Date: Procedure:

Attending Physician Signature:

APPENDIX C

Accessing Simulation Modules

Power on & Log In:

Press the white power button to turn on

the console (Figure 5).

Adjust the console so that it is

ergonomically comfortable using the

control panel on the left (Figure 6).

Looking through the viewfinder, you will

see a log in screen with an arrow in the

center. You can move the arrow on the

screen by inserting your fingers into the

instrument controls and pinching your

fingers together.

Note: Your username is to be created in

the system after your certificate from the

cognitive modules is confirmed .

Figure 5: Console overview

Figure 6: Console controls

APPENDIX D

Case Logging

In the upper right corner of the interface, click the small white arrow which will display the

following options:

-My Profile

-My Training

-My Bibliography

-My Cases

Select "My Cases" and on the following screen select "Add New Case" which will allow you to

log in a new case.

APPENDIX E

Console Surgeon Evaluation

This form is for residents in their final year who have already performed 15 cases in the

primary role of console surgeon. The evaluation is to be completed by the attending

physician and reviewed with the resident at the completion of the case. You must perform

this evaluation for at least 5 cases. Submit completed forms to the Surgical Educator.

Patient Sticker Resident: I Date:

Operation:

Skill Adequate More Practice

Recommended

Demonstrating understanding of trocar placement

and spacing

Understands principles of docking and is able to dock

in a timely fashion

Uses camera appropriately and is able to focus the

camera

Demonstrates appropriate clutching and maintains

hands in a comfortable workspace

Demonstrates ability to use third arm and switch

instruments

SAFETY: Does not move instruments that are not in

view

Demonstrates ability to troubleshoot system and

manage collisions

Please comment on areas of strength:

Please comment on opportunities for improvement:

The resident demonstrates competency on the robotic system. Yes No

The resident demonstrates competency on the robotic system. Yes No

Attending Name Attending Signature Date

=