upper tract surgery with the da vinci - the learning curve. invited lecture - bristol urological...
TRANSCRIPT
Upper tract surgery with the Da Vinci
Mr. Christian Bach
Fellow in Robotics, Southmead Hospital, Bristol, UK
Roadmap
Traditional concept of the Learning Curve
Partial Nephrectomy experienced robotic surgeon experienced laparoscopic surgeon
Pyeloplasty experienced open surgeon
Adrenalectomy junior vs. senior surgeon LC depending on skill of the assistant
How to shorten the curve classical approach surgical warm-up
New Concept of Learning curve
Traditional concept of the Learning Curve
First description by TP Wright in 1936
J Aeronaut Sci 1936; 3: 122.
WT (<20 min) after 30 cases
( p < 0.001 )
OT (<100 min) after 20 cases
( p < 0.001 )
The experienced Robotic Surgeon
Mottrie et al, Eur Urol. 2010 Jul;58(1):127-32
Surgeons experience vs. OT, WIT, eBL, PC repair,
complications
Mottrie et al, Eur Urol. 2010 Jul;58(1):127-32
• 15 to 20 cases to reach average open pyeloplasty time
Sorenson et al, J Urol. 2011 Jun;185(6 Suppl):2517-22
20 cases to reach mean LAP time
- 30 sec per operation
Brunaud et al, Am J Surg. 2008 Apr;195(4):433-8
Operative time vs.
108 min 88 min123 min 92 min
- Skill of assistant- Surgeons experience
Brunaud et al, Am J Surg. 2008 Apr;195(4):433-8
Roadmap
Traditional concept of the Learning Curve
Partial Nephrectomy experienced robotic surgeon experienced laparoscopic surgeon
Pyeloplasty experienced open surgeon
Adrenalectomy OT junior vs. senior surgeon OT vs. skill of the assistant
How to shorten the curve Classical approach Surgical warm-up
New Concept of Learning curve
Surgical warm-up
“ Preoperative warm-up for 15 to 20 minutes with simple surgical exercises leads to a substantial increase in surgical skills proficiency during follow-up tasks ”
“ Even the most experienced can increase specific psychomotor skills associated with a laparoscopic environment by doing simple exercises on a virtual reality simulator, just before an operation. These improvements are reflected in more accurate handling of tissue during laparoscopic cholecystectomy ”
“ Warm-up in a virtual reality environment improves performance in the operating room ”
Kohol et al, J Am Coll Surg. 2009 Feb;208(2):255-68
Moldovanu et al, JSLS. 2011 Oct-Dec;15(4):533-8
Calatayud et al, Ann Surg. 2010 Jun;251(6):1181-5
Concept of parallel learning
Definition individual steps
Quantification of difficulty
Introduction of structured training program
Training of simpler steps first
Monitoring of progress
Dev et al, BJU Int 2012 Apr;109(7):1074-80
Ralp – Surgical Steps Patient hospital number Date Consultants case
Step
1 Patient positioning, port placement, docking
421014 10 Aug 2011DAG
1385036 16 Aug 2011DAG
1360097 16 Aug 2011DAG
2037929 8 Sep 2011DAG
788753 14 Sep 2011DAG
2 Bladder take down anterior fat
796467 17 Aug 2011DAG
530724 8 Sep 2011DAG
788759 14 Sep 2011DAG
1114316 19 Sep 2011EWR
1385039 18 Okt 2011 DAG
3 Division of endopelvic fascia and DVC
796467 17 Aug 2011DAG
1365089 23 Aug 2011DAG
1364939 25 Aug 2011DAG
Proposal of surgical steps
Patient positioning, access, port placement, docking
Bowel mobilization
Hilar dissection
Tumor identification
Hilar control
Tumor excision
Renal reconstruction, renorrhaphy
Specimen retrieval and closure