Incorporating Robotics in Gynecologic Oncology Training Programs
Abstract & Commentary
By Robert L. Coleman, MD, Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.
Dr. Roberts is a consultant to GlaxoSmithKline, Eli Lilly Co., Abbott Laboratories, Sanofi-Aventis, and Pfizer; and serves on the speakers bureaus for GlaxoSmithKline, Eli Lilly Co., and OrthoBiotech.
Synopsis: Gynecologic oncology surgical procedures are increasingly being performed under the assistance of robotic-based laparoscopic methods. Robotic training for surgeons already skilled in open and laparoscopic procedures has been successfully mapped; however, training algorithms for those unskilled in open and traditional laparoscopy are site-specific and yet to be validated. The current report details one institution's development and experience in bringing the faculty and fellow robotic skill set to standard practice.
Source: Hoekstra AV, et al. Robotic surgery in gynecologic oncology: Impact on fellowship training. Gynecol Oncol 2009;114:168-172.
Robotic surgical procedures are increasingly being incorporating into the surgical management of gynecologic cancers, particularly early-stage endometrial and cervical cancer. Training gynecologic oncology fellows in surgical robotics is a complex process and depends on the comfort level and skill sets of their mentoring faculty. Traditional educational methods are inefficient, if not severely limited in the contemporary surgical robotics platform. The current report details the process of introducing a robotics program into a gynecologic oncology fellowship program over a 12-month period. In this time frame, faculty were first credentialed in robotics followed by a structured fellow education process, which involved video review, porcine animal labs, case observation, and graduated skill mastery based in live cases. The proportion of patients undergoing laparoscopic management of early cervical and uterine cancer increased from 3% to 44% following the transition. Likewise, the proportion of cases used for instruction of endometrial cancer management changed from 94% open to 40% open; the remainder was 49% robotic and 11% laparoscopic. For early cervical cancer, the proportion was 100% open to 50% robotic. Fellow participation increased as the transition became more mature; at 12 months, more than 90% of the robotic cases incorporated fellows. The transition time from bedside assistant to console was 3 months. The authors concluded their systematic transition to a robotics program not only dramatically influenced their primary approach to early endometrial and cervical cancer, but also successfully broadened their fellowship training program to incorporate formal instruction in this technology. Structured and validated tools for surgical education remain outstanding challenges with wider adoption.
Commentary
Substantial experience in robotic surgery among gynecologic oncologists is mounting, principally due to more widespread availability of the equipment and heightened interest in the technology believed to deliver minimally invasive surgery to a wider audience compared to convention laparoscopy. The process of training skilled surgeons, some of whom are also expert laparoscopists, has been formalized to include equipment training/troubleshooting, video review of procedures, participation in proctored animal models, observation of live cases, operating room orientation, and structured proctoring during the first 5 independent cases. The process of introducing the technology into fellowship training is much less structured and is likely quite heterogeneous given the individual faculty investment in the technology and availability of the equipment. Further compounding the instructional process is the need to teach surgical procedures in patients with indications like celiotomy. While the latter process involves side-by-side instruction and a great deal of direct trainee oversight, the necessary limitations of the single-user surgical console for robotic surgery requires a different approach.
As is presented in the current article, the first commitment (alternative term: investment) made by the institution was the preface that the technology should be a part of the fellowship training process and practiced independently by all academic faculty. This ensured the exposure to robotic instruction would be more uniform, although the types of cases the instructing surgeon felt were appropriate could vary.
The second commitment made by this group was that fellows should observe, learn to assist, and graduate from simple to more complex aspects of the procedure before gaining more full-time console access. A facilitator in this process was the availability of a teleproctoring screen, which enabled more directed instruction. However, as discussed in the article, this is no substitute for hands-on assistance as used in open or traditional laparoscopic cases, though this may come with dual console systems in development. It is noteworthy that closure of the vaginal cuff, considered one of the more difficult aspects of traditional laparoscopic hysterectomy was considered a basic step in robotic hysterectomy — a statement to improved technology (manual degrees of freedom) from the instrumentation.
The third important commitment (promise) made by the faculty was that once their own training was complete, they would strive for trainee proficiency by fellowship completion, preparing them for independent functionality. Credentialing for this skill set is ambiguous but not surprising given the inconsistencies of credentialing in many hospital systems for other endoscopic skill sets. Nevertheless, the 12-month experiment to transition an entire fellowship training program to robotics successfully highlights the opportunity of bringing a new procedural skill set to standard practice.
Suggested Readings
- Seamon LG, et al. A detailed analysis of the learning curve: Robotic hysterectomy and pelvic-aortic lymphadenectomy for endometrial cancer. Gynecol Oncol 2009;114:162-167.
- Mabrouk M, et al. Trends in laparoscopic and robotic surgery among gynecologic oncologists: A survey update. Gynecol Oncol 2009;112:501-505.
- Veljovich DS, et al. Robotic surgery in gynecologic oncology: Program initiation and outcomes after the first year with comparison with laparotomy for endometrial cancer staging. Am J Obstet Gynecol 2008;198:679.e1-e9.
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