Robotic surgical training: Where are we?

Highlights

• Proficiency with robotic hysterectomy and lymphadenectomy occurs after the first 20–30 cases.

• Mastery does not occur until much later.

• The learning curve for robotic surgery is comparable between fellows and attending physicians.

• Most robotic educational curriculums incorporate a didactic and a graduated hands-on experience.

Abstract

Background and objective

Over the past 10 years, robotic surgery has revolutionized the advancement of MIS in gynecologic oncology. As the use of robotic surgery has increased, so has the interest in the surgical training of gynecologic oncology fellows. The purpose of this review is to summarize the state of robotic surgical education in Gynecologic Oncology.

Methods

Several electronic databases were searched to identify studies that discussed robotic surgical education in gynecologic oncology. Particular attention was given to articles that discussed educational curriculum. The various curriculums were compared and summarized.

Results

The first reports of robotic surgery curriculums in gynecologic oncology emerged in 2008. Prior to that the early adapters had to rely on less structured curriculums that essentially used live animal models and cadaveric dissections on the robot to simulate live surgery. More recent surgical curriculums are more structured and include the same basic components: didactics and a graduated hands-on experience. There is also an accredited robotic educational curriculum, the Fundamentals of Robotic Surgery (FRS), which combine an on-line curriculum with dry lab and operating room components that can be scored using a validated assessment tool.

Conclusions

Robotic surgical education has come a long way in the decade that the robotic platform has been available in the U.S. Although there is still no standardized curriculum, most fellowship training programs in gynecologic oncology have fairly consistent training. Simulation training is another tool that can help a surgeon achieve proficiency quicker.

Introduction

The role of minimally invasive surgery (MIS) in gynecologic cancers was initially described in the 1990s with the first reports of laparoscopic lymphadenectomy for gynecologic malignancies by Childers et al. [1], [2], [3], [4]. Although the concept of MIS was innovative, and had clear potential advantages, it required a great deal of “laparoscopic dexterity” that was simply not taught in gynecologic oncology fellowship training programs at the time. As a result, only a few centers had surgeons with the skills to perform such procedures, resulting in a slow uptake of the use of MIS in gynecologic oncology. However, as technology improved, interest in MIS grew, and as gynecologic fellowship training programs incorporated MIS training, more centers were able to perform MIS for gynecologic malignancies. The uptake of this technology was slow and far from universal. It was not until the emergence of robotic technology that MIS was universally adopted. In the 2015 state of the subspecialty report, the Society of Gynecologic Oncology reported that over 99% of gynecologic oncologists now perform MIS [5].

Over the past 10 years, the advancement of robotic surgery has revolutionized MIS in gynecologic oncology. In 2005, the da Vinci Surgical System by Intuitive Surgical Inc. was approved by the Food and Drug Administration (FDA) for gynecologic surgery. Compared to conventional laparoscopy, robotic surgery incorporates 3-dimensional stereoscopic vision and ‘wrist-like’ instrumentation with improved dexterity and precision. This technology allowed for a broader adoption of MIS, because of the improved user comfort and ‘ease of use’ of the da Vinci Surgical System. There is no better example of this than the use of MIS for radical hysterectomy in the United States, which prior to the introduction of robotic surgery was performed by very few highly experienced laparoscopic surgeons. As the robotic surgical platform gained popularity and became universally adopted, MIS became an ideal option for the treatment of early stage cervical cancer and for staging of endometrial cancer [6], [7], [8].

As the use of robotic surgery in gynecologic oncology increased, so has the interest in the surgical training of gynecologic oncology fellows. In a recent survey of U.S. gynecologic oncology fellowship directors, 95% of institutions report utilizing robotic surgery; and 94% of the responding gynecologic oncology fellows in training plan to perform robotic surgery in their independent practice after fellowship [9]. The Society of Gynecologic Oncology (SGO) acknowledges the importance of MIS training, specifically robotic surgery, in the development of gynecologic oncologists that are proficient in both robotic and conventional laparoscopy [8]. However, there is currently not a clear “standard of training” for robotic surgery. Each individual gynecologic oncology fellowship training program relies on their own institutional training guidelines.