The introduction of an emergency safety protocol coupled with simulation training in robotic surgery, has enabled a more cohesive and efficient response to emergencies.

With the increasing popularity of robotic surgery, arise a unique set of challenges. In-order to minimise the risk and optimise patient safety, teams need to anticipate these, plan and train to improve familiarity with the nuances of robotic surgery. Human factors and simulation training (ST) are now an integral part of surgery and we have extended these principles to our robotic practice. From our experience with emergencies and a thorough debrief, we have realised the importance of an emergency safety protocol (ESP) for the undocking of the robot, and how training with the correct systems in place optimises our non-technical skills and improves our efficiency. This protocol is used across all robotic specialties allowing for clear communication, situational awareness and role clarity, thereby reducing errors in a high-pressured environment. We aim to share our protocol, highlight the importance of ST and show that coupling of the ESP with ST, including addressing a disrupted power supply and how to avoid the resulting loss of image capture, is where our paper contributes to the current literature. There is a paucity in the literature regarding emergency undocking, and also techniques for avoiding power interruptions, for which we utilise the Uninterruptible Power Supply (UPS) system. By sharing experiences and systems used, we create an opportunity that will result in a culture of shared learning in the robotic community, thereby encouraging other robotic teams to review their protocols and training practices and adapt as necessary.

Emergency Undocking Curriculum in Robotic Surgery.

Introduction Traditional instruction for robotic surgery is typically devoid of training that addresses the delineation of interprofessional roles for operating room personnel. An emergency undocking scenario was developed for robotic surgeons with the objectives of improving time to access the patient, provider knowledge of and confidence in emergency undocking, completion of predetermined critical actions, and delineation of operating room personnel roles. Methods Over one month, participants joined in three sessions: Session 1 - formative, Session 2 - review, and Session 3 - summative. Embedded standardized participants (ESPs) represented members of the interprofessional team. Prior to entering the operating room for Sessions 1 and 3, trainees were asked to complete a confidence survey and multiple choice questionnaire (MCQ) for knowledge assessment. Participants were randomized to one of two cases and participated in the reciprocal case for the final session four weeks later. Following Session 1, participants underwent an educational intervention, including the proper technique for emergency undocking, emphasis on operating room personnel roles, and hands-on practice. Obstetrics and Gynecology (OBGYN) residents in post-graduate Years 2-4 and attending physicians with robotics privileges at Summa Health Akron Campus or Cleveland Clinic Akron General Medical Center were invited to participate. A total of 21 participants enrolled and finished the study. Results Among the 21 participants, there was a significant increase in the baseline level of knowledge (p-value=0.001) and in the confidence of surgeons when faced with an emergency undocking after the completion of our curriculum (p-value=0.003). Additionally, an improvement in the undocking times (p-value<0.001) and an increase in the critical actions performed (p-value=0.002) were observed. Conclusion The results of this study demonstrate that incorporating this curriculum into the training programs of robotic surgeons is an effective way to improve the surgical skill of emergency undocking.

DUckCov: a Dynamic Undocking-Based Virtual Screening Protocol for Covalent Binders.

Thanks to recent guidelines, the design of safe and effective covalent drugs has gained significant interest. Other than targeting non-conserved nucleophilic residues, optimizing the noncovalent binding framework is important to improve potency and selectivity of covalent binders toward the desired target. Significant efforts have been made in extending the computational toolkits to include a covalent mechanism of protein targeting, like in the development of covalent docking methods for binding mode prediction. To highlight the value of the noncovalent complex in the covalent binding process, here we describe a new protocol using tethered and constrained docking in combination with Dynamic Undocking (DUck) as a tool to privilege strong protein binders for the identification of novel covalent inhibitors. At the end of the protocol, dedicated covalent docking methods were used to rank and select the virtual hits based on the predicted binding mode. By validating the method on JAK3 and KRas, we demonstrate how this fast iterative protocol can be applied to explore a wide chemical space and identify potent targeted covalent inhibitors.

Docking-undocking combination applied to the D3R Grand Challenge 2015.

Novel methods for drug discovery are constantly under development and independent exercises to test and validate them for different goals are extremely useful. The drug discovery data resource (D3R) Grand Challenge 2015 offers an excellent opportunity as an external assessment and validation experiment for Computer-Aided Drug Discovery methods. The challenge comprises two protein targets and prediction tests: binding mode and ligand ranking. We have faced both of them with the same strategy: pharmacophore-guided docking followed by dynamic undocking (a new method tested experimentally here) and, where possible, critical assessment of the results based on pre-existing information. In spite of using methods that are qualitative in nature, our results for binding mode and ligand ranking were amongst the best on Hsp90. Results for MAP4K4 were less positive and we track the different performance across systems to the level of previous knowledge about accessible conformational states. We conclude that docking is quite effective if supplemented by dynamic undocking and empirical information (e.g. binding hot spots, productive protein conformations). This setup is well suited for virtual screening, a frequent application that was not explicitly tested in this edition of the D3R Grand Challenge 2015. Protein flexibility remains as the main cause for hard failures.

Da Vinci robot emergency undocking protocol.

The role of robot-assisted surgery across gynaecology is evolving with increasing numbers of procedures being undertaken with varying degrees of complexity. While the risk of conversion is low at approximately 1 %, the reasons for conversion are variable. These range from technical issues with the robot, surgical complications such as haemorrhage and anaesthetics issues such as an inability to ventilate the patient adequately. While many conversions to open or laparoscopic approach are not due to life-threatening indications, it is important that the theatre staff are aware of the indication and can perform an emergency undocking as effectively, efficiently and safely as possible when the need arises. Unfortunately, there is a paucity of the literature available outlining such protocols. For this reason, we developed an emergency undocking protocol clearly outlining the role of each theatre staff member and the need for clear concise communication.