Consensus guidelines on the bedside assistant skills required in robotic surgery.

BACKGROUND: While bedside assistants play a critical role in many robotic operations, substantial heterogeneity remains in bedside assistant training pathways. As such, this study aimed to develop consensus guidelines for bedside assistant skills required for team members in robotic operations. METHODS: We designed a study using the Delphi process to develop consensus guidelines around bedside assistant skills. We generated an initial list of bedside assistant skills from the literature, training materials, and expert input. We selected experts for the Delphi process based on prior scholarship in the area of robotic bedside assistant education and experience facilitating robotic bedside assistant training. For each item, respondents specified which robotic team members should have the skill from a list of "basic" bedside assistants, "advanced" bedside assistants, surgeons, surgical technologists, and circulating nurses. We conducted two rounds of the Delphi process and defined 80% agreement as sufficient for consensus. RESULTS: Fourteen experts participated in two rounds of the Delphi process. By the end of the second round, the group had reached consensus on 253 of 305 items (83%). The group determined that "basic" bedside assistants should have 52 skills and that "advanced" bedside assistants should have 60 skills. The group also determined that surgeons should have 54 skills, surgical technologists should have 25 skills, and circulating nurses should have 17 skills. Experts agreed that all participants should have certain communication skills and basic knowledge of aspects of the robotic system. CONCLUSIONS: We developed consensus guidelines on the skills required during robotic surgery by bedside assistants and other team members using the Delphi process. These findings can be used to design training around bedside assistant skills and assess team members to ensure that each team member has the appropriate skills. Hospitals can also use these guidelines to standardize expectations for robotic team members.

Comparing observed and preferred instruction in robotic surgery.

BACKGROUND: The unique setup of robotic surgery challenges the traditional instructional dynamic between surgical learners and teachers. Previous studies have posited difficulties such as reliance on observational learning and ease of takeover. However, we lack understanding of how these instructional challenges manifest and are perceived by learners. Improving instruction has the potential to optimize education and performance in robotic surgery. METHODS: In this qualitative study, we conducted robotic case observations and learner interviews focusing on instruction in robotic surgery. We deductively generated codes in a theory-informed manner after review of the instructional literature in surgery, medicine, and other fields. We applied these codes in a rigorous directed content analysis of field notes and transcripts to identify themes. RESULTS: Thirty-eight faculty, fellows, and residents participated in 10 robotic cases and 20 semistructured interviews. Observed practices on the basis of case observations differed substantially from preferred practices on the basis of interview data. Using 37 codes, we identified 4 main themes related to instruction in robotic surgery: contextualization, individualization, autonomy, and multimodality. We contrasted observed and preferred instruction in each of these areas to generate instructional considerations that may better align preferences and practices. CONCLUSIONS: We observed several suboptimal instructional practices that contradicted preferred ways of learning. We suggested robotic-specific instructional considerations such as using multimodality to promote active learning and to reduce ambiguity. We also provided considerations applicable to all types of surgery, such as to include rationale to promote learning consolidation and to frame operative steps to allow trainees to plan their participation.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition.

OBJECTIVE: Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback. DESIGN: We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis. SETTING: We performed this study at a single tertiary academic institution: the University of California, San Francisco. PARTICIPANTS: We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment. RESULTS: Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment. CONCLUSIONS: We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.

Student challenges during third-year perioperative clerkships through the lens of faculty and residents: A qualitative study.

PURPOSE: Studies of medical students suggest they often find the transition from the pre-clinical curriculum to clinical rotations particularly challenging during perioperative clerkships. Educators could add a new perspective into students' clerkship experiences and potential interventions to improve them. The purpose of this study was to examine the educator perspective on students' experiences in perioperative clerkships. The findings could inform potential curricular interventions to facilitate student transition from a didactic environment into perioperative clerkships. METHODS: Semi-structured qualitative interviews were conducted with 16 faculty and residents in the departments of anaesthesia, obstetrics and gynaecology (OBGYN), and general surgery across multiple clinical teaching sites at one institution. Interview questions explored their perceptions of the challenges students face during their transition into perioperative clerkships and probed thoughts on curriculum interventions they believed would be the most beneficial. Interviews were recorded, transcribed and analysed thematically. FINDINGS: Three themes were identified. Faculty and residents perceive that student experiences on perioperative clerkships are shaped by (1) students' ability to adapt to the specialty and operating room norms on these clerkships, (2) students' understanding of how they can meaningfully contribute to the clinical team, and (3) dedicated teaching time constraints. Interventions were suggested to address educator expectations and student gaps, such as implementing a pre-clerkship orientation across anaesthesia, general surgery and OBGYN. CONCLUSIONS: To facilitate the medical student transition to perioperative clerkships, interventions should aid students in adapting to clerkship norms for these specialties and clarifying their role and expectations within the care team.

Home practice for robotic surgery: a randomized controlled trial of a low-cost simulation model.

Pre-operative simulated practice allows trainees to learn robotic surgery outside the operating room without risking patient safety. While simulation practice has shown efficacy, simulators are expensive and frequently inaccessible. Cruff (J Surg Educ 78(2): 379-381, 2021) described a low-cost simulation model to learn hand movements for robotic surgery. Our study evaluates whether practice with low-cost home simulation models can improve trainee performance on robotic surgery simulators. Home simulation kits were adapted from those described by Cruff (J Surg Educ 78(2): 379-381, 2021). Hand controllers were modified to mimic the master tool manipulators (MTMs) on the da Vinci Skills Simulator (dVSS). Medical students completed two da Vinci exercises: Sea Spikes 1 (SS1) and Big Dipper Needle Driving (BDND). They were subsequently assigned to either receive a home simulation kit or not. Students returned two weeks later and repeated SS1 and BDND. Overall score, economy of motion, time to completion, and penalty subtotal were collected, and analyses of covariance were performed. Semi-structured interviews assessed student perceptions of the robotic simulation experience. Thirty-three medical students entered the study. Twenty-nine completed both sessions. The difference in score improvement between the experimental and control groups was not significant. In interviews, students provided suggestions to increase fidelity and usefulness of low-cost robotic home simulation. Low-cost home simulation models did not improve student performance on dVSS after two weeks of at-home practice. Interview data highlighted areas to focus future simulation efforts. Ongoing work is necessary to develop low-cost solutions to facilitate practice for robotic surgery and foster more inclusive and accessible surgical education.

Robotic training for medical students: feasibility of a pilot simulation curriculum.

While robotic procedures are growing rapidly, medical students have a limited role in robotic surgeries. Curricula are needed to enhance engagement. We examined feasibility of augmenting Intuitive Surgical (IS) robotic training for medical students. As a pilot, 18 senior students accepted an invitation to a simulation course with a daVinci robot trainer. Course teaching objectives included introducing robotic features, functionalities, and roles. A 1-h online module from the IS learning platform and a 4-h in-person session comprised the course. The in-person session included an overview of the robot by an IS trainer (1.5 h), skills practice at console (1.5 h), and a simulation exercise focused on the bedside assist role (1 h). Feasibility included assessing implementation and acceptability using a post-session survey and focus group (FG). Survey responses were compiled. FG transcripts were analyzed using inductive thematic analysis techniques. Fourteen students participated. Implementation was successful as interested students signed up and completed each of the course components. Regarding acceptability, students reported the training valuable and recommended it as preparation for robotic cases during core clerkships and sub-internships. In addition, FGs revealed 4 themes: (1) perceived expectations of students in the OR; (2) OR vs. outside-OR learning; (3) simulation of stress; and (4) opportunities to improve the simulation component. To increase preparation for the robotic OR and shift robotic training earlier in the surgical education continuum, educators should consider hands-on simulation for medical students. We demonstrate feasibility although logistics may limit scalability for large numbers of students.

Assessment of Surgeon Performance of Advanced Open Surgical Skills Using a Microskills-Based Novel Curriculum.

Importance: The increase in minimally invasive surgical procedures has eroded exposure of general surgery residents to open operations. High-fidelity simulation, together with deliberate instruction, is needed for advanced open surgical skill (AOSS) development. Objective: To collect validity evidence for AOSS tools to support a shared model for instruction. Design, Setting, and Participants: This prospective cohort study included postresidency surgeons (PRSs) and second-year general surgery residents (R2s) at a single academic medical center who completed simulated tasks taught within the AOSS curriculum between June 1 and October 31, 2021. Exposures: The AOSS curriculum includes 6 fine-suture and needle handling tasks, including deep suture tying (with and without needles) and continuous suturing using the pitch-and-catch and push-push-pull techniques (both superficial and deep). Teaching and assessment are based on specific microskills using a 3-dimensional printed iliac fossa model. Main Outcomes and Measures: The PRS group was timed and scored (5-point Likert scale) on 10 repetitions of each task. Six months after receiving instruction on the AOSS tasks, the R2 group was similarly timed and scored. Results: The PRS group included 14 surgeons (11 male [79%]; 8 [57%] attending surgeons) who completed the simulation; the R2 group, 9 surgeons (5 female [55%]) who completed the simulation. Score and time variability were greater for the R2s compared with the PRSs for all tasks. The R2s scored lower and took longer on (1) deep pitch-and-catch suturing (69% of maximum points for a mean [SD] of 142.0 [31.7] seconds vs 77% for a mean [SD] of 95.9 [29.4] seconds) and deep push-push-pull suturing (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 85% for a mean [SD] of 141.4 [29.1] seconds) relative to the corresponding superficial tasks; (2) suture tying with a needle vs suture tying without a needle (74% of maximum points for a mean [SD] of 64.6 [19.8] seconds vs 90% for a mean [SD] of 54.4 [15.6] seconds); and (3) the deep push-push-pull vs pitch-and-catch techniques (63% of maximum points for a mean [SD] of 284.0 [72.9] seconds vs 69% of maximum points for a mean [SD] of 142.0 [31.7] seconds). For the PRS group, time was negatively associated with score for the 3 hardest tasks: superficial push-push-pull (ρ = 0.60; P = .02), deep pitch-and-catch (ρ = 0.73; P = .003), and deep push-push-pull (ρ = 0.81; P < .001). For the R2 group, time was negatively associated with score for the 2 easiest tasks: suture tying without a needle (ρ = 0.78; P = .01) and superficial pitch-and-catch (ρ = 0.79; P = .01). Conclusions and Relevance: The findings of this cohort study offer validity evidence for a novel AOSS curriculum; reveal differential difficulty of tasks that can be attributed to specific microskills; and suggest that position on the surgical learning curve may dictate the association between competency and speed. Together these findings suggest specific, actionable opportunities to guide instruction of AOSS, including which microskills to focus on, when individual rehearsal vs guided instruction is more appropriate, and when to focus on speed.

Expertise in perception during robotic surgery (ExPeRtS): What we see and what we say.

BACKGROUND: Given the challenges of teaching in robotic operating rooms, we sought to investigate the language of perceptual expertise used by robotic surgeons, in an effort to improve current approaches to robotic training. METHODS: Expert robotic surgeons reviewed 8 anonymous video clips portraying key portions of two robotic general surgery procedures and their comments were recorded and transcribed. Using content analysis, each transcript was double-coded and reconciled using a consensus developed codebook. RESULTS: Seventeen expert robotic surgeons participated and comments formed two primary themes: visual comprehension and surgical technique. Surgeons minimally used tactile language. Risk avoidance was a second-order theme dominating language used. CONCLUSIONS: Experts occasionally used tactile language and emphasized risk avoidance as they observed robotic surgery. Despite the need to communicate perceptual expertise to trainees in robotic surgery, tactile language was not exhibited by expert surgeons, revealing an important future area of focus for intraoperative teaching skills.

How Do Clinical Electives during the Clerkship Year Influence Career Exploration? A Qualitative Study.

Problem: Although many students begin medical school with some idea of their specialty interest, up to 80% of these students choose a different specialty by their final year. This pivot tends to happen in the clerkship year, when students are immersed in the clinical environment, gaining a practical understanding of the day-to-day work in different fields. Yet, in this year students have limited experiences with specialties. Clinical electives during the clerkship year may aid students in career development. The authors examined student career exploration through the lens of social cognitive career theory (SCCT). SCCT posits three variables that influence career development: personal goals, self-efficacy, and understanding outcome expectations. With this framework, the authors sought to understand how a program of clinical electives during the clerkship year influences students' perceptions of their career exploration. We aimed to: (1) describe an innovative clerkship elective program designed for career exploration, and (2) explore how this influenced students' career exploration using qualitative analysis. Intervention: Beginning in 2018, students at our institution were required to participate in three 2-week clinical electives during their clerkship year, called Clinical Immersive Experiences (CIExes). CIExes were categorized into four different types: apprenticeship, clinical skills building, integrative (multi-disciplinary), or subspecialty. Authors invited fourth year students to participate in interviews (January to March 2019) about how they selected electives and how these electives contributed to their career exploration. Interviews continued until reaching information sufficiency. Authors coded and analyzed transcripts using template analysis. Context: This curricular intervention took place in the context of large-scale curricular redesign. Students began clerkships partway into their second year of medical school. The family and community medicine clerkship, which was previously a 6-week core clerkship, was changed to a longitudinal format, thus freeing up 6 weeks for electives. Other core clerkships included anesthesia (2 weeks), medicine (8 weeks), neurology (4 weeks), obstetrics and gynecology (6 weeks), pediatrics (6 weeks), psychiatry (4 weeks), and surgery (8 weeks). Impact: From 15 student interviews, we identified three major themes. First, CIExes facilitated personalized career exploration. All students felt that at least one elective helped them solidify their decision about a specialty choice. Second, CIExes promoted focused learning and skills development that complemented core rotations. They noted the benefit of positive relationships with supervisors, particularly attendings, during these electives. Third, students highlighted how these electives fostered a positive learning environment and enhanced wellbeing. SCCT clarified how the CIEx program helped students advance their personal goals, self-efficacy, and outcome expectations during a pivotal time in medical school. Lessons Learned: We learned that from the student perspective, the inclusion of clinical electives in the clerkship year benefited students' career exploration by helping them develop and refine their career goals, increase self-efficacy, and test outcome expectations in a meaningful way as anticipated from SCCT. In addition, we found that CIExes created a positive learning environment that allowed deep relationships to develop in fields of interest and that supported a strong sense of wellbeing. Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1891545.

"There Is a Lot of Change Afoot": A Qualitative Study of Faculty Adaptation to Elimination of Tiered Grades With Increased Emphasis on Feedback in Core Clerkships.

PURPOSE: Medical schools responding to challenges with fairness, equity, learning environments, and student wellness have reconsidered clerkship grades. This study used the Concerns-Based Adoption Model (CBAM) to explore how faculty responded to a change in the approach to assessment from focus on grades toward focus on feedback. METHOD: This qualitative study used an inductive approach to analyze data from semistructured interviews with teaching faculty and education leaders at University of California, San Francisco, School of Medicine 6 months following the elimination of traditional tiered clerkship grades. Participants were recruited in 2019 using purposive sampling. Interview questions addressed participants' perceptions of the new approach to assessment and grading that emphasizes assessment for learning, including advantages and concerns. The authors analyzed data using thematic analysis informed by sensitizing concepts from CBAM. RESULTS: Nineteen faculty participated (11 medicine, 8 surgery). Faculty expressed optimism about the impact of the change on their clinical educator roles and sought faculty development to enhance feedback and assessment skills. Perceived benefits to students addressed learning and wellness, with concern for students' motivation and professional development. Faculty shared uncertainty about their roles and larger systemic consequences involving the residency match and institutional reputation. Participants acknowledged that traditional grading is imperfect, yet felt a departure from this system represented significant culture change. CONCLUSIONS: Faculty perceptions of the assessment and grade change in 2 large departments demonstrated tensions around grading. Their descriptions of change as an ongoing process aligned with CBAM and required them to consider new approaches and perspectives. While discourse about assessment and grading frequently focuses on learners, these findings support institutional consideration of the impact of changes in assessment on teaching faculty.

Near-Peer Learning During the Surgical Clerkship: A Way to Facilitate Learning After a 15-Month Preclinical Curriculum.

OBJECTIVES: To investigate the performance and perspectives of third-year medical students (MS3s) participating in near-peer learning (NPL) sessions during their core surgical clerkship following a 15-month preclerkship curriculum. DESIGN: An evaluation study of 7 NPL sessions developed and implemented by fourth-year medical students (MS4s) held from March 2019 to February 2020. MS4s taught 1-2 sessions per rotation that included test taking strategies, illness script development, radiology review, case-based multiple-choice questions, and rapid review. Participants completed a questionnaire with 11 seven-point Likert and open-ended questions after each session. Analyses included quantitative comparison of shelf score averages between NPL participants and nonparticipants and qualitative content analysis for open-ended questions. SETTING: Surgical clerkship at the University of California, San Francisco. PARTICIPANTS: Forty-eight (32%) MS3s participated, with an average attendance of 10 students per rotation. Thirty-three (69%) participants completed the questionnaire. RESULTS: MS3s enjoyed the session (6.9 ± 0.4), improved their knowledge (6.8 ± 0.5), and felt more prepared for the surgery shelf examination (6.5 ± 0.6). MS4 leaders found that MS3s always wanted radiology review, and their interest in test taking strategies and illness script development declined across the clerkship year. Participants had lower shelf exam scores compared to nonparticipants (68.1 vs 71.4, respectively; p = 0.04, ES = 0.03). Shelf exam scores increased over time in both cohorts. Each group had 2 shelf exam failures. Qualitative analysis suggests that MS3s appreciated the NPL's tailored approach and exam demystification, with a desire for increased NPL integration into the clerkship. CONCLUSION: Students participating in NPL were satisfied with the sessions. Participants may have been students who struggled as indicated by shelf exam scores and appreciated the support. The shift in preferred topics across the blocks reflects the students' development during clerkships. Near-peer teachers should adjust sessions over time to fit students' evolving needs.

Enhancing Operative Feedback: A Descriptive Trajectory for Surgical Development in Otolaryngology.

OBJECTIVE: Developmental frameworks are narrative descriptions of learner performance that may be useful to provide operative feedback tools in surgical education. The authors previously proposed the Technician, Anatomist, Anticipator, Strategist, Executive (TAASE) framework utilizing data collected from general surgeons and conjectured its applicability in other surgical specialties. Here, we construct a developmental framework in otolaryngology using similar techniques, then compare the results to TAASE. DESIGN: Ten otolaryngology educators participated in semi-structured, audio-recorded interviews, to explore how otolaryngology faculty characterize surgical learning at different levels of training. Researchers analyzed the transcripts using a thematic analysis approach to build a developmental framework. Results were then qualitatively compared to the TAASE trajectory. SETTING: Single tertiary academic medical center. PARTICIPANTS: Faculty within the Department of Otolaryngology-Head and Neck Surgery. RESULTS: Otolaryngology faculty characterized surgical development as an integrated trajectory of technical and cognitive skills progressing from specific operative tasks to a global understanding of patients and procedures largely consistent with stages outlined in the Technician, Anatomist, Anticipator, Strategist, and Executive model. A new theme identified was learner emotions, which may impact learning and hinder or enhance progression along the trajectory. CONCLUSIONS: Otolaryngology and general surgeons agree upon a common arc to operative maturity reflected by the TAASE trajectory. The TAASE framework may be useful as a tool for intraoperative assessment in otolaryngology to help promote quality feedback. Further research is needed to understand how emotions may influence operative skill development.

Trainee perception of cognitive load during observed faculty staff teaching of procedural skills.

OBJECTIVES: Although teachers impact learners' cognitive load, how specific teaching activities affect intrinsic, germane and extraneous load during procedural skills training is unknown. We sought to characterise teaching activities used in the exemplar procedural setting of colonoscopy, and to explore how they were enacted and how learners perceived them as affecting intrinsic, germane and extraneous cognitive load. METHODS: We observed 10 colonoscopies performed by eight different gastroenterology fellows and supervised by 10 different attending physicians at two hospitals, and recorded the teaching activities observed, as well as details of when they were used and how they were enacted. After the colonoscopy, each fellow completed the Cognitive Load Inventory for Colonoscopy to quantify intrinsic, germane and extraneous load. We then interviewed each fellow to determine how he or she perceived teaching as affecting cognitive load. Qualitative data were subjected to content analysis. Instances of germane load-promoting activities were correlated with measured germane load. RESULTS: We observed 515 instances of teaching activities. The intensity of teaching varied substantially, ranging from 0.7 to 3.3 activities per minute, as did the pattern of teaching activities used by different attending physicians. Little teaching occurred immediately before or after a procedure. Fellows usually perceived teaching as affecting cognitive load in ways that promoted learning, particularly by reducing intrinsic load and increasing germane load. Fellows strongly perceived that the provision of autonomy promoted germane load. Conversely, fellows perceived that excessive teaching increased extraneous load. Instances of germane load-promoting teaching activities correlated moderately with measured germane load. CONCLUSIONS: Teaching in the exemplar procedural setting of colonoscopy affected learners' cognitive load in mostly beneficial ways, yet even 'good' teaching activities had detrimental effects when used excessively. Teachers of procedures should consider learner experience, task complexity and environmental factors to modulate the modality, content and intensity of teaching to promote balanced cognitive load and learning. Teaching more reservedly during the procedure and taking advantage of pre- and post-procedure opportunities may help.

Integrating Robotic Technology Into Resident Training: Challenges and Recommendations From the Front Lines.

PURPOSE: To develop recommendations for improving the integration of robotic technology into today's apprentice-based resident training. METHOD: During a national meeting in 2017, 24 robotic surgeons were interviewed about their experiences integrating robotic technology into resident training. Qualitative thematic analysis of interview notes and recordings revealed themes related to challenges and recommendations. RESULTS: Four themes emerged, each corresponding to a general recommendation for integrating robotic technology into training. The first, surgical techniques versus tools, contrasts faculty's sequential mastery-surgical techniques first, then the robotic tool-with residents' simultaneous learning. The recommendation is to create separate learning opportunities for focused skill acquisition. The second theme, timing of exposure to the robotic tool, describes trainees' initial focus on tool use for basic surgical steps. The recommendation is to increase access to basic robotic cases. The third theme covers the relationship of laparoscopic and robotic surgery. The recommendation is to emphasize similar and dissimilar features during all minimally invasive surgical cases. The fourth theme, use of the dual console (which enables two consoles to operate the robot, the primary determines the secondary's functionality), highlights the unique teaching opportunities this console creates. The recommendation is for surgeons to give verbal guidance so residents completely understand surgical techniques. CONCLUSIONS: Surgical educators should consider technique versus tool, timing of exposure to the tool, overlapping and varying features of robotic and laparoscopic surgery, and use of the dual console as they develop curricula to ensure thorough acquisition and synthesis of all elements of robotic surgery.

A robotic teaching session: separating tool from technique to emphasize a cognitive focused teaching environment.

Most robotic curriculum requires simulation on a console prior to operative exposure. This practice does not permit experiencing the physical collisions with the robotic tools, which occurs during surgery. We designed and evaluated an innovative curriculum to address cognitive components and trouble-shoot robotic collisions when the surgeon lacks haptic feedback. We adapted our previous curriculum, designed to teach and document proficiency of robotic docking and instrument exchange, to include robotic collisions. Participants received a 10-min, didactic presentation describing finger grips, internal and external collisions, and instruction on how to trouble-shoot each type. Residents worked in pairs, one at the console and the other at bedside, to complete two simulation exercises. Participants manipulated the robot to determine how best to resolve the situations. Residents completed retrospective post-course surveys and instructors completed a final survey. For comparison, non-participants, PGY-matched surgical trainees, also completed a survey. All participants demonstrated proficiency in docking and instrument exchange. Compared to pre-session, post-session knowledge and confidence improved in five domains reflecting session objectives (p < 0.05). Participants could list and troubleshoot collisions more than the non-participant matched peers (p < 0.05). Instructors supported the additional collision components, but noted learners needed more time. Two of three non-participants expressed interest in a teaching session to address these components. Collisions occur using robotic technology and rarely get addressed in surgical training. We describe an opportunity for surgeons to trouble-shoot robotic collisions in a safe, simulated environment. This easily transferable curriculum represents one of the first industry-independent robotic teaching sessions for surgical trainees.

Microanalysis of video from a robotic surgical procedure: implications for observational learning in the robotic environment.

Without haptic feedback, robotic surgeons rely on visual processing to interpret the operative field. To provide guidance for teaching in this environment, we analyzed intracorporeal actions and behaviors of a robotic surgeon. Six hours of video were captured by the intracorporeal camera during a robot-assisted lower anterior resection. After complete review, authors reduced the video to a consecutive 35 min of highly focused robotic activity and finally, a 2-min clip was subjected to microanalysis. The clip was replayed multiple times (capturing 1, 2, 10, 60 and 120 s intervals) and activities were identified, such as right and left hand motion, tissue handling and camera adjustments recorded using a software program. Activity patterns were categorized into two main themes: change in operative focus occurs when there is an inability to obtain adequate tension, and observation of robot-assisted surgery is based on an incomplete visual framework. The surgeon manipulated tissue predominantly using blunt adjustments and rarely grasped it, likely as a way to avoid tissue trauma. A magnified operative field required precise dissection, which occurs robotically with movement of a single instrument against a static field (motionless second robotic arm). This meticulous technique is unlike the bimodal manipulation often used for laparoscopic dissection. Since residents have limited active participation in robotic cases, and therefore, rely heavily on the captured image for skill acquisition, we recommend surgeons to use focus shifts as an opportunity to describe their operative decision-making and highlight instrument manipulations specific to operating with robotic technology.