As an engineer by training, it makes my ears hurt to hear about “robotic surgery.” A robot, by definition, is completely automated and does not require the real-time input of a human to perform its task. Think “Terminator”, “R2D2”, or the more common assembly line robot in an automobile factory that welds the same chassis frame over and over again. Robotic surgery, when we arrive there, is when you can select the program for “Appendectomy” and the robot does the operation by itself. What we currently have is robotic-assisted surgery. The use of these machines in residency training is the focus of this blog.
There are many opinions on the clinical value of using a “robot” for performing surgery and the clinical benefit is debatable. A final conclusion may not come for some time, but is the focus of many panel-discussions, social media forums, and conferences that we hold every year. As a disclaimer, I have no conflicts of interest to disclose with regards to these machines. I do not currently use these platforms in my clinical practice. I am not technology contrarian either, as I was greatly involved in NOTES research back in the late 2000’s and am currently active in device development. I do serve as a Residency Program Director, and therefore, try to stay in tune with the needs of my residents as they progress through their training. These opinions are strictly mine, and do not represent the AAS, the University of New Mexico, or any other organizations I am a member of. My perspectives and comments are also from the view of General Surgery training alone.
Without a doubt, whether you are a fan or not, these “robots” are part of the clinical world we work in and are here to stay. To that end, we must acknowledge that our surgical trainees need exposure to these platforms. They will encounter them in practice and may become some of the primary users at their hospital. Hospitals, as they make new hires, are inquiring about experience with these machines. Trainees are asking about “robotics” training on the interview trail. So the questions become: Is it my responsibility as an academic faculty or residency program director to provide them with exposure and training? How much exposure do residents need/get? How do I provide these experiences?
I do believe it is our responsibility to provide exposure to our trainees. Most training institutions have at least one “robot” (likely used primarily by urology and gynecology, and depending on your institution, maybe general surgery too). Therefore, I think residents should have an opportunity to at least sit at a console, use a simulator, or observe the machine in action. There is no better way for a surgeon to see if there is value in a device than to see it and try it first-hand to make their own decision.
Is it our responsibility to provide certification and competency training? At this point, I would say “no”. These machines, while gaining traction, have not permeated general surgery sufficiently to make the argument for the residency programs to train residents to a certain standard. Perhaps, when the American Board of Surgery suggests that we need a defined category for “Robotic-assisted Surgery” should we consider providing proficiency training in this area. For now, I think residents have more to gain by learning good laparoscopic port placement and efficient laparoscopic execution as they are translatable skills for “robotic” surgery. At minimum I recommend that residents have training in a skills lab on a robotic simulator. In addition, they should spend a day observing a robotic-assisted case from start to finish. To gain adequate console time to become proficient, especially when attending surgeons are still learning or when there is not access to multi-console systems, is challenging. The resident gains very little from standing at the bedside swapping instruments for an attending all-day long. Being in a “robot” case and not sitting at the console has been reported as one of the most dreaded cases for trainees. Additionally, at this point I cannot recommend a dedicated rotation as many programs are struggling to meet basic requirements given the time constraints in the modern training era.
If we train our residents well to perform open surgery and laparoscopic surgery, learning to use a device that augments laparoscopy, whether a robotic-assisted platform or otherwise, will become instinctual, and indeed, intuitive. That is when we know we have trained our residents well.