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International Journal of Surgery 13 (2015) 115e123

Contents lists avai

International Journal of Surgery

journal homepage: www.journal-surgery.net

Review

An over-view of robot assisted surgery curricula and the status of theirvalidation

Rebecca A. Fisher, Prokar Dasgupta, Alex Mottrie 1, Alessandro Volpe 2,Mohammed S. Khan, Ben Challacombe, Kamran Ahmed*

MRC Centre for Transplantation, King's College London, King's Health Partners, Department of Urology, Guy's Hospital, St Thomas Street, London SE1 9RT, UK

h i g h l i g h t s

� Several projects are underway to create a curriculum for robotic surgery.� We review the main projects currently under development and validation.� The curricula propose a range of methods using several simulation models.

a r t i c l e i n f o

Article history:Received 4 August 2014Received in revised form20 November 2014Accepted 25 November 2014Available online 6 December 2014

Keywords:SurgeryCurriculumRoboticEducationTrainingUrology

* Corresponding author.E-mail address: kamran.ahmed@kcl.ac.uk (K. Ahm

1 OLV Vattikuti Robotic Surgery Institute, Dept. of U2 University of Eastern Piedmont, Maggiore della C

Urology, Novara, Italy.

http://dx.doi.org/10.1016/j.ijsu.2014.11.0331743-9191/© 2014 Surgical Associates Ltd. Published

a b s t r a c t

Introduction: Robotic surgery is a rapidly expanding field. Thus far training for robotic techniques hasbeen unstructured and the requirements are variable across various regions. Several projects arecurrently underway to develop a robotic surgery curriculum and are in various stages of validation. Weaimed to outline the structures of available curricula, their process of development, validation status andcurrent utilization. Methods: We undertook a literature review of papers including the MeSH terms“Robotics” and “Education”. When we had an overview of curricula in development, we searched recentconference abstracts to gain up to date information. Results: The main curricula are the FRS, the FSRS,the Canadian BSTC and the ERUS initiative. They are in various stages of validation and offer a mixture oftheoretical and practical training, using both physical and simulated models. Discussion: Whilst the FSRSis based on tasks on the RoSS virtual reality simulator, FRS and BSTC are designed for use on simulatorsand the robot itself. The ERUS curricula benefits from a combination of dry lab, wet lab and virtual realitycomponents, which may allow skills to be more transferable to the OR as tasks are completed in severalformats. Finally, the ERUS curricula includes the OR modular training programme as table assistant andconsole surgeon. Conclusion: Curricula are a crucial step in global standardisation of training and cer-tification of surgeons for robotic surgical procedures. Many curricula are in early stages of developmentand more work is needed in development and validation of these programmes before training can bestandardised.

© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Robotic surgery is a rapidly expanding field. In the past decade,over 1.5 million operations have been performed with the da VinciSurgical System [1] and an increasing number of centres worldwide

ed).rology, Aalst, Belgium.arit�a Hospital, Department of

by Elsevier Ltd. All rights reserved

are now investing in robots in specialties including Gynaecology,Urology, Cardiac, Thoracic, General and Head & Neck surgery. Insome areas such as urology, robotic surgery is now becoming thepreferred surgical approach for some indications, with reports of anestimated 80% of radical prostatectomies in the US in 2010 beingrobot-assisted [2]. Although robotic surgical training was originallyexploratory, now robotic surgery is so prevalent that there is a needfor a structured training curriculum for trainees [3].

Thus far, training for robotic techniques has been unstructuredand the requirements for trainee surgeons have differed fromhospital to hospital. Gaining credentials is therefore also variable

.

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123116

between institutions. There has been a call from major governingbodies such as the Society of Urologic Robotic Surgeons, EuropeanAssociation of Urology and the American Urological Association fordevelopment of training curricula increasing preclinical exposureto surgical techniques and validated assessment tools of profi-ciency. [4,5].

Several projects are currently underway to develop a roboticsurgery curriculum and are in various stages of validation. How-ever, the definition of the term ‘curriculum’ is broad: according tothe Oxford English Dictionary it is the “subjects comprising a courseof study.” In a medical context, the Postgraduate Medical EducationTraining Board (PMETB) (now part of the General Medical Council,UK) defines a curriculum as “a statement of the intended aims andobjectives, content, experiences, outcomes and processes of aneducational programme.” This includes a description of trainingstructure and the “expectedmethods of learning, teaching feedbackand supervision” [6,7].

Therefore it is unsurprising that within surgical education thereare several meanings to the term curriculum: some curricula are ashort full-time course or module whereas others are all-inclusivefellowship-style courses that take several weeks or months tocomplete. Additionally, a curriculum can also be considered to bethe entirety of experiences a trainee surgeon encounters in theirjourney from novice to expert.

This review outlines the historical perspectives of curriculumdevelopment, available curricula, their process of development,validation status and current utilization. It also identifies de-ficiencies in the literature and recommends direction of futureresearch.

2. Historical perspective of curriculum development

The challenges of developing curricula are not new to the sur-gical community, especially when considering the introduction oflaparoscopic surgery in the 1990s. In 1997 the Society of Gastro-intestinal and Endoscopic Surgeons (SAGES) introduced the Fun-damentals of Laparoscopic Surgery (FLS) course [8]. This is anevidence-based skills programme that was thoroughly validatedand is now a popular course that is widely used. In the US it is a pre-requisite for the ABS certifying examination (Appendix 1).

Although the FLS is a useful tool for minimally invasive surgicalskills, it does not encompass training specific to robotic surgery, so anew curriculum must be developed and validated. It is being usedas a benchmark for these new curricula, and various groupsdeveloping the robot assisted surgical curricula are aiming todevelop their programmes to be analogous to the FLS [9].

Because there is no gold standard assessment tool in robotics, ithas been difficult to determine concurrent validity, i.e. the perfor-mance correlationwith the gold standard. One group has suggestedCross-Method validity: comparing performance in a variety oftraining methods. They used Global Evaluative Assessment of Ro-botic Skills (GEARS) to compare previously validated training tools[10]. Although global assessment methods such as GEARS(11) andinstrument tracking methods such as trakSTAR™ Tool Tip Trackerare highly relevant to curricula, in this review we will focus on thecontent of the courses themselves rather than their assessments.An overview of available curricula has been provided in thefollowing sections.

3. Methods

To gain a comprehensive overview of curriculum developmentinternationally, we used several methods to gain information.Firstly, we did a PubMed search using the MeSH terms “surgery”,“robotic” and “education” and limited results to those with a full

text and published in the last 10 years. This search yielded 462results. From this we examined the results and selected only paperswith titles relevant to curricula, accreditation, programmes,teaching, or validation of teaching or assessment methods. Fromthis we gathered 33 relevant papers related to our subject. We readthese papers and identified those that were linked to a larger cur-riculum projects. Papers were only excluded if they clearly per-tained to an isolated validation study that had no currentapplication to a teaching curriculum. This included papersregarding validation or development of simulators themselves, asour group has recently reviewed this field [12]. Any references toother curricula within these papers were also flagged up for in-clusion in our review.

Realising that much of the work of these groups is currentlyunpublished and has only been presented at conferences, we thenused Google searches to find abstracts in conference archives forprojects already on our list. When we had identified the mainconferences accepting abstracts on this topic, we read through theirarchives for the last 5 years to check if we had missed any ongoingprojects. Over several months we familiarized ourselves with themain projects and did thorough Google searches of each, ensuringthat all data published online for each project was up to date.

When we had completed our list of projects and gained infor-mation on them, we discarded any projects that consisted of nomore than a single poster presentation or abstract, as these wereconsidered to be too small and undeveloped to be compared to thelarger projects described below.

4. FRS: Fundamentals of Robotic Surgery

There are currently two groups developing curricula under theworking title Fundamentals of Robotic Surgery (FRS). The largergroup based at Florida Hospital Nicholson Center is a large, multi-center project that has been in development for several years. Thesecond project, which we believe to be separate to the formergroup, was a poster presentation delivered at the SAGES 2012annual meeting, although no other information is available to ourknowledge. Both projects have been discussed in this review forcompleteness i.e. (a) Florida Hospital Group, and (b) Orlando Group.

4.1. Fundamentals of Robotic Surgery: Florida Hospital NicholsonCenter group

4.1.1. BackgroundThe Fundamentals of Robotic Surgery is a large multicenter

project based at the Florida Hospital Nicholson Center, with teammembers from theMinimally Invasive Robotics Association and theUS Department of Defense. It was officially launched online onMarch 1st 2014 and is currently undergoing validation.

The curriculum was developed by over 24 world experts in ro-botic surgery over two years. Content of the curriculum wasdecided through a series of consensus conferences attended by 14leading surgical societies, where the FRS team gained expert inputon the key skills and requirements of the robotic surgeon [13].Initial ideas at these conferences were built upon a previouslydeveloped proficiency-based curriculum by Dulan et al. [14], whichis described in full below.

After a first consensus conference to identify the 25 mainoutcome measures, the team split into three working groups forfuture conferences: a didactic and cognitive skills group, a psy-chomotor skills group and a team training and communicationsgroup. Each group identified a series of tasks, checklists or lecturesmost suitable to meet these learning outcomes.

When the FRS curriculum is fully developed there are plans tocreate a specialty-based accreditation scheme that will help

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123 117

trainees gain skills specific and most relevant to their area of work(Fig. 1). A series of specialty-based accreditation schemes arecurrently in development, with specialty curricula planned forUrology, Cardiothoracic surgery, Colorectal surgery, Spinal surgeryand for OR staff. The curriculum for Gynaecology has already beendecided, with consensus conferences for the remaining specialtiesplanned until May 2015 [15].

4.1.2. Course structure: skills taughtThe teaching curriculum itself is based on four modules

(Appendix 1) [13,15]. It is one of the most comprehensive projectscurrently under development, as it involves modules that not onlycover knowledge and practical skills but also communication andteamwork relating to robotic surgery. As the teaching aspect is socomprehensive, this curriculum seems to be highly suited to cen-tres undertaking robotic surgery for the first time, as it does not relyonmentors in your own centre asmuch as courses such as the ERUSinitiative.

4.1.3. Course structure: type of models usedPsychomotor skills are taught in module 3 on a new device

developed by the FRS team. The PsychomotorMulti-skill Device is adomed construct with different materials attached that allowpractice of the tasks in module 2. Using a physical model allowsstandardisation between centres that do not have available simu-lators. Although the Da Vinci robot is the only validated devicecurrently in use, they anticipate the arrival of new robots in thefuture and aim to build a curriculum not dependent on any specificrobot model.

4.1.4. OR training and mentorshipLike the FLS programme, the FRS curriculum is a first step to-

wards competency, not a full resident training programme. Centresadopting it in the future are likely to use the course as initialaccreditation upon which further training is built.

Fig. 1. FRS: Developing specialty qualifications from a common template [16] (‘???’shows that the name for the curriculum could be changed according to the specialty).

4.1.5. Assessment of proficiencyThe FRS assessment consists of 25 outcomesmeasures, split into

pre-, intra- and post-operative sections. Although only samples arecurrently available, the group plans a thorough mark scheme foreach task, including potential errors, desired outcomes, andmetricsfor assessment such as time, material damage and tissue damage(Table 1) [9,16].

4.1.6. Status of validationThe FRS curriculum remains unvalidated at present. The first of

five validation stages was announced to have begun in March 2014.Up to date details can be found at www.frsurgery.org.

4.1.7. Current applications to trainingTraining programme of surgical residents at Loma Linda Uni-

versity Medical Center uses the da Vinci Surgical Trainer's virtualand inanimate modules. Trainees must obtain scores of at least 80%on each training module and then complete the Fundamentals ofRobotic Surgery curriculum (described above). After performingthese steps trainees are permitted to start real-time clinicaltraining [17].

4.2. FRS: Fundamentals of Robotic Surgery e Orlando group

This relatively small group based at the Colon and Rectal Clinicof Orlando presented a short curriculum at the SAGES annualmeeting 2012. After conducting a literature review on the Funda-mentals of Laparoscopic Surgery programme and robotic surgery,they studied the Skills Simulator for da Vinci SI (Intuitive Surgical)at a local centre and identified five main tasks in robotic surgery.Their aim was to create an analogous curriculum to the Funda-mentals of Laparoscopic Surgery (FLS).

The FRS curriculum is based on five simulated tasks: CameraTargeting, Peg Board, Ring Walk, Energy Dissection and SutureSponge. Tasks are based on the Skills Simulator for da Vinci SI,although the programme has been developed with intent to createa device-dependent curriculum [18].

5. FSRS: Fundamental Skills of Robotic Surgery

5.1. Background

The Fundamental Skills of Robotic Surgery curriculum is asimulation-based course developed by an international team basedat the Roswell Cancer Institute, Buffalo, NY. The group havedeveloped a series of tasks from the opinions of a group of expertrobotic surgeons and the curriculum is assessed with a new tool,the Robotic Skills Assessment Score [19]. The curriculum has beenvalidated and has been in use at the Roswell Park Cancer Institute inNew York [20].

5.2. Course structure: skills taught

The fundamental skills for robotic surgery curriculum consists ofa series of 16 tasks grouped into four modules. Each task has threelevels of difficulty, followed by an evaluation stage. Tasks weredeveloped based on opinions of experts in robotic surgery and avirtual reality simulation engineer, with the incorporation ofalready validated tasks from the Fundamentals of LaparoscopicSurgery curriculum (Appendix 1) [21].

5.3. Course structure: type of models used

Tasks have been incorporated into a validated virtual realitysimulator, Robotic Surgical Simulator (RoSS), which was developed

Fig. 2. Overview of training modules in the RAST programme [20].

Table 1Outcomes Measures defined by the FRS group [9,16].

Pre-operative Intra-operative Post-operative

System settingsDockingErgonomic positioningRobotic trocarsOR set-upClosed loop commsSituation awarenessRespond to system errors

Energy sourcesClutchingCamera controlInstrument exchangeForeign body managementMulti-arm controlWrist articulationKnot tying

Eye-hand instrument coordinationAtraumatic tissue handlingCuttingFine & blunt dissectionNeedle DrivingSuture handlingSafety of operative field

Transition to bedside assistantUndocking

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123118

by the same team. The simulator retails between$95,000e$125,000 [22].

5.4. OR training and mentorship

There is no in-course OR training, but the developers suggestthat it be used as a structured starter module to a mentor-ledprogramme.

5.5. Assessment of proficiency

A scoring system has also been developed to measure level ofrobotic skills attained, the Robotic Skills Assessment Score, or RSA-score. It has been designed to standardize recognition of safepractice and attainment of crucial surgical skills during robotictraining. Its main focuses are time, bi-manual dexterity, criticalerror, safety in the operative field, and economy. It has shownconstruct validation, showing a disparity in scores when perfor-mance was compared in a group of 27 expert and non-expert ro-botic surgeons [23]. Although the RSA-Score was originallydesigned for use with the FSRS curriculum, it can also be applied toother simulation systems as they use the same tasks in theircurricula [19].

5.6. Status of validation

The FSRS has been validated in a recent multi-centre study ontwo randomized groups. In this study the robotic curriculum wasused on the Robotic Surgical Simulator (RoSS), which recorded all ofthe data during testing. Fifty-three participants were randomlyallocated to a control group or an experimental group. Members ofboth groups underwent a brief orientation with the da Vinci Sur-gical System (dVSS) led by an experienced dVSS user. Then theexperimental group completed the Fundamental Skills of RoboticSurgery curriculum. Both groups were then tested on three tasks onthe dVSS and their performance was recorded. When this had beencompleted the control group were given the opportunity to com-plete the curriculum and then be re-tested on the dVSS, forming acrossover group. Results showed significant improvement in theexperimental group and crossover groups, thereby demonstratingconstruct validity [21].

Construct validity has also been demonstrated on a group of 61surgeons grouped into novice (no robotic cases) and expert (>150cases) categories. Their performance was measured on four tasksfrom the FSRS and the expert group was shown to be performingsignificantly better than the novice group [24].

It is worth noting that the individuals that have undertaken allthe validation studies on the FSRS curriculum have a vested interestin the project, as the authors are the developers of the RoSSsimulator. The potential for bias in this work is such that it would beuseful to compare their results with validation studies performed

by a third party.

5.7. Current applications to training

A formal Robot Assisted Surgical Training (RAST) programmehas been in development at Roswell Park Cancer Institute. It takesbetween five days and three weeks to complete and consists of theFSRS curriculum and a series of further hands-on tasks (see figure).On completing the FSRS curriculum, trainees complete modules inbedside hands-on troubleshooting, live surgery case observation,hands-on surgical training (Fig. 2) [20].

The RAST developers have presented their progress with 43trainees undertaking the curriculum, and have shown it to beacceptable to the trainees and that is has an educationalimpact [20].

6. Erus robotic urology fellowship curriculum

6.1. Background

This new curriculum from the European Association of Urology(EAU) Robotic Urology Section is being developed by a panel ofinternational experts and has been through initial validation.Opinions were gathered qualitatively in a series of focus groupinterviews at the EAU (2013) and EAU Robotic Section UrologyCongress (2012) meetings [25,26].

6.2. Course structure: skills taught

The curriculum is a comprehensive multi-step scheme thattakes 3 months to complete. The course starts with an onlinetheoretical training module, followed by simulation and observa-tion in a mixed setting of dry lab, wet lab, and virtual reality (oneweek). The trainee then progresses to a fellowship stage, which

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123 119

consists of observation and table assistance of live surgery followedby console modular training in Robot-Assisted Radical Prostatec-tomy (RARP) under supervision. At the end of the 12-week pro-gram, the trainees undergo an assessment by their mentors, whichincludes previously validated global assessment scores for tech-nical (GEARS) and non-technical skills (NOTSS) (Appendix 1)[25,26]. Their ability to perform RARP is tested by blind revision ofthe video-recorded steps of a full procedure that has been per-formed by the trainees under supervision of their mentors.

6.3. Course structure: type of models used

This curriculum has a progressive use of different trainingmodels including an intensive week of theoretical training, dry lab,wet lab and live surgery.

6.4. OR training and mentorship

The final stage of the curriculum is a fellowship in robotic sur-gery, involving observation of live surgery, bedside assisting, andconsole modular training with a mentor, ideally in a dual consolesetting. The fellows are trained to progressively perform the sur-gical steps of the procedure at increasing surgical difficulty andfinally the entire surgical intervention.

6.5. Assessment of proficiency

After the first 3 weeks of didactic and cognitive training, thetrainee sits an e-learning exam. Technical skills are assessed at thebeginning of the fellowship and on days 28 and 35. Trainees aimtowards 90% performance on all simulated exercises and skillstasks. Finally, a full-length, unedited DVD of a robotic procedure isassessed by 2 expert robotic surgeons. Accreditation is grantedwhen the trainee has completed the fellowship stage, their mentoris confident that they are able to perform full procedures and thetechnical quality of the video-recorded surgical steps is consideredsatisfactory by blinded assessors.

6.6. Status of validation

The curriculum is in early stages of validation and more work isplanned, but an international study of 10 fellows undertaking thecourse has shown significant improvement in robotic skillsamongst the group [26]. Another study is ongoing, which involves alarger number of participants and includes a longer (6-month)training period and better defined requirements for modulartraining.

7. BSTC: basic skills training curriculum, university of toronto

7.1. Background

In Canada, the adoption of robotic surgery into clinical practicehas been less widespread than in the United States. Because of this,there is a need for multidisciplinary basic skills training for novicesacross several specialties. This curriculum teaches generic skills andis not tailored to any specific specialty [27].

7.2. Course structure: skills taught

The curriculum is a 4-week course. The first week comprises of adidactic lecture and self-directed online training modules(including use of the Fundamentals of Robotic Surgery Module 1)[28]. The trainees then undergo a 2-h standardised introduction tothe robot, including 30 min of basic robotic skills practice on

inanimate models. For the next 3 weeks, trainees complete 1-h sessions on the da Vinci Surgical Simulator, where they performexercises including camera navigation, third arm functionality, in-strument clutching, endowrist manipulation of objects, cautery,needle handling and driving, and dissection.

7.3. Course structure: type of models used

Practical skills were developed using inanimate benchtopmodels with the da Vinci Robot, and the da Vinci Surgical Simulator.Although exposure to each model is only for a short time, experi-ence with both a simulator and benchtop models gives a widerexposure to robotic skills.

7.4. OR training and mentorship

OR training is not included in this course as it is designed as aninitial training system for basic skills.

7.5. Assessment of proficiency

Proficiency was assessed using 2 standardised skill tasks withinanimate models: ring transfer and needle passing. Performancewas assessed by time to completion and number of errors.

7.6. Status of validation

A pilot study was conducted on 37 trainees. Performanceimproved significantly after the course on both inanimate taskstested (p < 0.01 and p ¼ 0.04 respectively) [27]. Further validationstudies are planned.

8. Proficiency-based robotic curriculum

A group at University of Texas Southwestern Medical Centerhave developed and validated a comprehensive, proficiency-basedrobotic curriculum. Tasks were developed by interviewing expertsand through observation of live robotic operations, which lead toidentification of 23 unique robotic skills. Nine inanimate tasks weredeveloped in addition to a half-day tutorial and onlinedidactics (Appendix 1) [14]. The curriculum takes two months tocomplete and trainees are expected to self-practice the nine tasksuntil they reach suitable levels of proficiency.

A group of 12 robotic surgeons completed the tasks and agreedthat theywere highly relevant for training and assessment, and thatthe tasks measured relevant skills, thereby demonstrating contentand face validity [29].

Construct validity was demonstrated in a group of eight expertrobotic surgeons and four medical students. They completed thenine tasks (five of which were modified or unmodified FLS tasksand four new models) and the expert surgeons were found to besignificantly better than the inexperienced students [30].

One-year skills retention was studied in 27 trainees, and thelevel found to be high. An interval in operative experience duringthis year decreased skills retention a small amount, and likewiseoperative experience during this time increased skills. Subjectswho required the most repetitions of the tasks to gain proficiencyalso had significantly worse retention than others [31].

9. Recommendations

Although several groups are currently developing roboticcurricula, there are four main groups: the FRS (Nicholson center),FSRS, BSTC and ERUS curricula (Table 2). For the purposes of thisreview we have considered these curricula as the courses most

Table 2An overview of the main robotic curricula [13,18,21,26,30].

An overview of the main robotic curricula in development

Name Fundamentals ofRobotic Surgery(FRS)

Fundamental skillsof Robotic Surgery(FSRS)

ERUS roboticsurgery trainingcurriculum

Proficiency-basedrobotic curriculum

Fundamentals ofrobotic surgery:Orlando group

Lead authorsor organisation

R Smith; V Patel;R Satava (Surgical,Urological,Gynaecological andCardiothoracicSocieties in the US)

AP Stegemann;K Ahmed; JR Syed;J Kaouk, Menon M,Guru et al.

EAU RoboticUrology Section(ERUS)

G Dulan; RV Rege;DC Hogg; KMGilberg-Fisher;NA Arain; ST Tesfay

JM Macgregor;R Kim; K Baldwin;C Glanville;R Pigalarga;M Soliman et al

Type of curriculum Training Module Training Module 12-weekComprehensiveTrainingProgramme

Training Module Training Module

Skills taught Lecture-basedmodule followed by10 psychomotortasks and checklist-based team andcommunicationstraining

16 simulated tasks E-learning module,dry lab/wet lab/virtual realitytraining. Structuredmentorship untilcompetent at fullprocedures.

E-learning module,half day interactivesession and 9 drylab tasks, which arepracticed for up to 8weeks untiltrainees areproficient

5 simulated taskson the SkillsSimulator for daVinci SI

Processof development

Multi-centreconsensusconferencesgathered opinionsand separateworking groupsdeveloped eachmodule

Developed fromopinions of expertrobotic surgeonsand a virtual realitysimulationengineer

Developed fromfocus groups atEAU/ERUSmeetings

23 unique roboticskills identifiedfrom interviewingexperts andwatching liveoperations, whichwere developedinto 9 tasks

Main tasksidentified byliterature reviewand working withthe Skills Simulatorfor da Vinci SI

Validation Not validated.Validation studiesplanned for 2014.

Face, content andconstruct validityhas beendemonstrated

Face and contentvaliditydemonstrated,more studiesplanned

Face, content andconstruct validitydemonstrated, withhigh 1-year skillsretention

Not validated

Simulationcomponents

Dry lab only, usesnew PsychomotorMulti-skills Device

Simulated on theRobotic SurgicalSimulator (RoSS)

Dry lab, wet lab andvirtual reality

Dry lab only Simulated on theSkills Simulator forda Vinci SI

Operating roomcomponents

None None Fellowship-stylemodular consoletraining.

None None

Current use Used in one centrein combinationwith da VinciSurgical Trainer'svirtual andinanimate modules

Designed to beincorporated into atrainingprogramme, suchas the Robot-Assisted SurgicalTrainingProgramme inRoswell Park since2007

Completed by 10trainees acrossEurope

Current useunknown

Current useunknown

Specialty Multi-specialty.Advanced curriculain severalspecialties planned

Multi-specialty Urology, currentlyfocused on Robot-Assisted RadicalProstatectomy

Multi-specialty Multi-specialty

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123120

likely to become the gold standard, as they are all large multicentreprojects that have on-going or planned validation studies. However,as validation results are currently non-existent orminimal for theseprojects, it may be several years before it is clear which type ofeducation will be the most effective and popular. At present, FRS isthe only course that has been launched for public use, and withvalidation studies planned for 2014/15 and expansion into specialtytraining already occurring, it appears to be the FRS that is mostlikely to become gold standard in the United States. The FRS(Orlando group) and the proficiency based robotic curriculum bothappear to be finite projects that are not intended for widespreaduse or further validation so will not be discussed further in ourconclusions.

While the FSRS is based on tasks on the RoSS simulator, FRS isbeing designed for use on the robot itself, with trainees completingtasks on a new Psychomotor Multi-skill device. The FRS group havesuggested that their curriculum has the potential of cross-application and could be adapted in the future for use on simula-tors and particularly on new robots, should an alternative to the daVinci robot be commonly used in the future. In light of the recentannouncement of the arrival of the Da Vinci Xi into the market, inthe coming years we are likely to see a departure from the currentstate where all centres have similar robots. Therefore we expectthat projects such as FRS will be more able to keep up with changesin technology and so will benefit from cross-application withoutadditional expenditure. It would also allow centres with more than

R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123 121

one specification of robot to have the same teaching and assess-ment protocols for trainees on all robots.

The ERUS curriculum benefits from a combination of dry lab,wet lab and virtual reality components, which may allow skills tobe more transferable to live surgery as tasks are completed inseveral formats. This is the only training curriculum available thatencompasses bench-top (synthetic) models, virtual reality simu-lators, live animal training, and cadaver training. Finally thetrainees complete modular training in the OR under supervision ofthe designated mentors. This gradual and varied style of training isideal as it ensures trainees have used the robot in a wide range ofcontexts before use on a patient, increasing patient safety and of-fering a good learning environment for trainees to ask questionsand practice their skills until they are competent.

One major disparity between the curricula in development iswhether they consist of a short course or a fellowship-style trainingprogramme. FRS, BSTC and FSRS are designed to be an initialqualification that can be incorporated into a centre's training plans.The new ERUS initiative curriculum's major benefit is that it followsthe trainee from novice to competent surgeon by including afellowship/mentorship stage in the OR. It is clear that if the aim ofthese curricula is to ensure competence across all trainees, afellowship-style training programme is most likely to produce thedesired outcome as a longer-term programme means a trainee islikely to have more structured guidance throughout training.

One major consideration when comparing curricula is the re-sources available to undertake the training programme. A centre'sability to purchase a simulator for training or spare a robot fortraining may be limited in some cases. The Texas Southwesterngroup working on the proficiency-based curriculum highlightedthis as they were given a da Vinci robot for sole use in their skillslabs, and so proficiency-based training could be carried out there[14]. Other centres may not be able to spare a robot for training andso trainees may be challenged to find time when the robot is not inuse [14]. On the other hand, for a centre that is new to roboticsurgery, a proficiency-based curriculum on a physical model maybe ideal to hone skills on a robot that is not yet in full-time use.

It is at this point a good moment to discuss not just the de-ficiencies of each curriculum, but the points where they can buildon each other. It seems that the best way to tackle a trainingchallenge is through long-term, structured mentorship, as shownby the ERUS curriculum. However, most of the basic skills teachingin the ERUS curriculum is similar to other courses, with the ma-jority being taught in a 1-week focused course that includes dry lab,wet lab and virtual reality sessions. Therefore any of the curriculamentioned could be adapted into a fellowship programme like theERUS initiative. The FRS course is particularly strong for this pur-pose, as its Psychomotor Multi-skill device makes training acrossseveral robotic platforms easy, with no need to change assessmentmeasures. Their intensive course also includes team training andcommunication skills, which would be useful if it were followed bya period of fellowship-style training.

From our research here, we would recommend that future workon curricula moves towards fellowship-based training, whereinitial intensive courses are supported by several weeks or monthsof structured mentorship, which can help the trainee to becomecompetent as quickly as possible. We particularly recommendtraining schemes that use a wide range of technical skills training,ideally using wet lab, dry lab and simulation if possible. Althoughthis may be a more expensive and time-consuming method, it islikely to produce more confident trainees, who have more trans-ferrable skills as they have experience in performing tasks on

several platforms before using them in the OR. In addition to this,wemust also bewary of changing technology in the future, and so atraining programme must be able to adapt to new robotic systemsas they are introduced. Therefore basing a curriculum entirely on asimulator may not be advantageous, as the curriculum will have tobe redesigned with the introduction of new technology.

A limitation of our studywas the challenge of identifyingwhat isa curriculum and what is not. As many projects are in ongoingstages of development and validation, a systematic PubMed searchwould not give us up-to-date information as much initial work ispresented at conferences. However, the paucity of literature in thisarea meant that we were also able to manually identify and eval-uate the relevance of each paper in turn without risking its exclu-sion by automated searches. Although the methodology we usedcould not classify this article as a systematic review, due to theunpublished nature of most of this work, using only databases suchas Medline and PubMed would have left significant gaps in ouroverview of this field.

10. Conclusions

The main curricula are the FRS, the FSRS, the BSTC and the ERUSinitiative. They are in various stages of validation and offer adifferent mixture of theoretical and practical training, using bothphysical and simulatedmodels. We consider the strongest offeringsto be those that use a variety of models in a fellowship-style course,particularly if these methods are transferable from one robotspecification to another, therefore the ERUS initiative and FRScurricula have the most useful application. The challenge for theseteams over the coming years will be to thoroughly validate theircurricula and clarify how their project fits into existing trainingprogrammes. Like the FLS course in laparoscopic surgery, it is ex-pected that one of these may become a prerequisite for furthersurgical training, in a bid to standardise training nationally andeven internationally and certify surgeons for specific robotic sur-gical procedures. It is therefore important at this time that surgicaleducators worldwide work together to push curriculum develop-ment to achieve this goal.

Ethical approval

None required.

Sources of funding

None.

Author contribution

Rebecca Fisher: Writing the article, data collection andinterpretation.

Prokar Dasgupta: Writing the article, data collection.Alex Mottrie: Interpreting data, Critical revisions.Alessandro Volpe: Interpreting data, Critical revisions.Mohammad S Khan: Interpreting data, Critical revisions.Ben Challacombe: Conception and design, writing the article.Kamran Ahmed: Conception and design, writing the article.

Conflicts of interest

None.

Appendix 1. An overview of curriculum content [6,11,12,19,23,24]

Name Fundamentals of LaparoscopicSurgery (FLS) (for comparison)

Fundamentals of RoboticSurgery (FRS)

Fundamental skillsof Robotic Surgery (FSRS)

ERUS robotic surgerytraining curriculum

Basic skills trainingcurriculum, Toronto

Proficiency-based roboticcurriculum

Fundamentals ofrobotic surgery:Orlando group

Modulesincluded

1. Web based study guides:covers didactics, interactivepatient skills scenario,manual skills training,practice questions

2. Technical skills curriculum:proficiency based technicalskills completed on the FLSLaparoscopic Trainer.

1. Introduction to roboticsystems: minimallyinvasive surgery,robotic systemadvantages andcomponents, systemfunctionality.

2. Didactic instructionse.g. robot docking,trocar placement.

3. Physical modeltraining, on newPsychomotormulti-skill device

4. Team training& communication

1. Basic consoleorientation

2. Psychomotor skillstraining (ballplacement, spatialcontrol)

3. & 4 Intermediatesurgical skills

1. Online e-learning2. Observation of live

surgery (bedside/console)3. Simulation and observation

(procedure specific: dry lab,wet lab, virtual reality)

4. Fellowship: Observationof live surgery, bedsideassisting, performing partthen full procedure withdual console and mentor.

1. Lecture and onlinetraining modules

2. 2-hour introductionto robot

3. 3 weeks of sessionson the Da vinciSurgical Simulator

1. Online module(multiple choice questions)

2. Half day interactive session3. Technical skills

1. Simulated taskmodule

Manual Skillsdeveloped

5 FLS manual skills:� Peg transfer� Precision cutting� Placement and securing

of ligating loop� Simple suture with

extracorporeal knot

7 FRS tasks onPsychomotorMulti-skill Device:� Docking/instrument

insertion� Ring tower transfer� Knot tying� Railroad track� Fourth arm cutting� Puzzle piece dissection� Vessel energy dissection

16 tasks on the RoboticSurgical Simulator (RoSS):� Instrument and camera

control� 4th arm control� Ball placement� Spatial control� Needle handling� Basic electrocautery� Tissue cautery� Tissue retraction� Blunt tissue� Vessel dissection� Knot tying

Trainees complete a widerange of manual skills tasksthat are either genericor procedure-specific.These occur in simulated,dry lab and wet lab settingsbefore being introducedin the OR.

Da Vinci Surgicalsimulator tasks:� Camera navigation� 3rd arm functionality� Instrument clutching� Endowrist object

manipulation� Cautery� Needle handling

and driving� Dissection

9 inanimate exercises:� Peg transfer� Clutch and camera

movement� Rubber band transfer� Simple suture� Clutch and camera

peg transfer� Running and cutting

rubber band� Pattern cut� Running suture

5 simulated taskson the SkillsSimulator for daVinci SI:� Camera targeting� Peg board� Ring walk� Energy dissection� Suture sponge

Skillsdeveloped

Didactic & Cognitive;Psychomotor skills

Didactic & cognitive;Psychomotor skills; Teamtraining and communications

Didactic & cognitive;technical skills; module3 & 4 focuses on integrationof knowledge and skills

Didactic & cognitive;technical skills, integrationof knowledge and skills;application of skills to theOR.

Didactic & cognitive;Psychomotor skills

Didactic & cognitive;Psychomotor skills

Psychomotor skills

Assessment 2-part exam coveringcognitive knowledge,with a focus on clinicaldecisions, and manual skillsare tested on the FLSlaparoscopic trainer box.

Online e-learning exam,simulated assessmentand skills tasks. DVDassessment of a procedure,reviewed by 2 experts.

Proficiency is assessedon 2 tasks benchtopmodels. Performanceis based on time tocompletion and numberof errors.

R.A.Fisher

etal./

InternationalJournal

ofSurgery

13(2015)

115e123

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R.A. Fisher et al. / International Journal of Surgery 13 (2015) 115e123 123

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