Justen Kozlowski

Ambulatory movements, team dynamics and interactions during robot-assisted surgery

To analyse ambulatory movements and team dynamics during robot‐assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events.

The Loud Surgeon Behind the Console: Understanding Team Activities During Robot-Assisted Surgery

OBJECTIVES To design a data collection methodology to capture team activities during robot-assisted surgery (RAS) (team communications, surgical flow, and procedural interruptions), and use relevant disciplines of Industrial Engineering and Human Factors Engineering to uncover key issues impeding surgical flow and guide evidence-based strategic changes to enhance surgical performance and improve outcomes. DESIGN Field study, to determine the feasibility of the proposed methodology. SETTING Recording the operating room (OR) environment during robot-assisted surgeries (RAS). The data collection system included recordings from the console and 3 aerial cameras, in addition to 8 lapel microphones (1 for each OR team member). Questionnaires on team familiarity and cognitive load were collected. PARTICIPANTS In all, 37 patients and 89 OR staff members have consented to participate in the study. RESULTS Overall, 37 RAS procedures were recorded (130 console hours). A pilot procedure was evaluated in detail. We were able to characterize team communications in terms of flow, mode, topic, and form. Surgical flow was evaluated in terms of duration, location, personnel involved, purpose, and if movements were avoidable or not. Procedural interruptions were characterized according to their duration, cause, mode of communication, and personnel involved. CONCLUSION This methodology allowed for the capture of a wide variety of team activities during RAS that would serve as a solid platform to improve nontechnical aspects of RAS.

Technical mentorship during robot-assisted surgery: a cognitive analysis

To investigate cognitive and mental workload assessments, which may play a critical role in defining successful mentorship.

Robot‐assisted approach to ‘W’‐configuration urinary diversion: a step‐by‐step technique

To describe a detailed step‐by‐step approach of our technique for robot‐assisted intracorporeal ‘W’‐configuration orthotopic ileal neobladder.

Development, validation and clinical application of Pelvic Lymphadenectomy Assessment and Completion Evaluation: intraoperative assessment of lymph node dissection after robot-assisted radical cystectomy for bladder cancer

To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot‐assisted radical cystectomy (RARC).

MP51-05 DOES TRAINEE PERFORMANCE IMPACT SURGEON'S STRESS DURING ROBOT-ASSISTED SURGERY?

INTRODUCTION AND OBJECTIVES: Stress increases mental workload leading to reduction in surgical performance and subsequently risking patient safety. Console surgeon and their teams often experience mental stress, yet there is little research about objective measurement of stress levels in the operating room during Robot-assisted Surgery (RAS). In the study, brain activity data are used to differentiate between causes of mental stress of mentor surgeon and the impact of trainee performance during RAS. METHODS: EEG data from surgical mentor while observing 87 Urethro-Vesical Anastomoses (UVA) and 74 Pelvic Lymph Node Dissections (PLND) performed by 3 trainees, as well as performing 26 UVA and 26 PLND is recorded. Level and type of mental stress were determined using the power spectral density, during different frequencies, of signals from 20 channel EEG. Performance scores were used to identify the relationship between performance and stress. Stress caused by worry about ability of safe completion were estimated by using the brain activity during upper alpha (11-12 Hz), sensorimotor rhythm (SMR, 12-15 Hz), and low beta (19-22 Hz) bands in the “Cz” channel (area in motor cortex). The activity at the upper beta and gamma was used to estimate stress level and anxiety and fear caused by risk prediction. RESULTS: Mentor’s brain faces two main types of stresses during RAS. While observing low quality performance by trainee surgeons, the cause of mentor’s mental stress is mostly worries about lack of proficiency of trainee surgeon (Type 1). However, stress of mentor while performing surgery or observing a high quality performance by trainee surgeon, is mostly the result of situation awareness and risk prediction on the operative field (Type 2). These two types of stress activate different areas of the brain in specific frequencies. CONCLUSIONS: EEG can be used to separate different types of stress experienced during performing and mentoring robot-assisted surgery. A deeper understanding of the difference and effect of these stresses and their outcomes can lead to targeted intervention and quality improvement. Source of Funding: Roswell Park Alliance Foundation.

Multimodal team interactions in Robot-Assisted Surgery

Communication gaps have been systematically linked to failures during surgery; however few studies have addressed challenges related to the remoteness of the surgeon during robot-assisted surgery (RAS). While studies on team communication in the Operating Room (OR) rarely report on nonverbal aspects, our initial work has shown that the vast majority of interaction events between the console surgeon and the right bed side assistant is nonverbal. This study focuses on improving our understanding of the nature of the multimodal interactions between surgeons and right bed side assistants. Six robot-assisted radical prostatectomies were recorded and the interaction events between the surgeon and the right bed side assistant were categorized by type (verbal/nonverbal), topic, and sender. The proportion of verbal and nonverbal events varied with the topic of the interaction. Strategies to improve team communication during surgery should take into account both the use of nonverbal communication means and the change in communication strategies based on purpose.

Use of Robotic Anastomosis Competency Evaluation (RACE) for assessment of surgical competency during urethrovesical anastomosis

INTRODUCTION We sought to evaluate the Robotic Anastomosis Competency Evaluation (RACE), a validated tool that objectively quantifies surgical skills specifically for urethrovesical anastomosis (UVA), as a tool to track progress of trainees, and to determine the predictive value of RACE. METHODS UVAs performed by trainees at our institution were evaluated using RACE over a period of two years. Trainees were supervised by an experienced robotic surgeon. Outcomes included trainee-related variables (RACE score, proportion of UVA performed by trainee, and suturing speed), and clinical outcomes (total UVA duration, postoperative urinary continence, and UVA-related complications). Significance was determined using linear regression analysis. RESULTS A total of 51 UVAs performed by six trainees were evaluated. Trainee RACE scores (19.8 to 22.3; p=0.01) and trainee proportion of UVA (67% to 80%; p=0.003) improved significantly over time. Trainee suture speed was significantly associated with RACE score (mean speed range 0.54-0.74 sutures/minute; p=0.03). Neither urinary continence at six weeks nor six months was significantly associated with RACE score (p=0.17 and p=0.15, respectively), and only one UVA-related postoperative complication was reported. CONCLUSIONS Trainee RACE scores improved and proportion of UVA performed by trainees increased over time. RACE can be used as an objective measure of surgical performance during training. Strict mentor supervision allowed safe training without compromising patient outcomes.

Are gestures worth a thousand words? Verbal and nonverbal communication during robot-assisted surgery

Communication breakdowns in the operating room (OR) have been linked to errors during surgery. Robot-assisted surgery (RAS), a new surgical technology, can lead to new challenges in communication owing to the remote location of the surgeon away from the patient and bedside assistants. Nevertheless, few studies have studied communication strategies during RAS. In this study, 11 robot-assisted radical prostatectomies were recorded and the interaction events between the surgeon and two bedside surgical team members were categorized by modality (verbal/nonverbal), topic, and pair (sender and receiver). Both verbal and nonverbal modalities were used by all pairs. The percentage of nonverbal interactions differed significantly by pair: 66% for the Surgeon-Physician Assistant, 50% for the Physician Assistant-Scrub Nurse, and 25% for the Surgeon-Scrub Nurse, indicating different communication strategies across pairs. In addition, there was a significant dependence between topic and the percentages of verbal and nonverbal events for all pairs. Strategies to improve team communication during RAS should take into account the use of verbal and nonverbal communication means and the variation in interaction strategies based on the topic of communication.

V12-05 REVISITING THE ABDOMEN AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY: TIPS AND TRICKS FOR ROBOT-ASSISTED REPAIR

and median length of stay was 2 days (2-12). All cases were completed robotically. Intraoperative blood loss was negligible. Four patients experienced a Clavien grade II complication (urinary tract infection requiring antibiotics). At a median follow-up of 320 days (55-907) no recurrences occurred. CONCLUSIONS: Robotic ureteral reimplantation for ureteroenteric strictures is a safe and highly effective procedure. Given the suboptimal success rate of endoscopic treatment, robotic repair has become a first treatment option in our centers.