Mohamed Sharif

Fundamental Skills of Robotic Surgery: A Multi-institutional Randomized Controlled Trial for Validation of a Simulation-based Curriculum

OBJECTIVE To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS). METHODS FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group. RESULTS Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively). CONCLUSION FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills.

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.

Construct validation of the key components of Fundamental Skills of Robotic Surgery (FSRS) curriculum--a multi-institution prospective study.

BACKGROUND Recent incorporation of simulation in surgical training necessitates developing validated platforms for training and assessment. A tool should fulfill the fundamental criteria of validation. OBJECTIVE To report the ability of a simulation-based robotic training curriculum-Fundamental Skills of Robotic Surgery (FSRS)-to assess and distinguish between different performance levels of operator experience (construct validity). MATERIALS AND METHODS This is a prospective multicenter observational study. Participants were classified as novice (0 robotic cases performed) and experts (>150 robotic cases performed). All participants were required to complete 4 key tasks in a previously validated FSRS curriculum: ball placement, coordinated tool control, fourth arm control, and needle handling and exchange. Using the metrics available in the simulator software, the performances of each group were compared to evaluate construct validation. RESULTS A convenience cohort of 61 surgeons participated. Novice group (n = 49) consisted of 41 fellows/residents/medical students and 8 trained open/laparoscopic surgeons, whereas expert group consisted of 12 surgeons. The novice group had no previous robotic console experience, whereas the expert group had >150 prior robotic cases experience. An overall significant difference was observed in favor of the expert group in 4 skill sets (p < 0.05). Time to complete all 4 tasks was significantly shorter in the expert group (p < 0.001). The expert group displayed significantly lesser tool collision (p = 0.002) and reduced tissue damage (p < 0.001). In performing most tasks, the expert groups camera (p < 0.001) and clutch usage (p < 0.001) was significantly greater when compared with the novice group. CONCLUSION The components of the FSRS curriculum showed construct validity. This validation would help in effectively implementing this curriculum for robot-assisted surgical training.

Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC).

To determine short‐term health‐related quality of life (HRQL) outcomes after robot‐assisted radical cystectomy (RARC) using the Bladder Cancer Index (BCI) and European Organisation for Research and Treatment of Cancer (EORTC) Body Image Scale (BIS).

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.

Understanding Cognitive Performance During Robot-Assisted Surgery

OBJECTIVE To understand cognitive function of an expert surgeon in various surgical scenarios while performing robot-assisted surgery. MATERIALS AND METHODS In an Internal Review Board approved study, National Aeronautics and Space Administration-Task Load Index (NASA-TLX) questionnaire with surgical field notes were simultaneously completed. A wireless electroencephalography (EEG) headset was used to monitor brain activity during all procedures. Three key portions were evaluated: lysis of adhesions, extended lymph node dissection, and urethro-vesical anastomosis (UVA). Cognitive metrics extracted were distraction, mental workload, and mental state. RESULTS In evaluating lysis of adhesions, mental state (EEG) was associated with better performance (NASA-TLX). Utilizing more mental resources resulted in better performance as self-reported. Outcomes of lysis were highly dependent on cognitive function and decision-making skills. In evaluating extended lymph node dissection, there was a negative correlation between distraction level (EEG) and mental demand, physical demand and effort (NASA-TLX). Similar to lysis of adhesion, utilizing more mental resources resulted in better performance (NASA-TLX). Lastly, with UVA, workload (EEG) negatively correlated with mental and temporal demand and was associated with better performance (NASA-TLX). The EEG recorded workload as seen here was a combination of both cognitive performance (finding solution) and motor workload (execution). Majority of workload was contributed by motor workload of an expert surgeon. During UVA, muscle memory and motor skills of expert are keys to completing the UVA. CONCLUSION Cognitive analysis shows that expert surgeons utilized different mental resources based on their need.

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.

PD46-11 UTILIZATION OF ROBOTIC ANASTOMOSIS COMPETENCY EVALUATION (RACE) FOR EVALUATION OF SURGICAL COMPETENCY DURING URETHRO-VESICAL ANASTOMOSIS

INTRODUCTION AND OBJECTIVES: There is increased emphasis on the measurement of competency in medical education and in maintenance of certification. The digital rectal exam (DRE) is an essential and important component of the physical examination but medical students are graduating with minimal experience due to the intimate nature of the exam and difficulty articulating the skill. We previously used a modified Delphi method with 10 experts to create a novel, validated assessment instrument for measuring medical student DRE proficiency, termed the Digital Rectal Exam Clinical Tool (DiRECT). We sought to demonstrate construct validity of the DiRECT in medical students and residents at different training levels. METHODS: The DiRECT instrument was developed using a modified Delphi method with 5 radiation oncologists and 5 urologists. The consensus panel identified 5 pertinent domains and determined levels of distinction for each. To validate the instrument, patients gave consent for paired digital rectal exams. The attending and trainee (medical student or resident) independently completed the DiRECT and the trainee’s responses were referenced against the expert’s. The DiRECT was scored using a partial credit model assigned by the study team. Training years were assigned to all participants, beginning at 1 for 3rd year medical students. The relationship between DiRECT score and training years was analyzed with linear regression. RESULTS: The DiRECT was completed 34 times by medical students and 15 times by urology resident physicians (PGY2-6). One of five attending urologists completed the corresponding DRE for scoring reference. Each trainee’s result as a percent score using our partial credit model is seen in Figure 1. The relationship between training years and partial credit score was statistically significant (p 1⁄4 0.0141) and with a medium to large effect size (r 1⁄4 12.4%). As level of training increased, the scores closely approximated those of the attending physician. When adjusting for attending physician, training level approached but did not reach statistical significance (p 1⁄4 0.087). CONCLUSIONS: We previously showed the ability of the DiRECT to reflect the nuances of complex versus benign exams in second year medical students. These additional data suggest validity of the instrument to differentiate between trainees of differing experience levels. Source of Funding: University of Virginia Academy of Distinguished Educators