Robotic surgical training in an academic institution

Abstract

Objective: To detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams.

Summary background data: Remote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically.

Methods: Advanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors' two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics.

Results: Established surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding.

Conclusion: Robotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.

Figure 1. The surgeon’s console is placed 10 feet from the patient’s side. A patient-side surgical cart positions and drives the articulating instruments while an assistant facilitates the procedure and performs instrument exchanges. Surgeons essentially become immersed in the surgical landscape. (Inset) The surgical endowrist provides seven degrees of operative freedom.

Figure 2. Cross-section of the thorax shows the position of the three-dimensional videoscope as well as the intraatrial robotic arms and endowrists.

Figure 3. Setup of the operating room for general surgery procedures displays the patient-side surgical cart positioned over the patient’s right shoulder.

Figure 4. Performing a Nissen fundoplication requires two accessory ports in addition to the robotic instrument and camera ports. The left-sided accessory port allows delivery of the ultrasonic scalpel; the right-sided accessory port is used for retracting devices.

Figure 5. Magnified three-dimensional vision provides improved visualization of valvular structures. (A) A prolapsing segment of the posterior mitral leaflet is excised using tissue scissors and tissue forceps in the right hand and left hand, respectively. (B) An annuloplasty band is secured to complete the mitral repair procedure. Two needle holders are used to place sutures through the annulus. Computer assistance allows the surgeon to be ambidextrous in placing sutures around the annulus.

Figure 6. A Nissen fundoplication is performed. (A) Cadiere forceps are used to execute the fundal wrap procedure. (B) Sutures are used to secure the wrap around the esophagus just as in conventional or laparoscopic procedures.