Trainee and teacher learning together: dual console and the three arms

Abstract

Background: Transitioning from open to laparoscopic surgery was a slow process, often taking several years. The transition to robotics has been more systematic but growth from a robotic surgeon to a teacher without impeding trainee education has been challenging. As faculty surgeons get trained in robotics, there is generally a year-long hiatus in trainee participation. We describe a method of robotic education involving the use of the fourth arm (Xi) or third arm (Si), allowing for faculty and trainee growth together. Methods: A tertiary care hospital system with hepatopancreaticobiliary and advanced GI surgery fellowships was the back drop for this trial program. The surgeons were recently trained and the aim was to gain personal robotic surgery experience without compromising trainee experience. The fourth arm (Xi) or third arm (Si) was used on every robotic case that was performed by the surgeons at the institution. These cases performed consisted of advanced hepatobiliary and foregut procedures and included basic procedures like a cholecystectomy. The trainee was then transitioned from the fourth arm (X) or third arm (Si) to arm one and two. Results: All trainees completed online training modules and performed simulations prior to any console work. The fourth arm was used in every case. The trainees were placed in the dual console positon rather than at bedside which was felt not provide robotic-specific experience. As the trainees showed competence in the assistant role; could finger-clutch and show arm control, the surgeon handed over two operating arms and took the fourth arm. Using this technique of graduated responsibility and robotic-specific training, trainees were able to graduate to dual arm work quickly. For example, a routine hiatal hernia repair could be handed over to the trainee using two robotic arms within three cases. More importantly, both the faculty and trainee obtained robot-specific experience together. Conclusion: Use of the fourth arm allows for a graduated progression in robotic training. We believe that dual console position allows for more superior and relevant robot-specific training than bedside laparoscopic assistant position. This method allows for a quicker transition to a dual-arm robotic surgeon role for the trainees, and a concomitant learning curve for faculty and trainee. We would propose a multi-center trial to look at this method of robotic training.