Console Surgeons Research Articles

Learning curve in robotic liver surgery: easily achievable, evolving from laparoscopic background and team-based

PurposeLimited and heterogeneous literature data necessitate a focused examination of the learning curve in robotic liver resections. This study aims to assess the learning curve of two surgeons from the same team with differing laparoscopic backgrounds. MethodSince February 2021, San Raffaele Hospital in Milan has implemented a robotic liver surgery program, performing 250 resections by three trained console surgeons. Using cumulative sum (CUSUM) analysis, the learning curve was evaluated for a Pioneer Surgeon (PS) with around 1200 laparoscopic cases and a New Generation Surgeon (NGS) with approximately 100 laparoscopic cases. Cases were stratified by complexity (38 low, 74 intermediate, 85 high). ResultsBoth PS and NGS demonstrated a learning curve for operative time after 15 low-complexity and 10 intermediate-complexity cases, with high-complexity learning curves apparent after 10 cases for PS and 18 cases for NGS. Conversion rates remained unaffected, and neither surgeon experienced increased blood loss or postoperative complications. A “team learning curve” effect in terms of operative time emerged after 12 cases, suggesting the importance of a cohesive surgical team. DiscussionThe robotic platform facilitated a relatively brief learning curve for low and intermediate complexity cases, irrespective of laparoscopic background, underscoring the benefits of team collaboration.

619 Training the Trainees in Robotic Surgery – a UK Pilot Scheme

Abstract Aim Training the trainees in robotic surgery is a specialised and crucial process, given the precision and complexity involved in performing operations using robotic systems. Robotic training for trainees is challenging due to limited access to robotic systems and the lack of training opportunities. We describe how we implemented a training programme for trainees at West Hertfordshire Teaching Hospitals (WHTH) NHS Trust within a year of the consultants starting their robotics programme. Method Specialist trainees at WHTH who would have been offered training in laparoscopic surgery in colorectal, upper gastrointestinal and general surgery were selected to train as console surgeons on the CMR Surgical Versius system. All trainees had been on a first assist course and had experience in assisting in robotic surgery. Training included online modules, metrics-based virtual training, and technical skills assessment. Live operating was supervised by consultant trainers who sat beside the trainee. Results Six trainees ranging from ST4 to ST8 level were selected to partake in the training programme over a period of six months. Operations were broken down into modular parts and included segmental colectomies, anterior resections, cholecystectomy, and inguinal hernia repair. The trainees have participated in over thirty operations. Feedback from consultant trainers was given verbally and through work-based assessments. No adverse events were reported in training cases. Conclusions Robotic surgical training for specialist trainees can be implemented safely and in a timely manner. Objective metrics such as docking time, console time and volumetric hand motion may help with trainee assessment in the future.

Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series.

This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan). We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction. Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days. In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Task division by multiple console surgeons is beneficial for safe robotic pancreaticoduodenectomy implementation and education.

The optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022. This study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach). This study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618min, p < 0.001), and the postoperative major complication was less frequent (45% vs. 12%, p = 0.003) in the multiple approach group, although less experienced surgeons performed the multiple approach (number of RPD experiences: 19 cases vs. 5 cases, p < 0.001). The console surgeon turnover between the resection and reconstruction resulted in a safe pancreatojejunostomy performed by the less experienced surgeon (number of pancreatic reconstruction experiences: 6.5 vs. 14 cases, p = 0.010). Surgeons who started RPD with a multiple approach observed a reduction in surgical time and a lower incidence of complications earlier than those who started with a single approach. Task division during the early introduction phase of RPD using the multiple approach demonstrated potential contributions to improved surgical outcomes and enhanced educational benefits.

Robot-assisted approach using a laparoscopic articulating vessel-sealing device versus pure-robotic approach during distal pancreatectomy.

Robotic distal pancreatectomy (RDP) has emerged as a minimally invasive approach to left-sided pancreatic tumors. This study aimed to evaluate the efficacy of the robot-assisted approach (RAA) using a laparoscopic articulating vessel-sealing device (LAVSD) during RDP by comparing it with the pure-robotic approach (PRA). Among 62 patients who underwent RDP between April 2020 and December 2023 at Fujita Health University, 22 underwent RAA (the RAA group). In RAA, console surgeons mainly prepared the surgical fields, and assistant surgeons actively dissected the adipose and connective tissues using LAVSD. The surgical outcomes of these patients were compared with those of 40 consecutive patients who underwent RDP with PRA. In total, 28 males and 34 females with a median age of 71years were analyzed. The console surgeon's prior experience of performing RDP was similar between the groups (RAA; median, 6 [range, 0-36], PRA; median, 5.5 [range, 0-34] cases). The operation time was significantly shorter in the TST group (median, 300.5 [range, 202-557] vs. 363.5 [range, 230-556]min, p = 0.015). Major complications (Clavien-Dindo ≥ grade 3a) occurred less frequently in the RAA group (4.6% vs. 25.0%, p = 0.028). Although the median postoperative hospital stay was slightly shorter in the RAA group (median, 12 [range, 8-38] vs. 14.5 [8-44]days, p = 0.095), no statistically significant difference was observed. Compared with PRA, RAA using LAVSD is found to be safe and feasible in introducing RDP for operators with little experience.

A resident robotic curriculum utilizing self-selection and a web-based feedback tool.

To describe an obstetrics and gynecology residency robotic curriculum, facilitated by a web-based feedback and case-tracking tool, allowing for self-selection into advanced training. Phase I (Basic) was required for all residents and included online training modules, online assessment, and robotic bedside assistant dry lab. Phase II (Advanced) was elective console training. Before live surgery, 10 simulation drills completed to proficiency were required. A web-based tool was used for surgical feedback and case-tracking. Online assessments, drill reports, objective GEARS assessments, subjective feedback, and case-logs were reviewed (7/2018-6/2019). A satisfaction survey was reviewed. Twenty four residents completed Phase I training and 10 completed Phase II. To reach simulation proficiency, residents spent a median of 4.1h performing required simulation drills (median of 10 (3, 26) attempts per drill) before live surgery. 128 post-surgical feedback entries were completed after performance as bedside assistant (75%, n = 96) and console surgeon (5.5%, n = 7). The most common procedure was hysterectomy 111/193 (58%). Resident console surgeons performed portions of 32 cases with a mean console time of 34.6 ± 19.5min. Mean GEARS score 20.6 ± 3.7 (n = 28). Mean non-technical feedback results: communication (4.2 ± 0.8, n = 61), workload management (3.9 ± 0.9, n = 54), team skills (4.3 ± 0.8, n = 60). Residents completing > 50% of case assessed as "apprentice" 38.5% or "competent" 23% (n = 13). After curriculum change, 100% of surveyed attendings considered residents prepared for live surgical training, vs 17% (n = 6) prior to curriculum change [survey response rate 27/44 (61%)]. Attendings and residents were satisfied with curriculum; 95% and recommended continued use 90% (n = 19).This two-phase robotic curriculum allows residents to self-select into advanced training, alleviating many challenges of graduated robotic training.

Initial Experience of Robot-Assisted Laparoscopic Nephroureterectomy in Japan: A Useful Technique Using a Vessel Sealing Device for Securing a Good Surgical Field and Efficient Sealing.

Although robot-assisted nephroureterectomy (RANU) has been increasingly used worldwide, the history of RANU remains short, and the optimal surgical method for performing RANU has yet to be established. Here we introduce the ideal approach for RANU using the Vessel Sealer Extend (VSE). RANU was performed by using a da Vinci Xi surgical system with fenestrated bipolar forceps (by the left arm), and monopolar scissors or needle drivers (by the right arm), and the VSE (by the third arm). First, nephrectomy and lymphadenectomy were performed at the kidney direction stage, followed by the removal of the distal ureter and suturing of the bladder at the bladder direction stage. The key point of our technique is that the console surgeon can continue to obtain the optimal surgical field by traction using the third arm, and thus cut the tissue by smoothly switching between the right hand and the third arm without the need to exchange instruments, especially in the kidney direction stage. In this study we performed RANU in nine patients and lymphadenectomy in seven patients. The median console time was 195 (range: 165-265) min, the median blood loss was 55 (range: 5-179) ml. In eight cases of RANU using the VSE, no lymphatic leakage was observed and all procedures could be performed safely. The use of VSE provides sufficient coagulation and optimal surgical field development, thus allowing console surgeons to perform RANU more safely.

Three-incision robotic major lung resection for cancer.

BackgroundRegardless of the current trend in reduced port surgery, robotic surgery generally requires multiple (≥4) skin incisions for robotic arms and patient-side surgeons. In addition, the use of multiple arms results in interreference between the arms and the patient-side surgeon. In the current study, we reviewed our initial experience of a less invasive robotic approach for lung cancer.MethodsWe used 3 arms of the Da Vinci Xi system in an original manner: the camera was set at the most ventral arm for patients and the forceps for right and left hands were set at the more dorsal arms. We made a 4-cm incision in the eighth intercostal space along the middle-axillary line for the insertion of 2 ports for a camera and forceps. This window was eventually used for the extraction of the resected lobes. In addition, we made 1-cm incision along the posterior-axillary line for the remaining arm, and a 1.5-cm incision along the anterior-axillary line for a utility window for the patient-side surgeon.ResultsOur port setting contributed to preventing interference between the 2 adjacent arms (camera and forceps), as well as to improving the performance of the patient-side surgeon who does not experience interference from the robotic arms. During the initial experiences of 39 patients, the same procedure was successfully completed by 3 different console surgeons. There were no catastrophic events during the operations or in the 90-day postoperative period, although we experienced 2 open conversions (5%) for noncritical bleeding.ConclusionsWe established a 3-incision robotic surgery for lung cancer, which in addition to being patient-friendly, may facilitates collaboration between the console-surgeon and patient-side surgeon without compromising the performance of the console surgeon.

Impact of positive surgical margin status in predicting early biochemical recurrence after robot-assisted radical prostatectomy

We investigated the association between positive surgical margin (PSM) status and biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP) to develop a prognostic factor-based risk stratification model for BCR. We analyzed the data of 483 patients who underwent RARP at our hospital between October 2010 and April 2019; 435 patients without neoadjuvant therapy were finally included. The BCR-free survival rate was determined using Kaplan-Meier analysis. Effects of the PSM status, including the number of PSMs, Gleason score (GS) at a PSM, and the maximum PSM length for BCR, were investigated using Cox regression analysis. BCR was confirmed after RARP in 61 patients (14.0%), and PSM was confirmed in 74 patients (17.0%); PSM was a significant predictor of BCR (p < 0.001). The median number of PSMs was 2 (1-6), and the median maximum length of PSM was 6.0 (2.0-17.0) mm. Multivariable analysis showed lymph node invasion (p < 0.001), GS of ≥ 7 at a PSM (p = 0.022) and a maximum PSM length of > 6.0mm (p = 0.003) were significant predictors of BCR. We classified the patients without lymph node invasion into good-, intermediate-, and poor-risk groups according to the other two risk factors (presence of 0, 1, and 2 factors, respectively) and rates of 1-year BCR-free survival (100.0, 72.7, and 48.1%, respectively). Higher GS at PSM and greater length of PSM were significant predictors of BCR after RARP, and console surgeons should be careful to prevent PSM during RARP.

Quantifying the “Assistant Effect” in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance

Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP). Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors. 92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P=0.011), and prior laparoscopic experience (P<0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho=0.248, P=0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P=0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing. This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.

PE21 - Robotic surgery is safely performed for patients and healthcare workers during COVID-19 pandemic

Introduction & Objectives: In this study, we investigated the safety of robotic surgery during the pandemic period concerning new-acquired COVID-19 infections for both patients, assessed by follow-up telephone interview, and healthcare workers, assessed by swab tests on SARS-CoV-2. Materials & Methods: We performed a retrospective single-centre cohort study of patients undergoing robotic surgery in the initial 2-months period of COVID-19 focusing on safety. Patients’ COVID-19 infection status was assessed by telephone follow-up at a minimum of 14 days (median: 48) after robotic surgery. All healthcare workers involved in robotic surgery including console surgeons, bedside surgeons, anesthetists, scrub nurses and anesthesia nurses were investigated for presence of SARS-CoV-2 in nasopharyngeal swabs at three different time points during the study period from 12 March to 11 May 2020. Results: After 61 robotic surgeries, 1 patient (1.6%) had a COVID-19 infection. 60 healthcare workers (4 console surgeons, 8 bedside surgeons, 21 anesthetists, 13 scrub nurses and 14 anesthesia nurses) that were cumulatively exposed to 1,187 hours of robotic surgery had no COVID-19 infection. One patient with proof of SARS-CoV-2 on postoperative day two after radical prostatectomy had complete recovery without need for ventilation. After this potentially contagious robotic surgery, 8 healthcare workers with direct patient contact had no COVID-19 infection after 2 weeks and follow-up with each 3 nasopharyngeal swabs. Conclusions: Early clinical experience of robotic surgery during COVID-19 pandemic on 61 patients shows that robotic surgery can be safely performed for both patients and healthcare workers. In particular, there was no COVID-19 infection among 8 healthcare workers with direct contact during potentially contagious robotic surgery on a patient for whom COVID-19 infection was proven two days after surgery.

A Novel Resident Robotic Curriculum Using Self-Selection for Advanced Training and a Single Web-Based Tool for Feedback and Case-Tracking

Study Objective Describe a novel two-phase robotic curriculum facilitated by a web-based feedback and case-tracking tool, which allows residents to self-select into advanced training. Design Descriptive. Setting Academic Hospital. Patients or Participants OBGYN residents and faculty. Interventions Phase I (Basic), required of all residents, includes online training modules, assessment, and robotic dry lab. Phase II (Advanced) console training is elective. Residents complete 10 SIM drills to proficiency before performing live surgery. A web-based tool is used for surgical feedback. Resident online assessments, SIM lab reports, feedback, and case-logs were reviewed (7/2018-6/2019). Attendings and residents completed a beta-tested satisfaction survey. Measurements and Main Results All 24 residents completed Phase I training. Phase II was initiated by 12 residents and 10/12(83.3%) completed all 10 SIM drills. A median of 10(3,26) attempts were required to complete each drill with a mean time of 5.1hrs to complete all drills. 128 web-based post-surgical feedback entries were completed. Residents performed as bedside assistants (75%,n=96), console surgeon (5.5%,n=7), or both (19.5%,n=25). Most common tracked procedure was hysterectomy 111/193(57.5%). Console surgeons performed 32 cases with a mean console time of 34.6±19.5min. Most common procedure steps included: colpotomy/cuff closure 31.1%, uterine artery 75% and utero-ovarian vessel seal/transection 84.4%(n=32). 28/32(87.5%) Global Evaluative Assessment of Robotic Skills (GEARS) assessments were completed. Mean GEARS score 20.6±3.7(n=28), communication (4.2±0.8,n=61), workload management (3.9±0.9,n=54), and team skills (4.3±0.8,n=60). Residents completing >50% of case were assessed as “apprentice” 38.5% or “competent” 23.1%(n=13). 27/44(61.4%), satisfaction survey response rate. After curriculum change, attendings considered residents prepared as bedside assistants and console surgeons (100%), whereas only 16.7% were prepared before (n=6). Respondents were satisfied with the curriculum (95.0%), found the web-based tool helpful to give/receive feedback (90.0%), and recommended continued use (90.0%) (n=19). Conclusion This novel robotic curriculum allows residents to self-select into advanced training. A web-based tool improves individualized feedback and case-tracking alleviates many challenges of graduated robotic training.

The development of a robotic gynaecological surgery training curriculum and results of a delphi study

BackgroundTechnology for minimal access surgery is rapidly progressing in all surgical specialities including Gynaecology. As robotic surgery becomes established in increasing numbers of hospitals, there is no set curriculum for training in robotic gynaecological surgery or the assistant role in use in the UK. The purpose of this study was to determine a list of competencies that could be used as the basis of a core robotic gynaecological surgery curriculum, to explore its acceptability and the level of interest in undertaking training in robotics among obstetrics & gynaecology (O&G) trainees.MethodsA four-round Delphi study was conducted using members and associates of British & Irish Association of Robotic Gynaecological Surgeons (BIARGS). In Round 1 respondents were asked to propose standards that could be used in the curriculum. In the following three rounds, the respondents were asked to score each of the standards according to their opinion as to the importance of the standard. Items that scored a mean of 80% or above were included in the final proposed curriculum. Following this, a national survey was conducted to explore the interest among O&G trainees in undertaking a formal robotic training for the first assistant and console surgeon roles.ResultsThe items proposed were divided into three separate sections: competencies for a medical first assistant; competencies for a console surgeon; continued professional development for trained console surgeons. From the national survey; 109 responses were received of which 60% were interested in undertaking a formal training for the first assistant role, and 68% are expressing interest in training for the console surgeon role.ConclusionUndertaking a Delphi exercise to determine a core gynaecological robotic training curriculum has enabled consensus to be achieved from the opinions of BIARGS members/associates. There is interest among O&G trainees at all levels of training to gain experience and develop their skills in robotic surgery by undertaking a formal training in robotic surgery at both the first assistant and console surgeon level.

P131 REVEALING THE ERGONOMIC CRISIS OF AN UPPER GASTROINTESTINAL ROBOTIC SURGEON – STILL A LOT TO IMPROVE IN MINIMALLY INVASIVE SURGERY

Abstract Introduction/Aim Minimally invasive technologies have improved outcomes after esophagectomy and the use of robotic technology in Europe is rapidly increasing. Even though robotic technology was primarily developed to improve perioperative outcomes, many robotic surgeons complain about ergonomics when using existing devices. Aim of this study is to evaluate the ergonomics of the newest robotic technology in a center of excellence for upper gastrointestinal surgery. Background and Methods Starting 02/2017 the latest available robotic system (davinci xi) was introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n&gt;300 esophageal cases/year). Surgeons ergonomics were studied using a standardized video capture and touch sensor protocol (Fig 1 &amp; 2). Data recorded were analyzed to study whether the new robotic system was used in an ergonomic fashion throughout robotic esophageal surgery. Results From 02/2017 – 05/2019, a total of 90 mainly upper gastrointestinal robotic cases including 45 Esophagectomies for cancer and 25 Heller Myotomies were performed. All cases were performed safely without operation-associated intraoperative complications. Even though experienced robotic console surgeons used the robotic device, the davinci xi arm rest was used in less than 25% of surgery time (Fig. 3), resulting in loss of efficacy when using the robotic range of motion. Video documentation using the new technology is provided to showcase the dilemma. Conclusion Robotic technology allows for safe minimally invasive upper gastrointestinal surgery. Further development in robotics should focus on improvement of surgeons ergonomics.

Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center.

The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery. A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy. A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case. The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications.

Initial single institution experience with robotic biliary surgery and bilio-enteric anastomosis in southeast Asia.

Presently, experience with robotic biliary surgery (RBS) is increasing worldwide although widespread adoption remains limited. In this study, we report our initial experience with RBS. Retrospective review of a single institution prospective database of 95 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2018. Of these, 27 patients who underwent RBS were included in this study. RBS was performed by three principal console surgeons of whom one surgeon performed 23 (85%) and supervised all cases. Additionally, to evaluate our initial outcomes with bilio-enteric anastomoses, eight consecutive pancreatoduodenectomies were included. Of the 27 RBS performed, these included 10 hepaticojejunostomies with bile duct resections (including two concomitant pancreatoduodenectomies and one right hepatectomy) for choledochal cysts, bile duct strictures and biliary malignancies; five liver resections with hilar lymph node clearance for gallbladder cancer; four for Mirizzi syndrome; two cholecystectomies with cholecystoenteric fistula and two bile duct exploration after failed endoscopic treatment of choledocholithiasis. There were no open conversions, no 90-day mortality and four (14.8%) major (>Grade II) morbidities. The median post-operative stay was 6 (range 1-29) days and there was one (3.7%) 30-day readmissions. Of our first 18 robotically constructed bilio-enteric anastomoses, there was only one (5.5%) early anastomotic complication (bile leak requiring reoperation). Our initial experience demonstrated that RBS can be adopted safely with a low open conversion rate. Robotically constructed bilio-enteric anastomosis can be performed safely with a low anastomotic complication rate.

Impact of a Wireless System Upon Verbal Communication in a Simulated Robotic Operating Theater

ObjectiveTo compare the efficacy of communication via the standard Da Vinci Si speaker system with a wireless, hands-free audio system in a prospective blinded study. MethodsNine hundred and sixty surgical phrases were spoken in a simulated robotic operating room (OR), including 480 phrases expressed via the Da Vinci Si speakers and 480 phrases expressed through a wireless, hands-free system. Using a dual console robotic system, communication was evaluated. Wireless headsets were given to the console and assistant robotic console surgeons, bedside assistant, anesthesiologist, and circulating nurse. An accurate response was defined as hearing the phrase correctly and transcribing it on a data sheet. The primary outcome was the number of correct phrases recorded during the study and secondary outcomes included subjective clarity and effectiveness of communication reported using a Likert scale. ResultsOverall, the wireless, hands-free system increased the accuracy of communication (390/480 [81.3%]) compared to the conventional robotic system (310/480 [64.4%]; P <.001). The bedside assistant, anesthesiologist, and circulating nurse had significantly fewer correct phrases recorded than the assistant robotic console surgeon when using the robotic speakers (P <.05 for all). In contrast, there were no significant differences in the number of correct phrases recorded between different positions when using the wireless system. Subjectively, the wireless system resulted in improved clarity and effectiveness of communication (P = .021; P <.001, respectively). ConclusionRobotic operating systems have intrinsic barriers to effective communication between the surgeon and the rest of the operating room team. Improved communication could reduce surgical errors and improve patient safety.

VS03.04: MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY WITH ROBOTIC ASSISTANCE AND IMMUNOFLUORESCENCE: MODULAR STEP UP APPROACH FOR SAFE INTRODUCTION OF NEW TECHNOLOGY

Abstract Description Minimally invasive technologies have improved outcomes after esophagectomy and the use of robotic technology in Europe is rapidly increasing. Aim of this study is to evaluate the introduction of new technologies in a center of excellence for upper gastrointestinal surgery. Methods A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the center for the future of surgery (San Diego, CA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the davinci xi and stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n &gt; 300 esophageal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to safely perform robotic thoracic assisted Ivor Lewis esophagectomy. Results From 02/2017–02/2018, a total of 35 robotic cases were performed. All cases were performed safely without operation-associated complications. Level of difficulty was increased based on our modular step up approach without quality compromises. Video documentation using the new technology is provided. Conclusion The standardized training protocol and our modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications. Disclosure All authors have declared no conflicts of interest.

The concentration of console surgeons: prospective evaluation of the loss of attention in robotic-assisted procedures.

To prospectively evaluate the possible loss of attention among console surgeons performing robotic-assisted procedures using a validated psychological test. The concentration of one console surgeon was assessed before and after 25 robotic-assisted procedures (radical prostatectomies) using the validated d2 attention test (computer-assisted, Hogrefe test systems, Germany). Error frequency, work rate, and accuracy of task performance were evaluated as parameters of the fluctuation in concentration. Data were correlated with clinical parameters, including console times, positive surgical margin rates and the use of a nerve-sparing procedure. Pre- and post-operative test results revealed no differences in the number of items performed, but a significant decline in the error-corrected performance between the pre- and post-operative tests was observed with increasing console time (p = 0.046; median console time 123min.). No differences in the pre-operative tests for consecutive procedures (mean time between procedures 93min.) were found, whereas the number of errors (missed items) increased in the post-operative tests (p = 0.0025). The measured differences in test results showed no association with the positive surgical margin rate. A planned nerve-sparing procedure tended to result in a lower level of concentration found in pre-operative testing (p = 0.07). Concentration decrease and loss of attention during robotic-assisted procedures can be measured validly using the d2 attention test. Longer console times lead to loss of attention but consecutive procedures do not decrease the test or surgical performance. Further studies need to address whether similar effects apply to the comparable open or other robotic procedures or to different levels of surgeons experience.

Surgical training in robotic surgery: surgical experience of robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy with and without resident participation.

Robotic-assisted surgery is becoming more popular in general surgery. Implementation of a robotic curriculum is necessary and will influence surgical training. The aim of this study is to compare surgical experience and outcomes with and without resident participation in robotic inguinal herniorrhaphy. A retrospective review of patients who underwent either unilateral or bilateral robotic-assisted transabdominal preperitoneal (TAPP) inguinal herniorrhaphy, with and without resident participation as console surgeons from January through December 2015, was performed. Patient demographics, procedure-related data, postoperative variables, and follow-up data were analyzed. A total of 104 patients were included. Patients were significantly older in the Resident group (57.5±14.1 vs 50.6±13.5years, p=0.01). Gender, BMI, and ASA classification were similar between groups. There were similar mean operative times for unilateral (89.9±19.5 vs 84.8±22.2min, p=0.42) and bilateral (128.4±21.9 vs 129.8±50.9min, p=0.90) inguinal herniorrhaphy as well as mean robot console times for unilateral (73.2±18.4 vs 67.3±29.9min, p=0.44) and bilateral (115.5±24.6 vs 109.3±55.4min, p=0.67) inguinal herniorrhaphy with and without resident participation, respectively. Postoperative complications included urinary retention (11.1 vs 2.0%, p=0.11), conversion to open repair (0 vs 2%, p=0.48), and delayed reoperation (0 vs 4%, p=0.22) with and without resident participation, respectively. Patients' symptoms/signs at follow-up were similar among groups. Robotic-assisted TAPP inguinal herniorrhaphy with resident participation as console surgeons did not affect the hospital operative experience or patient outcomes. This procedure can be implemented as part of the resident robotic curriculum with rates of morbidity equivalent to those of published studies.Level of evidence 2b.