Overview. Learning Objectives

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2 Overview The rapid and widespread adoption of robotics in surgery has changed the minimally invasive surgical landscape within the last decade. Such rapid adoption and dissemination of this technology has largely resulted from the perceived benefits of improved ergonomics, dexterity, safety, and ease of surgery. Each year, an increasing number of general surgery cases are being performed with robotic assistance. As more hospitals continue to adopt this platform, it is becoming increasingly essential that general surgeons become properly trained in robotic technology. As the clinical applicability and implementation of robotic surgery moves forward, it is imperative that a structured curriculum which encompasses the acquisition of basic robotic skills and procedural tasks be made available to surgical trainees. This robotic surgery curriculum has been developed to guide robotic surgery training throughout the General Surgery Residency. A general overview of the curriculum can be seen in Figure 1. Learning Objectives 1. Describe the individual components of the da Vinci System including the surgeon console, patient cart, and vision cart. 2. Learn the basics of electrosurgery including: how electrical currents are harnessed in electrosurgery, how generators and energy instruments work, and best practices for electrosurgery. 3. Become familiar with the various types and functions of available Endowrist instruments. 4. Develop proficiency in core da Vinci technical skills through virtual reality simulation exercises and hands-on experience in a dry laboratory environment. 5. Become proficient in tasks required to beside assist robotic surgery cases including: port placement, docking the patient cart, and instrument insertion and exchange. 6. Develop proficiency in the skills necessary to perform live da Vinci Surgery cases including: mastery of the instruments, handling of tissue, and appropriate decision making and judgement.

3 Robotic Surgery Training Pathway Cognitive Component Technical Component Case Observation* Required Readings* Hands-On *Denotes mandatory requirement. Time Requirements of Mandatory Components: da Vinci emodules (2.5 hours) Case Observation (Varies) Required Reading (30 mins) da Vinci Virtual Reality Modules (5 hours) Cognitive component must be completed prior to starting technical component. (10 Cases) Console Surgeon Training Figure 1 : Overview of robotic surgery curriculum

4 C O G N T V E C O M P O N E N T da Vlinci elearning and Assessment Residents must complete the appropriate elearning for the both the da Vinci Si and Xi consoles to be granted simulator privileges. Course topics include basic system terminology, functions and safety features (Table 1 ). e-modules for da Vinci Si and Xi da Vinci Si Modules da Vinci Xi Modules dv Si for Residents and Fellows dv Si EndoWrist Stapler 45 Assessments: Si Comprehensive Assessment dv Si EndoWrist Stapler Assessment dv Xi EndoWrist Stapler Assessment dv Si EndoWrist Vessel Sealer Assessment dv Xi EndoWrist Vessel Sealer Assessment Table 1: Required elearning Modules Upon completion, trainees must pass the corresponding assessments with a score of 80% or better. All trainees must forward their certificate of completion to the Surgical Educator. Certificates must be received two weeks prior to the trainee's scheduled n-service Training session. All completion certificates will be uploaded to New nnovations to enable faculty to verify completion. Access to create a user account. See Appendix A for additional details regarding user account setup and e-module enrollment. Case Observation Residents must observe three robotic cases and submit appropriate documentation signed by the attending physician (see Appendix B). Required Reading Residents are encouraged to review the following selected articles published on robotic-assisted surgery which focus on its application to General Surgery. Barbash, G..,Glied, S.A. (2010). New Technology and Health Care Costs-the Case for Robotic Assisted Surgery. New England Journal of Medicine 363(8): Buchs,N.C.,Addeo, P.,Bianco, F.M.,Gorodner,V.,Ayloo, S.M., Elli, E.F.,et al. (2012). Perioperative Risk Assessment in Robotic General Surgery: Lessons Learned from 884 Cases at a Single nstitution. Arch Surg 147(8): Maeso,S., Reza, M., Mayol,J.A., Blasco,J.A.,Guerra, M.,Andradas, E.,et al. (2010). Efficacy of the Da Vinci Surgical System in Abdomi nal Surgery Compared with that of Laparoscopy: A Systematic Review and Meta-analysis. Annals of Surgery 252(2):

5 T E C H N C A L C O M P O N E N T da Vinci Virtual Reality Simulation Modules The technical skills component requires that trainees first demonstrate proficiency in da Vinci surgery skills through completion of a series of virtual reality modules on the da Vinci Surgical Skills Simulator. For instructions on gaining access to the simulation modules, refer to Appendix C. The main menu of the simulator console contains 8 different modules comprised of a series of exercises. Exercises within the 8 da Vinci modules have been assigned to four levels (i.e., ntroductory, Beginner, ntermediate, and Advanced) based on increasing difficulty of exercises (Table 2). Getting Started Complete the ntroductory Module: Trainees must first complete the Surgeon Console Overview for instructions on how to operate the da Vinci console prior to completion of the skills modules. Baseline Testing Trainees are required to complete baseline testing on the Beginner Module. This requires that the sequence of 11exercises in the Beginner level module be completed in one sitting with no prior practice. Module Mastery Exercises within the Beginner, ntermediate and Advanced modules must then be completed in a mastery based learning fashion. This necessitates that exercises within the Beginner, ntermediate, and Advanced modules be completed one-by-one, in sequence, until a score of 85% with "green checks" in all fields (i.e. time, economy of motion, instrument collisions, instrument force, vision of instruments, master of work-space range, drops, etc.) is achieved-indicating mastery of all areas tested. For emphasis, trainees must start with the "Camera Targeting 11 exercise within the Beginner Module and master the exercise before advancing to the next exercise (i.e. Scaling). However, trainees are permitted to advance to the next exercise of the curriculum before mastery of a given exercise is achieved if they have attempted a task >10 times. Despite being able to initially advance through the remaining exercises, trainees must revisit exercises they found challenging and achieve a score of 85% or greater to complete this portion of the technical skills curriculum. Record of Performance The da Vinci console will record your performance. t is imperative that trainees complete modules under their designated login only. Completion of modules under the default username will not provide the necessary documentation to fulfill curricular requirements. For a record of your module scores, please contact the Surgical Educator.

6 Console Module Surgeon Console Overview ntroductory Module Exercise Using the Simulator Ergonomic Adjustment Understanding cons Overview of Controls 1 Error Messages Beginner Module Console Module Exercise Camera & Clutching Camera Targeting 1 Scaling Ring Walk 1 1 EndoWrist Manipulation Pick and Place 1 Peg Board EndoWrist Manipulation 2 Matchboard 1 Ring and Rail 1 1 1, Energy & Dissection Energy Switching 1 j Energy Dissection 1 l Needle Driving Suture Sponge 1 1 Dots and Needles 1 ntermediate Module Console Module Exercise Camera & Clutching Camera Targeting 2 Ring Walk 2 1 Energy & Dissection Energy Switching 2 Energy Dissection 2 J EndoWrist Manipulation 1 Peg Board 2 1 EndoWrist Manipulation 2 Matchboard 2 Ring and Rail 2 Needle Targeting Needle Targeting. Thread the Rings 1 Needle Driving Suture Sponge 2 Dots and Needles 2 Advanced Module Console Module Exercise Camera & Clutching Ring Walk 3 1 Energy & Dissection Energy Dissection 3 EndoWrist Manipulation 2 Matchboard 3 l Needle Driving Suture Sponge 3 l Tubes 1 Suturing Skills Vertical Defect Suturing 1 Horizontal Defect Suturing Continuous Suturing Suturing Practice - nterrupted Suturing Table 2: da Vinci Virtual Reality Simulator Modules l l J

7 da Vinci Overview n-service Training Trainees must complete a live n-service Training led by a da Vinci surgeon or lead educator. This course offers learners hands-on experience using the da Vinci system and requires a time commitment of 4 hours and details the content found in Table 3. Guided Tool Change nstrument Arm Status End0Wrist nstrument Best Practices Surgeon Console Overview Successful mplementation of a da Vinci Surgery Session Leadership structure within the da Vinci operating room ' ' 1 1 Communication between the OR staff and surgeon Task assignment Standardization of the da Vinci System location System Component Overview Vision Cart Value 1 Surgeon Console Value Patient Cart Value Docking the Patient Cart Cannulas & Trocars Basic Port Placement Patient Positioning Patient Cart Overview: Positioning, Driving, and Docking EndoWrist nstrument Overview Components and Features nsertion and Removal Components and Features Touchpad Stereoviewer Display Master Controllers Footswitch Panel Surgeon Console Activities Dual Console Activities Emergency Procedures Fault Modes Event Logs Disable Patient Cart Arm or Master Controller Emergency Stop nstrument Release Kit Conversion to Open or Laparoscopic Surgery \ 1'. Hard-Cycle Power Troubleshooting Powering Off and Storing the System Table 3: da Vinci n-service Training Content ' l

8 Bedside Assist Training Bedside Assist Case Completion Subsequent to the da Vinci n-service Training, the resident must log 10 cases in the primary role of bedside assistant, focusing on establishing proficiency in each of the following areas: Port placement Docking the patient cart nstrument insertion and exchange Assisting during the procedure Case Logging These cases should be logged using the da Vinci Case Tracker. See Appendix D for additional instructions on electronic case logging. Performance Evaluation Residents must seek feedback from the attending physician regarding their performance. Console Surgeon Training Console Case Completion Upon completion of bedside training, residents must complete at total of 20 cases in the primary role of console surgeon. Residents will be granted the opportunity to participate as the console surgeon when the attending physician deems the resident to be sufficiently proficient in robotic surgical techniques. The resident will initially perform specific tasks as directed by the attending physician and will advance toward completion of more difficult portions of procedures. Resident participation and progression is at the sole discretion of the attending physician. Case Logging Trainees should log console cases using the online da Vinci Case Tracker. Residents are required to complete more than 50% of the case in order to count the case. See Appendix D for additional instructions on electronic case logging. Performance Evaluation Residents must seek feedback from the attending physician for qualifying robotics procedures. During the Chief Year, the resident should be able to demonstrate overall competency and perform both bedside and console surgeon tasks. An attending physician will be required to complete a postprocedure evaluation for 5 cases (see Appendix E). A minimum of 5 cases completed as a console surgeon must include a post-case review with the attending surgeon. The resident must be deemed as competent on the console for all of these cases. These cases must be performed with at least 2 different attendings and must be performed during the final year of residency. c====j

9 Hands-On Dry Laboratory Simulation Trainees are required to participate in a hands-on dry laboratory prior to sitting at the console to operate. This high-fidelity simulation requires trainees to interact with physical models while operating the actual da Vinci Surgical System Console. The nine exercises used in this inanimate skills module are designed to hone basic robotic surgical skills including: instrument handling, suturing (simple interrupted and running), knot-tying (surgeon's and square knots), camera driving and navigation, and clutching (Figure 2). Trainees are required to complete baseline testing for the nine tasks prior to progressing through the module. 2.Clutch/Camera Movement 3.Rubber Band Transfer 4. Suture (Simple nterrupted) 5.Clutch & Camera Peg Transfer 6.Rubber Band Transfer 7.Running/Cutting Rubber Band Figure 2: The nine exercises of the inanimate skills module. c====j

10 Ongoing Training The following activities are suggested to further develop and maintain proficiency in da Vinci Surgery skills and practices. Console Practice Residents are required to log 60 minutes on the simulator bi-weekly when on the MS Service. Video Library Review The Clinical Robotic Surgery Association (CRSA) has a video gallery showing robotic surgeries in various categories including: bariatric, colorectal, oncology, etc. Membership is free for residents and fellows. Visit clini calrobotics.com to create an account and view videos. The da Vinci Surgery Community has many videos of general surgery robotic cases. Log in to the community ( Alternatively, da Vinci training videos are available through the Fundamentals of Robotics Surgery (FRS) Curriculum. Log in to the program (

11 APPENDX A Joining the da Vinci Online Community Visit: Click on "Join the Community" nput your information to establish a login. Make certain to indicate that you are a "Resident or Fellow" so that your interface displays properly. Enrollment in emodules n the upper right corner of the interface, click the small white arrow which will display the following options: -My Profile -My Training -My Bibliography -My Cases Select "My Training" and on the following screen select "Add New Training" which will allow you to Search Online Training (see Figure 3). You are required to complete modules for both the da Vinci Si and Xi. To add the appropriate modules, input the following parameters select the System (Si or Xi) and the appropriate software. Software parameters for the Si and Xi are P9 and P6, respectively. Enroll in the modules as shown in Figure 4. Figure 3:Search Online Training My Training Figure 4: Required Training Modules for Si and Xi

12 APPENDX B Robotic Surgery Case Observation PGY: _ You must document observation of 3 cases. Submit completed forms to the Surgical Educator. Case 1 Date: Procedure: Attending Physician Signature: Case 2 Date: Procedure: Attending Physician Signature: Case 3 Date: Procedure: Attending Physician Signature:

13 APPENDX C Accessing Simulation Modules Power on & Log n: Press the white power button to turn on the console (Figure 5). Adjust the console so that it is ergonomically comfortable using the control panel on the left (Figure 6). Looking through the viewfinder, you will see a log in screen with an arrow in the center. You can move the arrow on the screen by inserting your fingers into the instrument controls and pinching your fingers together. Figure 5: Console overview Note: Your username is to be created in the system after your certificate from the cognitive modules is confirmed. Figure 6: Console controls

14 APPENDX D Case Logging n the upper right corner of the interface, click the small white arrow which will display the following options: -My Profile -My Training -My Bibliography -My Cases Select "My Cases" and on the following screen select "Add New Case" which will allow you to log in a new case.

15 APPENDX E Console Surgeon Evaluation This form is for residents in their final year who have already performed 15 cases in the primary role of console surgeon. The evaluation is to be completed by the attending physician and reviewed with the resident at the completion of the case. You must perform this evaluation for at least 5 cases. Submit completed forms to the Surgical Educator. Patient Sticker Resident: Date: Operation: Skill Demonstrating understanding of trocar placement and spacing Understands principles of docking and is able to dock in a timely fashion Uses camera appropriately and is able to focus the camera Demonstrates appropriate clutching and maintains hands in a comfortable workspace Demonstrates ability to use third arm and switch instruments SAFETY: Does not move instruments that are not in view Demonstrates ability to troubleshoot system and manage collisions Adequate More Practice Recommended Please comment on areas of strength: Please comment on opportunities for improvement: The resident demonstrates competency on the robotic system. Yes No The resident demonstrates competency on the robotic system. Yes No Attending Name Attending Signature Date =