Fundamentals of Robotic Surgery

The Fundamentals of Robotic Surgery (FRS) is an assessment curriculum meant to supplement the education and skill training of robotic surgeons. The program provides opportunity for these surgeons to demonstrate basic skills and knowledge that make them successful in their profession. Ultimately, FRS hopes to serve as a standard accreditation of skill in robotic surgery. Development has spanned four years and involved over 80 robotic surgery experts, medical educators, behavioral psychologists, psychometricians, and statisticians. Experts represented all major surgical specialties that utilize robots in the United States, the Department of Defense, and the Veterans Administration.

History

Consensus Conferences

Consensus Conference 1: Outcomes Measures (December 12–13, 2011)

Experts from surgical societies, surgical educational societies, surgical boards, and other relevant organizations met to determine which critical skills should be included in the FRS curriculum. Task deconstruction then took place to identify subtasks and errors that should be measured. A matrix of tasks was created using a modified Delphi methodology where tasks were matched with errors, quantitative metrics, and a description of the desired outcome. An anonymous classic Delphi rating was used to ensure concurrence, prioritize task ranking, and eliminate low-scoring tasks.

Consensus Conference 2: Curriculum Planning (April 29–30, 2012)

Four specific goals were addressed to begin the development of the curriculum:

1. Review the Outcomes Measures Table developed during Consensus Conference 1
2. Select which outcomes from the table should be included in the curriculum
3. Review and edit the Alliance of Surgical Simulation for Education and Training (ASSET) curriculum template
4. Begin curriculum development with metrics for each skill/task/error and formative/summative assessment tools

A full-cycle development process was utilized during curriculum planning, beginning with outcomes and metrics. To ensure the final curriculum and assessment methods met the requirements to determine proficiency, all stakeholders and accrediting bodies were to be involved in the development process.

Consensus Conference 3: Curriculum Development (August 17–18, 2012)

The goal was to complete the four modules of the curriculum, as follows:

1. Introduction to Surgical Robotic Systems
2. Didactic Instructions for Surgical Robotic Systems
3. Psychomotor Skills Curriculums
4. Team Training and Communication Skills

Consensus Conference 4: Validation Study Design (November 17–18, 2012)

The design of the FRS validation study was reviewed by clinicians, researchers, psychologists, and psychometricians in order to determine if it would satisfy the criteria for high stakes testing and evaluation. The discussion included:

1. Defining the research questions
2. Developing hypotheses within construct validity
3. Defining what constitutes an “expert” for benchmarking purposes
4. Criteria for institutions participating in Phase 4 studies (see study phase description below)
5. Determining what will be measured

• Face validity
• Content validity
• Construct validity
• Concurrent validity
• Predictive validity
• Inter-rater reliability
• Test-retest reliability
• Usability
• Acceptability

6. Study design phases

• Phase 1: Pilot at Florida Hospital Nicholson Center (logistics and refinements to model)
• Phase 2: Get face and content validity from the society leadership and boards
• Phase 3: Get face, content, and construct validity at test sites
• Phase 4a: Get concurrent validity with video correlations
• Phase 4b: Get predictive validity through the full research study at 14 research sites (ACS/AEI Accredited Institutes)

Validation Trials (January–October 2015)

The FRS curriculum is currently being tested for validity at 14 additional locations in the United States and Europe, as follows.

• Athens University – Athens, Greece
• Baylor University Medical Center, – Dallas, TX
• Beth Israel- Harvard – Boston, MA
• Center For Advanced Medical Learning And Simulation (CAMLS), USF – Tampa, FL
• Carolinas Healthcare System Charlotte, NC
• Duke University Hospital– Raleigh, NC
• EndoCAS, University of Pisa– Pisa, Italy
• Hartford Hospital – Hartford, CT
• Imperial College – London, UK
• Lahey Clinic – Boston, MA
• Lehigh Valley Health Network – Allentown, PA
• Louisiana State University Health, New Orleans, LA
• Madigan Army Medical Center– Tacoma/Seattle, WA
• Methodist Institute for Technology, Innovation and Education (MITIE)– Houston, TX
• University of Pennsylvania Health System – Philadelphia, PA

The Florida Hospital Nicholson Center acts as the FRS headquarters.

FRS Components

Online Curriculum

The online FRS curriculum was developed to be specialty and device independent and therefore teaches basic robotic principles. This will ensure that the FRS Online Curriculum can still be used as new surgery robots are developed. The four modules serve as a guide to robotic surgical systems, the cognitive skills required for safe use of these systems, the psychomotor skills relevant to robotic surgery, and the communication skills pertinent to clearly and effectively interact with surgical team members.

Psychomotor Skills Device

A Psychomotor Skills Device was developed as a standardized physical model on which surgeons could complete a series of tasks with the aid of a surgical robot in order to display specific skills. To ensure that only skilled and well trained surgeons could property perform the tasks during the psychomotor test, tasks were created with the following goals in mind:

1. Tasks should be 3 dimensional
2. Testing tasks should have multiple learning objectives that incorporate multiple skills while training tasks should have more focused learning objectives
3. Tasks and teaching methods should be cost effective
4. Tasks are designed on the physical model for assessment, but virtual reality models can be developed for training
5. Physical models are designed to be compatible with any robotic surgical system
6. Tasks are simple to administer and have inter-rater reliability
7. Preference is given to tasks with existing validity evidence

The benchmark criteria for each task was set by the learning curve of expert surgeons. These experts were invited to perform each task until they completed two consecutive trials with no improvement in their performance. The mean score of the performance of many experts was then calculated and set as the level of proficiency that much be achieved. The standard deviation was taken to determine levels for beginner, competent, expert, and master.

Simulator Exercises

Virtual reality simulation modules have been developed for 6 of the 7 FRS tasks: Ring Tower Transfer, Knot Tying, Railroad Track, 4th Arm Cutting, Puzzle Piece Dissection, and Vessel Energy Dissection. Simulation modules have been developed for the following systems:

• Intuitive Surgical da Vinci Skills Simulator
• Mimic dV-Trainer
• Simbionix Robotix Mentor

Robotic Surgeon Leadership Virtual World (RoboTeamView)

The Team Training Virtual World is an online game-like simulator that allows the user to act as the robotic surgeon in pre-operation, operation, and post-operation scenarios. Virtual Heroes has been contracted to create the Virtual World in close collaboration with the research team at Florida Hospital’s Nicholson Center.

Other Components

FRS has developed Team Training Videos and the Team Training Role Playing Script to supplement the existing components. The Team Training Videos are integrated into the final module of the Online Curriculum and allow the user to analyze interactions between members of an OR team. The Team Training Role Playing Script allows users to act out OR team interactions in person with one another in order to practice proper request, check-in, and call-out formats. (CITE)

Gynecology Specialty

An additional curriculum module and four additional psychomotor tasks (Bladder Flap, Colpotomy, Cuff Closure, and Ureter Dissection) were developed specifically for robot-assisted gynecological surgery. The curriculum covers an introduction to robot-assisted gynecology surgery, important literature on robotics, duties of the bedside assistant and the console surgeon, technical skills, and team training and communication.

Specialty curricula had been planned for Urology, Cardiothoracic Surgery, Colorectal Surgery, Spinal Surgery, and Operating Room Staff, but funding could not be secured.

References

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