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Draft to Date: June 1, 2019
Courtney Green, MD [email protected]
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UCSF General Surgery
Resident Robotics Curriculum—DRAFT
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Curriculum Content Overview Pg 3
Detailed Curriculum:
STAGE I Pg 5
STAGE II Pg 6
STAGE III Pg 6-7
STAGE IV___________________________________Pg 8
**Refreshers**________________________________Pg 9
Session Outlines:
Dry Lab Pg 11
Proficiency Assessment ___ __Pg 12
Wet Lab _______________ _____________Pg 15
Simulator Access Set-Up Pg 16
Simulation Completion Form Pg 17
Case Logs
Bedside Surgeon Pg 18
Console Surgeon Pg 19
Attending Evaluation Pg 20
Letter for QEC Pg 21
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UCSF General Surgery Resident Robotics Curriculum
UCSF Curriculum:
Stage I: (Online modules) (Dry Lab) Docking Proficiency Stage II: (Dry Lab) Docking Proficiency Stage III: (Simulation) Documentation Stage IV: (Bedside/Console Procedures) Documentation **Refreshers** Goals:
1. Appreciate the potential advantages and disadvantages unique to robotic surgery and identify operations appropriate for robotic approach.
2. Understand the basic components of a robotic operating system and how they interact with each other
3. Recognize patient safety issues unique to robotic surgery 4. Learn how to dock the robot on to the patient, assist in the procedure and insert and
exchange robotic instruments. 5. Become comfortable with basic manipulation of robotic instruments, to include
camera control and clutching 6. Become comfortable assisting the primary surgeon using the dual robotic console
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Documentation: All documentation should be uploaded to the Robotic Smartsheet. Contact Alexi Callen if you cannot find the email sent with the link to access @ [email protected] The following list reflects all of the documentation components associated with UCSF’s Robotic Curriculum that are collected for the Department of Surgery.
1. Online module certificate (.pdf) 2. Docking proficiency form (.pdf) 3. Simulation completion sheet (with photographs of scores) 4. Bedside case log form(s)(10 cases total) 5. Console case log form(s) (20 cases total) 6. In depth console assessments (2 faculty) (2 separate docs) 7. Complete case list (to attached to chairman’s letter) 8. Letter from chairman
Qualification Equivalency Certification:
FDA regulated certification issued by Intuitive Surgical (With the proposed curriculum design, UCSF could become one of the few residency programs in the country with enough robotic exposure to realistically provide this opportunity to any and all general surgery residents) Letter from Department Chair (FDA requirement): documenting resident experience and competency at the time of graduation. To obtain QEC, UCSF residents need to meet the following requirements:
1. Successfully complete and document Stages I-IV a. Online Modules b. Dry Lab/Docking proficiency c. Console Exercises d. Bedside surgeon documentation for minimum of 10 cases e. Console surgeon for minimum of 20 cases
2. Completion of wet lab (SF or Sunnyvale) 3. Complete 2 detailed console reviews
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Detailed General Surgery Curriculum:
STAGE I: Online E-Modules / Training Videos Goals: be able to describe current robotic systems, list standard equipment, demonstrate ability to troubleshoot, describe benefits of robotics, demonstrate maneuvers to manage complications and errors that may occur. Instructions: www.daVinciSurgeryCommunity.com. Go to “Join the community.”
Fill in mandatory information: Drop down to Hospital (UCSF Medical Center). Enter specialty. Once logged in, save email and PW for future login sessions. Under the “Training” drop down, go to “Online training modules.”
Select Training on “da Vinci Xi” add to “My Training.”
Xi, System Modules for Residents/Fellows (P4/P4b) You are required to watch all the following sections FOR RESIDENTS/FELLOWS
a. Basics of Electrosurgery b. dV Xi System Overview c. dV Xi System Patient Cart and Draping d. dV Xi Vision System e. dV Xi System Docking f. dV Xi Intraoperative Patient Cart Use g. dV Xi System Surgeon Console h. dV Xi System Comprehensive Assessment
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Once you complete the training, please upload your assessment certificate to the Robotic Smart sheet. If you need assistance with access, please email Alexi Callen in the Surgery Education Office: [email protected]
If you have questions or need assistance with online training please contact one UCSF’s Intuitive Surgical Representatives: [email protected] for UCSF or VA; [email protected] for CPMC or Kaiser
STAGE II: Dry Lab OR Dry Lab
• During orientation week (interns) +/- Summer PGY2 year (and new transplants) • 1-2 hour session with surgical attendings in OR8 (Parnassus campus) • Groups of 3-5 • Yearly • Hands on overview of robot tool functions: docking/instrument exchange/collisions • Didactics on collisions • Completion of docking proficiency form (Qualtrics assessment)
• Docking proficiency form • Trouble-shooting collisions
STAGE III: Simulation Console Exercises
Da Vinci Skill Simulator Exercises: There are multiple simulators available for access at the surgical campuses where UCSF residents rotate. Simulators have several exercises to help users become more familiar with the robotic functions. We have identified some specific exercises to illustrate appropriate readiness for the operative environment.
All exercises can be accessed on any simulator. Locations and availability of the simulators vary by campus. Please see below for details:
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Campus # of Sims
Simulator Location Availability Access
Contact prior to use:
Questions?
PARNASSUS 2 OR 8
S0550
OR8: When OR not in use (+ evenings and weekends)
OR- Badge No
S0550: 24 hours Badge **use sign in sheet*
For badge access issues contact Surgery Education Office
MISSION BAY 2 In OR x2 OR: When OR not in use (+ evenings and weekends)
Badge No Lissette Chow [email protected]
CPMC
MISSION BERNAL
2 In OR OR: When OR not in use (+ evenings and weekends)
Badge No Joseph Cabrera (MB) 201-893-2877 Jessica Holman (VN) 415-600-5882
VAN NESS
2 In OR
KAISER 1 In OR OR: When OR not in use (+ evenings and weekends)
Badge No
Scott Randall
269-579-7978
VAMC 1 In OR OR: When OR not in use (+ evenings and weekends)
Badge No
Please see attached form (pg 16) for step-by-by step instructions for accessing the simulators.
Residents are required to achieve a score of 85% on each of the exercises. Some will be easy, but others will take multiple attempts to improve skills and reach 85%. We ask that
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residents take a screen shot (photo of monitor) with >85% completion of each exercise and document on the attached sheet (Pg 17) the date, time and location of completion. Once all the required modules have been completed with a score of 85% or greater, upload the form (Pg 17) to the Robotic Smartsheet. If you need assistance with Smartsheet access, please email Alexi Callen in the Surgery Education Office: [email protected]
Additionally, when you complete a task with a score >85% take a photograph of the robotic screen (illustrating the task name and your score). There is a place on the Smartsheet to upload each of the 6 photographs.
1. Camera targeting 1 2. Peg Board 2 3. Energy switching 1 4. Ring walk 2 5. Thread the rings 6. Suture sponge 2
If you have questions or need assistance with simulator training please contact your local Intuitive Rep: [email protected] for UCSF or VA; [email protected] for CPMC or Kaiser
STAGE IV: Bedside/Console Procedures
Bedside procedures: • Scrubbed, bedside assistant • ROLE: Participate in port placement, inserting trocars, docking the robot, inserting and
exchanging instruments, operate assistant port, trouble shoot collisions • 10 Cases required for UCSF • Document via Case Log (pg 18) and upload to smartsheet
Console procedures:
• Should have completed simulation exercises • Track cases and type/degree of console participation • Identify degree of involvement and types of skills utilized
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• Document via Case Log (pg 19) and upload to smartsheet
Final Console Evaluation
• After 20 cases have been completed • In depth performance review by two different attending surgeons for 2 separate robotic
cases (pg 20)
**REFRESHERS**
Bedside Review
• Monthly (usually during 1st week) • 1-6 residents per group – (residents on service) • Recurring at rotation sites for resident review • Organized with Da Vinci rep
Console Practice There are multiple simulators available for access at the various surgical campuses. Simulators have several exercises to help users become more familiar with the robotic functions. Although we have identified some required exercises for practice, we encourage residents to explore all exercises throughout their training. Maintenance of robotic skills is best achieved with consistent use. We encourage residents to access the consoles for practice during/before rotations where robotic cases are likely to be encountered. All exercises can be accessed on any simulator. Locations and availability of the simulators vary by campus.
Additional Robotic Resources:
Rotation Folders: UCSF Box Folders with case-specific pre-operative review materials. These are maintained by attending surgeons from each rotation and can be accessed using the following link:
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https://ucsf.box.com/s/7lbjconqbu0brka3o08rvcon5648hz23
Online Webinars: Weekly live webinars on robotic operative topics (peer-to-peer discussions hosted by Intuitive Surgical) with focus on the following specialties: Thoracic, MIS and Colorectal. For more information or to be included on the mailing list, please email: Rob Fletcher @ [email protected]
QEC Certification: To obtain a QEC certification you must compile the following documents and request a letter of recommendation from the Chair of the department of surgery. (pg 20)
1. Online module certificate 2. Docking proficiency sheet 3. Documentation of simulation completion 4. Bedside assistant cases (10) 5. Console cases (20) 6. Comprehensive attending review (2x)
Wet Lab: (specific lab outline on pg 15) **Of note, wet labs will initially be optional for UCSF residents. However, to obtain QEC residents will be expected to complete 1 of each lab prior to graduation. Sunnyvale Lab: When: Early June (yearly) – 4 hours Who: 16 spots (4 groups of 4). Upcoming R4s/R5s have first priority then open to others (fellows, residents, etc) Staffed: 4+ UCSF affiliated robotic general surgery attendings Chicken Lab: (Mission Bay) (Details pending) When: Q3 mo or Q4mo (second Saturday) 10am-noon Who: 4-8 students (priority) Staffed: Chern? Rogers? Kratz?
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DRY LAB SESSION:
Goals: • To improve resident knowledge and procedural competency with the robotic instrument • Participants will be able to recognize unique components of the robotic tool including:
o Port placement o Docking robot o Instrument Insertion and Exchange o Camera functions o Trouble shooting collisions
• Participants will be able to SAFELY and efficiently dock the robot and exchange instruments. Objectives:
• Describe the steps for docking the robot • List 3 key components of port placement • Demonstrate ability to dock robot and exchange instruments • Compare features of internal and external collisions • Recognize different types of collisions and explain how to manage
Activities: 1. Instructors will walk through the key steps, highlighting important features 2. Participants will complete an assessment to demonstrate competency in docking robot and
instrument exchange 3. Instructors will describe features of external and internal collisions 4. Participants will practice managing collisions from console and bedside.
~*~*~*~*~*~*~*~**~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~* 1) Walk through
PORT PLACEMENT • Size of ports: 8mm for camera, vessel sealer; 12mm for stapler, • Working distance for Xi robot: ~8cm apart • Measurements: to be performed after insufflation and creation of pneumoperitoneum • Port insertion: to second black line imprinted on trocar
BRINGING ROBOT TO BEDSIDE • Lighted green crosshatch marker (+) for guidance to center robot • Grab and move • Clutch to bring arm • Release tab = BEEP
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ARM STAGES • Insert camera into port & adjust angle • “Target” anatomy • Dock remaining arms
EXTERNAL ADJUSTMENTS ***Avoid Collisions*** • Clearance • Arm spacing and alignment • Burp / Assess for collisions
INSTRUMENTATION ***Avoid Instrument Injuries*** • Guided (visualize) tool exchange • Camera exchange • Clean camera / flip scope • Connect cables • LED lights
2) Proficiency Assessment Dock robot, camera and instruments to target anatomy.
Instrument Exchange Clean camera
Theme Skill ATTEMPT 1 2 Bringing Robot to Bedside
Green + 5cm from camera port Grab and move feature
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Clutch to bring arm to port Use release tab to dock. Hear beep
Arm stages Camera angle correct Camera target anatomy Dock remaining arms
External Adjustments Avoid Collisions
Adjust patient clearance Adjust proper spacing and alignment (fist width of elbows)
Burp ports Instrument Exchange Avoid Injuries
Guide tool exchange Guided camera exchange Use clutch at top of arm to move and advance instrument
Scope flip and cleaning Connect cables to energized instruments Identify colored LED light indications.
3) Collisions Info:
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3) Collisions Troubleshooting:
CONSOLE: internal • Cholecystectomy exercise • Arms: 1) Tip up; 2) Prograsp 3) Camera; 4) scissors • Balloon retraction
CONSOLE: external
• Cholecystectomy set up • Arms(BAD): 1) Tip up; 2) Prograsp 3) Camera; 4) scissors • Dropped clip in pelvis • CG set up—participant reach for clip • BEDSIDE TROUBLE SHOOT – patient clearance
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WET LAB OUTLINE
The goal of this lab is to provide residents with an opportunity to work with live tissue using robotic technology. The focus will be on applying surgical techniques and concepts in this unique environment. Instructors will be present and provide individual feedback for console surgeons. However, instructors will not be allowed to sit at the console and thus must rely on verbalization of instruction using language, gestures or a combination of both.
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Simulator Access Instructions:
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SIMULATION COMPLETION FORM
You are encouraged to explore all the exercises, but the following are required. To meet the requirement you need to achieve a score of 85%. Some will be easy, but others will take multiple attempts to improve your skills and reach 85%. Please record your score, the date you achieved it and the location of the simulator used in the table below. Once all the required modules have been completed with a score of 85% or greater, upload this form to the Robotic Smartsheet. If you need assistance with Smartsheet access, please email Alexi Callen in the Surgery Education Office: [email protected]
Module Date Completed Location Score (%) Camera targeting 1
Peg Board 2
Energy switching 1
Ring walk 2
Thread the rings
Suture sponge 2
***Don’t forget to upload a photograph of the robotic screen illustrating the task name and your score for each module listed above.
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ROBOTIC CASE LOG: Bedside Assistant Please place stickers from cases in which you were the bedside assistant and participated in inserting trocars, docking the robot, and inserting and exchanging instruments. You need a minimum of five cases. Once complete, please upload to the Robotic Smartsheet.
Patient Sticker Date Attending Operation
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ROBOTIC CASE LOG: Console Surgeon Please place stickers from a minimum of 5 cases in which you were the console surgeon and performed a significant portion of the case. You may copy this page as many times as necessary. Once complete, please upload to the Robotic Smartsheet.
Min/Mod/Max: Refers to the amount of time at the console you were acting as surgeon. (Min = 0-24% of the case as primary surgeon, Mod = 25-50% of the case as primary surgeon, Max = > 50% as primary surgeon)
Skills 1-6: Mark all that apply: 1) Retraction, 2) Tissue Manipulation, 3) Dissection, 4) Suture, 5) Electrocaudery/Staple, 6) other
Patient Sticker Date/ Attending
Operation/ Min/Mod/Max
Skills (1-6)
Jane Doe, MRN 1234567 1/1/17 Sigmoid
colectomy 1 X
2 X
3
Chern Min X
Mod Max 4 5 6
1
2 3
Min
Mod Max 4 5 6
1
2 3
Min
Mod Max 4 5 6
1
2 3
Min
Mod Max 4 5 6
1
2 3
Min
Mod Max 4 5 6
1
2 3
Min
Mod Max 4 5 6
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Attending Evaluation: Console Surgeon This form is for residents in their final year who have already performed 20 cases as console surgeon. The evaluation is to be completed by the attending physician and reviewed with the resident at the completion of the case. Once complete, please upload to the Robotic Smartsheet.
Patient Sticker Resident Date
Operation
Skill Adequate More Practice Recommended
Demonstrates 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 between instruments
SAFETY: Does not move instruments that are not in view
SAFETY: Recognizes tissue response to assess grip strength and handles tissue appropriately
Demonstrates ability to troubleshoot system and manage collisions
Please comment on areas of strength: Please comment on opportunities for improvement: The resident demonstrates competency on the robotic system. YES NO ____________________________ ______________________________ Attending Name Attending Signature
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Example QEC letter from Department Chair
Date:
Regarding: Robotic Surgical Qualification Equivalency Certificate
To Whom It May Concern:
As the interim chairman of the Department of Surgery at the University of California, San Francisco (UCSF), it is my honor and pleasure to voluntarily recommend an exceptional candidate, (Candidate Name), for your Robotic Surgeon Qualification Equivalent Certification.
I have worked directly with (Candidate Name) for 7 years as a surgical resident in our general surgery program. He/She has excelled in all 6 core competencies, patient care, medical knowledge, professionalism, systems-based practice, practice-based learning, and interpersonal and communication skills.
At UCSF we are exceptionally proud of our residents and their ability to independently operate safely and efficiently within the full scope of general surgery procedures during their final years of training. This has afforded our graduates the opportunity to seamlessly transition to independent practice immediately following residency without additional training.
Brief background into UCSF Robotics Curriculum: As you are aware, practicing surgeons who wish to begin performing robotic procedures are required to complete a training protocol through industry, and document a minimum number of proctored cases. While this has been successful at many institutions, we believe that we have the unique opportunity during the 5-7 year training program of our residency to far surpass these minimums and better prepare surgical residents to be successful in robotic general surgery procedures.
In 2016 our department implemented the UCSF General Surgery Robotic Resident Curriculum. This was developed with assistance from a group of multidisciplinary academic surgeon-educators whose focus was to improve the quality and consistency of resident and fellow education in robotic surgery. Our goals are to further standardize and streamline robotic surgery curricula, to support advances in educational resources, and collaborate effectively in regional to national dissemination. Surgical residents who have completed the full extent of this curriculum progress through didactics and on-line robotic training modules, demonstrate robotic docking proficiency and successful robotic simulation competence, have completed at least 2 robotic tissues labs and have performed a minimum of 10 bedside robotic cases and 20 cases as console surgeon.
We have included the robotic cases that (Candidate Name) participated in below. (Candidate Name) has clearly proven to be a dedicated, talented, safe and efficient robotic surgeon at UCSF. I give my highest recommendation to (Candidate Name) for the Robotic Surgery Qualification Equivalent Certificate.
Sincerely,
(Program Chair)
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Robotic Surgical Log for (Candidate Name) for (time period)
Procedure Number as console surgeon
Number as bedside assistant
Abdominoperineal Resection
Abdominal Colectomy
Adrenalectomy
Cholecystectomy
Esophagectomy
Gastrectomy
Gastric Bypass (Revision)
Heller Myotomy
Hepatectomy
Inguinal Hernia Repair
Left colectomy
Low anterior resection
Other (not listed)
Pancreatectomy (+/- Splenectomy)
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Parastomal Hernia Repair
Proctectomy
Rectopexy
Right colectomy
Sigmoid colectomy
Thoracic Wedge Resection
Thoracic Lobectomy
Total Colectomy with J-pouch and DLI
Ventral Hernia Repair
_____________________ ______________________________
Resident Name Signature
_____________________ ______________________________
Program Director Date
_____________________ ______________________________
Department Chair Date
