Upper tract surgery with the Da Vinci

Mr. Christian Bach

Fellow in Robotics, Southmead Hospital, Bristol, UK

- the Learning Curve

Roadmap

Traditional concept of the Learning Curve

Partial Nephrectomy experienced robotic surgeon experienced laparoscopic surgeon

Pyeloplasty experienced open surgeon

Adrenalectomy junior vs. senior surgeon LC depending on skill of the assistant

How to shorten the curve classical approach surgical warm-up

New Concept of Learning curve

Traditional concept of the Learning Curve

First description by TP Wright in 1936

J Aeronaut Sci 1936; 3: 122.

Partial Nephrectomy

WT (<20 min) after 30 cases

( p < 0.001 )

OT (<100 min) after 20 cases

( p < 0.001 )

The experienced Robotic Surgeon

Mottrie et al, Eur Urol. 2010 Jul;58(1):127-32

Surgeons experience vs. OT, WIT, eBL, PC repair,

complications

Mottrie et al, Eur Urol. 2010 Jul;58(1):127-32

Literature Overview

Mottrie et al, Eur Urol. 2010 Jul;58(1):127-32

• 26 cases until WIT plateau reached

Benway et al, Eur Urol. 2009 Mar;55(3):592-9.

Mean 17.8 min

• 19 cases until plateau reached

Benway et al, Eur Urol. 2009 Mar;55(3):592-9.

Mean 140 min

JSLS (2011)15:291–297

• After first 5 RPN, OT/WIT = last

18 LPN

• No sign. difference in eBL, HS

J Urol. 2011 Jun;185(6 Suppl):2517-22

• 15 to 20 cases to reach average open pyeloplasty time

Sorenson et al, J Urol. 2011 Jun;185(6 Suppl):2517-22

20 cases to reach mean LAP time

- 30 sec per operation

Brunaud et al, Am J Surg. 2008 Apr;195(4):433-8

Operative time vs.

108 min 88 min123 min 92 min

- Skill of assistant- Surgeons experience

Brunaud et al, Am J Surg. 2008 Apr;195(4):433-8

Roadmap

Traditional concept of the Learning Curve

Partial Nephrectomy experienced robotic surgeon experienced laparoscopic surgeon

Pyeloplasty experienced open surgeon

Adrenalectomy OT junior vs. senior surgeon OT vs. skill of the assistant

How to shorten the curve Classical approach Surgical warm-up

New Concept of Learning curve

Classical approach to training

Orvieto et al., BJU Int. 2012 Jul;110(1):2-13

Surgical warm-up

“ Preoperative warm-up for 15 to 20 minutes with simple surgical exercises leads to a substantial increase in surgical skills proficiency during follow-up tasks ”

“ Even the most experienced can increase specific psychomotor skills associated with a laparoscopic environment by doing simple exercises on a virtual reality simulator, just before an operation. These improvements are reflected in more accurate handling of tissue during laparoscopic cholecystectomy ”

“ Warm-up in a virtual reality environment improves performance in the operating room ”

Kohol et al, J Am Coll Surg. 2009 Feb;208(2):255-68

Moldovanu et al, JSLS. 2011 Oct-Dec;15(4):533-8

Calatayud et al, Ann Surg. 2010 Jun;251(6):1181-5

JSLS 2012 Jan-Mar: 16(1): 3-9

Time Cobra rope

Average suturing errors Time for suturing task

Concept of parallel learning

Definition individual steps

Quantification of difficulty

Introduction of structured training program

Training of simpler steps first

Monitoring of progress

Dev et al, BJU Int 2012 Apr;109(7):1074-80

Ralp – Surgical Steps  Patient hospital number Date Consultants case

Step      

1 Patient positioning, port placement, docking

421014 10 Aug 2011DAG

  1385036 16 Aug 2011DAG

  1360097 16 Aug 2011DAG

  2037929 8 Sep 2011DAG

  788753 14 Sep 2011DAG

       

2 Bladder take down anterior fat

796467 17 Aug 2011DAG

  530724 8 Sep 2011DAG

  788759 14 Sep 2011DAG

  1114316 19 Sep 2011EWR

  1385039 18 Okt 2011 DAG

       

3 Division of endopelvic fascia and DVC

796467 17 Aug 2011DAG

  1365089 23 Aug 2011DAG

  1364939 25 Aug 2011DAG

Proposal of surgical steps

Patient positioning, access, port placement, docking

Bowel mobilization

Hilar dissection

Tumor identification

Hilar control

Tumor excision

Renal reconstruction, renorrhaphy

Specimen retrieval and closure

New concept of Learning Curve

Take Home Message

Learning Curve 20- 30 cases

Laparoscopic skills helpful

Skilled assistant beneficial

Think of warm up

Structured program needed

Parallel learning instead of proctoring?