Is Robotic Surgery Highlighting Critical Gaps in Resident Training?

摘要

Integrating robotic surgery into resident training is challenging. The robotic environment requires reconsideration of the apprenticeship model for surgical training and development of new curricula and instructional approaches to ensure skill acquisition. The surgical literature has mentioned the need to improve resident training in robotic surgery. This article highlights components of the robotic teaching environment that limit the efficacy of current training models. By targeting these components, educators can begin to develop more effective curricula and instructional strategies for surgical residents.The robotic learning environment is complex. It incorporates a physically distant operative field, separating the trainer and the trainee; it makes the surgeon less dependent on assistance from a resident; and it necessitates acquisition of perceptual expertise without tactile information. At teaching hospitals, residents are exposed to an increasing number of robotic procedures, yet this often occurs in the context of observers, not participants. This has resulted in an emerging training gap. By considering relevant cognitive learning theories, we can guide surgical educators to new approaches to reduce this gap.While recent literature highlighted the feasibility and safety of implementing robotic curricula in residency, few studies have evaluated their efficacy, or described curricular components in detail.1 Surgical educators need a deep understanding of the robotic environment to appropriately evaluate the efficacy of resident integration in the operating room.Robotic technology provides independence for surgeons. Using the robot, 1 surgeon controls 4 robotic arms and manipulates the camera independently, decreasing the need for residents as assistants. While beneficial to hospitals with limited staffing, this aspect of robotic surgery presents challenges in teaching settings. Typically, in open or laparoscopic operations, residents obtain technical skills as surgical assistants, providing retraction and tissue manipulation essential for creating a functional operative field. This experience allows learners to understand how the surgeon's movements (degree of tension or retraction) affect the operative field. Residents stand across from, or adjacent to, the attending surgeon throughout the procedure—often with arms entangled in an effort to create adequate visualization. Residents directly observe the attending physician's physical movements, including minute details of individual digit placement,2 while performing each operative step.Robotic surgery technology is entirely different. It creates a physical distance between the operating surgeon, the operative field, and any assistants or learners. Residents are positioned at the bedside assisting with instrument exchange, or seated at a console distant from the sterile operative field. They cannot see the attending's physical movements, and cannot appreciate when the attending surgeon “clutches,” repositioning the hands, maximizing economy of motion. Residents also are unaware when the attending reaches for the foot pedal to swap robotic arms or activate electrocautery. Residents are limited to observing the movements of the robotic arms, either extracorporeally from the bedside or intracorporeally from a console or monitor.To learn to perform the movements as they appear on the screen, the resident must recreate the movements of the surgeon seated at the console. In contrast, in open and laparoscopic surgery, the operating surgeon's movements are open and visible. In the robotic environment, the operating surgeon's movements cannot be fully appreciated. How will residents understand what physical movements on the console are needed to translate into the same observed actions seen on the screen?The frequent experiential instruction that occurs in surgical training becomes complicated by a physically separated operative field (described by Zemel and Koschmann2 as the comb