Training and credentialing in Robotic Surgery in India

Current perspectives

Abstract

Robotic surgery has changed the landscape of surgery and ushered in a new era of technology-assisted minimally invasive surgery. There is a paradigm shift from traditional open surgeries to minimal access surgery, with robotic surgery being the new standard of care in some surgical fields. This change comes with an unprecedented influx of innovations in technology related to minimal access surgery, robotics and artificial intelligence. Despite the exponential advances in technology, there is a lacuna in the training and credentialling of robotic surgeons. In India, no dedicated training curriculum exists for trainees in robotic surgery. Thus, as robotic surgery continues to develop in India, it is imperative that robust training and credentialing systems are in place to ensure that patient safety and surgical outcomes are not compromised.

INTRODUCTION

As the field of surgery evolves along with the rest of the world, with an unprecedented influx of innovations in technology and techniques, there is a need for continuing education and training of surgeons to catch up with these advanced technologies. Robotic surgery is one such technology that changed the landscape of surgery and ushered in a new era of minimally invasive surgery, with more advanced and adaptable technology as compared to laparoscopic surgery.

The advent of robotic surgery was revolutionary, from initial scepticism to being the new standard of care in multiple fields of surgery. India is no exception to this; robotic surgery has become the norm in many institutes, especially in the fields of gastrointestinal surgery (robotic oesophagectomy and gastrectomy), surgical oncology (robotic cytoreductive surgery), general surgery (robotic hernia repair, cholecystectomy, choledochal cyst excision), urology (robotic prostatectomy and cystectomy) and gynaecology (robotic hysterectomy/myomectomy). Despite this, no standard curriculum exists for the training of robotic surgeons. At present, the trend of practicing robotic surgeons includes a fellowship course followed by clinical practice. During the advent of robotic surgery, this was acceptable; however, as robotic surgery continues to develop, it is imperative that robust training and credentialing systems are in place to ensure that patient safety and surgical outcomes are not compromised.

HISTORY OF ROBOTIC SURGERY

The description of the first robotic surgery done often varies amongst authors. It is generally accepted that Kwoh et al., who in 1985, utilised the PUMA 560 robotic system for neurosurgical biopsies.[¹] However, the first surgery done was credited to Davies et al., who performed a transurethral resection of the prostate who used a later series PUMA 650 system.[²] However, the dominant driving force for the development of active robotic systems was the urgent necessity of telepresence. The US Military team researched telepresence and telesurgery to potentially reduce mortality and morbidity of the military personnel in areas of conflict.[³] The Automated Endoscopic System for Optimal Positioning (AESOP) robotic platform was created by researchers, many of whom were initially involved in the initial military projects researching telesurgery and telepresence. The AESOP system used voice control functions for the positioning of the laparoscopic camera system (can delete). Modifications of the AESOP system resulted in the creation of the ZEUS operating system. The Zeus operating system was a three-armed platform that utilised the voice-activated camera system of the AESOP robotic platform. Similarly, Intuitive Surgical released the SRI Green Telepresence system, which later was modified into the current da Vinci system. These systems dominated the field of robotic surgery for a decade.[⁴] The first general surgery procedure was done using the da Vinci system in Belgium in 1997 for a cholecystectomy. Since then, various surgeries in different fields have been attempted successfully, with a paradigm shift towards converting open surgeries into minimally invasive surgeries.

Robotic surgery is not new to India. India received its first robotic system in 2000 at All India Institute of MedicalSciences, New Delhi. Since then, there has been an unprecedented growth in robotic surgery throughout India, encompassing all fields of surgery.[⁵]

NEED FOR ROBOTIC SURGERY TRAINING

In recent years, robotic surgery has been widely popularised and most fields of surgery have adopted it into their regular practice. Despite this, no validated or standardised curriculum for the training and credentialing of robotic surgery exists.

Robotic surgery represents a technological change; although viewed as an evolution of laparoscopic surgery, the skill set required is of another cadre. In laparoscopic surgery, the skills necessary involve manoeuvring within a restricted range of movement, whereas robotic surgery involves advanced console control and manoeuvring skills without any haptic feedback.[⁶]

Hence, as with the advent of any new surgical technology, responsible and comprehensive training and credentialing are prerequisites to ensure that patient safety and surgical outcomes are not affected during the training procedure.

A comprehensive training programme involving progression from simulation to real-time training is required to acquire skills in robotic surgery safely. A two-pronged progressive tiered approach, from pre-clinical to clinical training, attempts to minimise the footprint of surgical education on patient outcomes and has been embraced by several different groups. Assessments can be made between each training module.

A comprehensive curriculum-based simulation training effectively provides an excellent base for the initial training period; it can help tackle barriers faced by trainee surgeons during their learning curve in a safe and controlled environment, thus ensuring patient safety.[⁷⁸] There is an urgent need to fill this lacuna in robotic surgery training with a structured training course in skills, technology and troubleshooting.

ROBOTIC SURGERY TRAINING PARTS

For trainees to attain the requisite knowledge and skills to provide safe and effective patient care, surgical training in robotics should involve a structured, competency-based curriculum that allows the trainee to progress in a graduated fashion. This structured curriculum should involve pre-clinical and clinical components to facilitate the proper adoption and application of robotic surgery-specific skills. Robotic surgery credentialing should involve an expert-determined, standardised educational process, including a minimum proficiency criterion.[⁸]

A comprehensive training programme ideally consists of four primary modalities [Figure 1]:

Figure 1: Modalities of robotic training program

1. Knowledge acquisition
2. Skills training in a simulation setting
1. Dry lab simulation
2. Wet lab simulation
3. Virtual reality simulators.
3. Modular training
4. Non-technical skills training.

Knowledge acquisition

Knowledge acquisition must be twofold – First, the trainee must learn about the robot technology, functions, basic troubleshooting, device parameters and limitations of the system. Second, knowledge must be developed for individual surgical procedures; this involves patient selection, procedure indications, pre-operative preparation, patient and system positioning, docking, port placement and establishment of pneumoperitoneum, procedural steps, complications and their management. Informal hands-on tutorials may be integrated into this pre-clinical stage of the training; this creates a low-stress, interactive experience with the robot that will make the surgeon less dependent on the robot operator, thereby increasing confidence and ease of flow during the preparation phase.[⁸⁹]

Online tutorials on the fundamentals of the da Vinci Robot are provided by the vendor of the Robot-Intuitive Surgical®; these tutorials cover technical and functional aspects of the robot and troubleshooting tips. Certification in these online modules is considered a vital part of robotic surgery training and is a prerequisite in most centres.

Skills training

An apt robotic training programme requires a gradual transition between knowledge acquisition and performance of actual surgeries as with any new modality of training. Skills lab training involves the following:

Dry lab

Dry lab simulation is generally the first step in formal skills training. It is cost-effective and can reliably simulate real-time challenges. In addition, it is effectively a good interface for trainees to manage basic console troubleshooting. The consumables for the exercises can be modified according to availability and can consist of everyday items such as needles, sutures and beads to sophisticated dry vascular and bowel models. However, the disadvantage of the dry lab system is that assessment is complex; maintaining a standardised record is not feasible in all cases. A keen observer or evaluator for each trainee is required for the sessions to have benefit.[⁶]

To this effect, Siddiqueet et al. developed and validated the Robotic Objective Structured Assessment of Technical Skills (R-OSATS), an assessment tool that uses five standardised inanimate robotic surgery drills. A proctor directly observes the performance of the five drills: 'tower transfer', 'roller coaster', 'Big Dipper', 'train tracks' and 'figure-of-eight'. Performance for each drill is assessed across four categories: (1) accuracy, (2) force/tissue handling, (3) dexterity and (4) efficiency. Each exercise is scored from 0 to 20; the minimum passing score was 14 for each activity. Studies done showed that this tool showed validity and reliability in trainees and faculty surgeons from the branches of general surgery, urology and gynaecology.[¹⁰]

Wet lab

Wet lab training involves animal and cadaveric simulation models. These have the distinct advantage of simulating the human tissue consistency and anatomy. Wet lab training is considered one of the essential parts of a robotic training programme and is now incorporated into several training courses.[¹¹] Obvious disadvantages include ethical concerns and financial limitations; the costs of an animal skills lab are substantially increased due to a different robotic system requirement. Despite all these limitations, wet lab courses seem to enable a successful transition into robotic surgery and maintain techniques in clinical practice in the short and long term.[¹²]

Virtual reality simulators

Virtual reality (VR) simulation is now considered a vital part of robotic surgery training. Advantages include easy assessment and evaluation of progress. At present, five leading VR simulators are used for training, namely Robotic Surgical Simulator (RoSS™; Simulated Surgical Systems, Buffalo, NY); dV-Trainer™ (Mimic Technologies, Inc., Seattle, WA); SEP Robot™ (SimSurgery™, Norway); the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA) and more recently the Robotix mentor™ (3D systems, formerly Symbionix, Israel). Face validity, content validity and construct validity (except the RoSS system) have been determined to be accurate in these simulators. Apart from basic skills, these simulators also have applications to simulate procedure-specific components. The trainee sits at the console, and the console arms move, mimicking the operating surgeon. These help trainees to learn specific movements for specific procedures with movement feedback which can be used for evaluation. Finally, VR simulators also have an essential role in the maintenance of acquired robotic skills by providing a safe medium for practice.[⁶]

Modular training

After adequate acquisition of skills from simulation sessions, wet and dry lab sessions, the trainee then progresses to training in the operating room. Each trainee must have a dedicated mentor to guide and oversee training. The trainee starts with the most straightforward part of the procedure and gradually progresses to other facets of the operation according to the mentor's discretion. The transition of the mentor from a preceptor role (who steps in when required) to a proctor role (who solely supervises and allows the trainee enough opportunity to operate) indicates the progression of the candidate's training.[⁶]

Non-technical skills

Non-technical skills such as communication skills, leadership and teamwork, situational awareness and decision-making are of paramount importance and are grossly underestimated skills necessary for the robotic surgeon. A unique challenge seen in robotic surgery is the physical separation between the surgeon and the patient; thus, communication skills, teamwork and other non-technical skills are paramount in this setting. Studies have also demonstrated that non-technical skills are shown to impact the success of a surgical procedure significantly.[¹³] Theseskills can also be acquired by training courses such as Non-Technical Skills for Surgeons and Oxford NOTECHS II (Non-technical Skills Training Tools).

CURRENT SCENARIO IN INDIA

As of October 2021, more than 76 robotic installations are present in India in government and private institutions with more than 500 trained surgeons [Figure 2]. There are nine systems in government-funded institutions, including the All India Institute of Medical Sciences New Delhi, SGPGI Lucknow, PGIMER Chandigarh, All India Institute of Medical Sciences Rishikesh, All India Institute of Medical Sciences Jodhpur,Safdarjung Hospital New Delhi, Jawaharlal Institute of Post-Graduate Medical Education and Research and Delhi State Cancer Institute. Apart from government-funded institutes or medical colleges, there are numerous private training institutes all over India that conduct training courses, fellowships or observerships for robotic surgery. Apart from formal training sessions, junior faculty and residents may also get informally trained in robotic-assisted surgeries. The current scenario is that the consultant gets trained in robotic surgery fellowships and slowly transitions from doing open cases to robotic-assisted cases. As the consultant/faculty transit from open to robotics, junior faculty, fellows or residentsalso learn skills and proceduresand thereby gain experience. This is reflective of the general acceptance of robotic-assisted surgeries by the general public and government/private sector.

Figure 2: Spectrum of robotic training institutes in India

CREDENTIALING PATHWAYS

The arrival of robotic surgery into the operating room brings its own sets of challenges and difficulties for the surgical team. Surgical educators have a colossal responsibility to ensure not only the training of robotic surgery but also the standardisation and maintenance of competency of robotic surgeons. The challenge faced is the lack of a standardised curriculum, structured training and regulation. As with the advent of laparoscopic surgery, thorough credentialing systems are required to maintain standards of care. At present, several global certification programs are present, which Indian residents can apply to, and are listed below:

Fundamentals of robotic surgery

Fundamentals of robotic surgery (FRS) is a certification course created on 1 March, 2014, by a team of over 80 international robotic surgeons, medical educators, behavioural psychologists, statisticians and psychometricians. It is a multi-speciality course with a proficiency-based curriculum of basic skills to train and assess robotic surgery trainee surgeons and address the gaps in robotic surgery training. The course is divided into four modules: introduction to surgical robotic systems, didactic instructions for robotic surgery systems, psychomotor skills curriculum, team training and communication skills. A multi-speciality, multi-institutional randomised control trial was conducted between April 2015 and November 2016, showing better performance of those trained after completion of FRS as compared to controls.[¹⁴¹⁵]

Fundamental skills of robotic surgery

Fundamental skills of robotic surgery (FSRS) is a validated simulation-based course developed by an international group based at the Roswell Cancer Institute. The curriculum involves a series of 16 tasks grouped into four modules that are assessed with the Robotic Skills Assessment Score, which was designed for the FSRS course.[¹⁶] No OR-based training is present, but it serves as a foundation to other mentor-led programs. A formal Robot-Assisted Surgical Training (RAST) program from the Roswell Park Center Institute uses the FSRS curriculum with other hands-on tasks and takes between 5 days to 3 weeks to complete. There are three levels of certification: basic, intermediate and advanced. Bedside hands-on troubleshooting, live surgery case observation and hands-on surgical training (HoST), da Vinci robotic surgical hands-on experience and training in an animal lab are also part of the training offered in the RAST programme.[¹⁷]

da Vinci Robotic courses

The sponsor of da Vinci, the Intuitive, also conducts various training courses that are now considered a prerequisite to the clinical use of the robot. It consists of four phases: Phase 1 – introduction to da Vinci Technology, Phase 2 – technology training, Phase 3 – initial case series and Phase 4 – continuing development [Figure 3]. Apart from the training modules, Intuitive also features videos on their platform of various surgical specialities.[¹⁸]

Figure 3: Da Vinci robotic course training course curriculum

TRAINING OPPORTUNITIES IN INDIA FOR ROBOTIC SURGERY

Formal robotic surgery training in India is still in its infancy; however, the potential for growth is very promising. Courses offered by government-funded hospitals are the mainstay for formal training for residents – MCh in various specialities as well as MCh in minimally invasive surgery being the courses offered. Apart from super specialities, Indian institutes are also beginning to train general surgery residents in the fundamentals of robotic surgery. Basic skill sessions from dry to wet labs and informal console training and workshops are some of the ways, in which residents get exposed to robotic surgery during their residency. The da Vinci Xi dual console also permits trainees to visualise and assist the primary surgeon using the same robot [Figure 4].

Figure 4: Da Vinci Xi dual console

Telestration has also become a recent trend in training residents and fellowship candidates in India. This is defined as a technique of drawing freehand markups or annotations and guidance by displaying hands or other structures over images and videos. This can be projected in a two-dimensional (2D) or 3D mode, thereby enabling trainees to get live direct instructions and guidance from the consultant surgeon. Telestration usually is used in a remote teaching setting; however, hands-on, on site training also be used where the instructor and trainee are in the same operating room. The on site training telestration model is what is usually used in the Indian setting, whereby the instructor and trainee are both in the operating room and the instructor guides the trainee about dissection planes, anatomy and orientation using 'ghost tools'.[¹⁹]

Academic courses for minimally invasive surgery in India:

1. MCh Minimally Invasive Surgery, All India Institute of Medical Sciences, New Delhi and Rishikesh: Three years course on minimally invasive surgery involving robotic surgery and laparoscopic surgery
2. FNB MAS: Three year course conducted through the National Board of Examinations involving laparoscopic and robotic surgery training
3. AIntuitive Robotic Onboard Program and Education: Intuitive India has collaborated with the All India Institute of Medical Sciences, to expose next-generation surgeons to robotic-assisted surgery. This initiative was created to familiarise resident surgeons with robotic-assisted surgery and technology, clinical applications and benefits.

Apart from the above-mentioned training facilities, a number of privately funded centres exist and are mainly under the Vattikuti foundation.

Vattikuti foundation

The Vattikuti Foundation is a not-for-profit organisation founded by Mr. Raj and Padma Vattikuti dedicated to the education and mentoring of the robotic surgery community. It is committed to making robotic surgery cost-effective and accessible to underprivileged communities. The foundation has partnered with several hospitals worldwide to create a network of institutes.[²⁰] In India, the Vattikuti Foundation has partnered with several multi-speciality hospitals and created its network [Table 1] and non-network hospitals [Table 2] to develop independent centres within their main campuses.

Table 1: Network Hospitals in India

Table 2: Non-Network Hospitals in India

In addition, the Vattikuti Foundation offers several national fellowship opportunities conducted in its partner or network hospitals [Table 3].[²¹]

Table 3: Fellowship opportunities offered by Vattikuti foundation

Training institutes are expected to drastically increase, as will the number of robotic installations. Young and experienced surgeons alike are rapidly embracing robotic surgery. Previously, due to the lack of adequate training facilities and proctors, most surgeons were forced to train outside of India; however, this trend has recently changed. With the advent of new training opportunities including fellowships, MCh positions and workshops, Indian surgeons now have an opportunity to train within the country, thereby reducing travel costs and providing more opportunities without the strain of cultural and language barriers.

Apart from the interest from surgeons, there is a growing interest in minimally invasive procedures from the general public. With the introduction of Ayushman Bharat, a National Health Protection Scheme, there is increased financial coverage for patients, even for robotic surgeries. Thus, this provides an opportunity for the more vulnerable patients to have access to minimally invasive procedures.

ROBOTIC SURGERY ASSOCIATIONS IN INDIA-CLINICAL ROBOTIC SURGERY ASSOCIATION INDIA

Clinical Robotic Surgery Association (CRSA) is a not-for-profit association created in 2009 which focuses mainly on robotic surgery in various fields of surgery, namely, general surgery, upper gastrointestinal, hepatobiliary, thoracic, colorectal, vascular, transplant, endocrine, oncology and bariatrics. The association connects various robotic surgeons, trainees and interested surgeons who share their expertise and advice on robotic surgeries. Videos and live demonstrations of different techniques and approaches to robotic surgery of other specialities are shared. The association also conducts various events and seminars for advances and methods of robotic surgery.[²²]

CRSA is the only active robotic surgery association in India. The Indian Chapter of CRSA was created on 1 January, 2019, aiming to bring together surgeons from all over India to develop educational programmes and develop research in robotic surgery. The association conducts various seminars, conferences and CMEs to promote the advancement of robotic surgery. It also is a source of networking for trainees and surgeons interested in robotic surgery. CRSA India chapter membership confers members access to expert surgical training-video library, peer-reviewed journals, conferences and offers for in-site training.[²²]

CLINICAL ROBOTIC SURGERY ASSOCIATION SCORE

In 2012, at the 4^th worldwide CRSA congress whose theme was on 'Training and Quality Assessment', a CRSA Basic Competency score was devised. This was two pronged, namely assessing competency in terms of 'Setup Console' and 'Intraoperative'. Each area had five parameters for a total of 10 parameters assessed and a maximum score attainable of 50. This score was further ratified subsequently in the following year by an expert panel. Thus, the use of this score can be incorporated into the numerous robotic surgery training courses and may be included in the final credentialling certificate of the trainee to establish an objective assessment of the training received.[²²]

CONCLUSION

Despite the acquisition of a significant number of robotic installations, there is a lacuna in the training of robotic surgeons in India. The primary form of training involved is sponsored training courses which are usually a prerequisite before clinical use of the robotic platforms; however, there have been concerns raised about the competency of surgeons using this technology.[¹⁵²³]

There is an urgent need to develop a comprehensive curriculum for the training of robotic surgeons in this country. Although robotic technology and creative talent are available in India, a structured approach for training with a strict curriculum-based modular training with assessment is the dire need of the hour. CRSA India chapter launched recently canplay a major role in this direction.

Ethical approval

All India Institute of Medical Sciences, Rishikesh, does not require ethical approval for review articles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.