Defining digital surgery: a SAGES white paper.

BACKGROUND: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas. METHODS: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology. RESULTS: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth. CONCLUSION: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study.

BACKGROUND: Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery. METHODS: Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook. RESULTS: Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility. CONCLUSION: This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Expertise in perception during robotic surgery (ExPeRtS): What we see and what we say.

BACKGROUND: Given the challenges of teaching in robotic operating rooms, we sought to investigate the language of perceptual expertise used by robotic surgeons, in an effort to improve current approaches to robotic training. METHODS: Expert robotic surgeons reviewed 8 anonymous video clips portraying key portions of two robotic general surgery procedures and their comments were recorded and transcribed. Using content analysis, each transcript was double-coded and reconciled using a consensus developed codebook. RESULTS: Seventeen expert robotic surgeons participated and comments formed two primary themes: visual comprehension and surgical technique. Surgeons minimally used tactile language. Risk avoidance was a second-order theme dominating language used. CONCLUSIONS: Experts occasionally used tactile language and emphasized risk avoidance as they observed robotic surgery. Despite the need to communicate perceptual expertise to trainees in robotic surgery, tactile language was not exhibited by expert surgeons, revealing an important future area of focus for intraoperative teaching skills.

Transforming Surgical Education through a Resident Robotic Curriculum.

Objective: Here, we describe a systematic approach to design, implement, and assess a robotic surgery curriculum for surgical residents. By describing our process, including identifying and addressing institutional challenges, we illustrate successful development of a robust curriculum. Summary Background Data: As robotic-assisted surgeries increase, educational challenges have emerged and illustrate an alarming impact on medical training. Robotic curricula are frequently grounded in the industry's educational materials resulting in a variety of existing resident curricula that lack cognitive components and critical evaluation. As such, surgical educators struggle to identify the curricular restructuring needs that likely accompany emerging technologies. It is essential to develop a curricular framework for the surgical education community to approach the ongoing and inevitable integration of new technologies. Methods: Our process parallels the widely accepted approach to curricular development in medical education described by Kern et al. Using this 6-step model, we describe derivation of a curriculum that was data driven, features multimodal educational strategies, and provides documentation methods that allow for continued evaluation and assessment at the individual and departmental level. Results: This study highlights the systematic process of design, implementation and assessment of a robotic surgery curriculum for surgical residents. Built on a robust national and local needs assessment, and further strengthened by preemptive identification of institutional challenges, this curricular model includes a structured documentation system that allows for ongoing evaluation, assessment, and monitoring of curricular progress. Conclusions: We illustrate a robustly built curricular structure that can be adopted, adapted, and successfully implemented at other training institutions around the world.

Teaching in the robotic environment: Use of alternative approaches to guide operative instruction.

BACKGROUND: With the rapid growth of robotic-assisted surgery, surgical educators recognize the need to develop appropriate curriculum for trainees. However, the unique robotic learning environment challenges educators to determine the most appropriate ways to instruct surgical residents. The purpose of this study was to characterize the instructional techniques used in the robotic teaching environment by observing attending surgeon's language and behaviors during resident robotic dissection. STUDY DESIGN: Attending robotic surgeons guided senior residents through robotic dissection of live porcine tissue. Three observers documented the language, gestures and behaviors occurring at three different stations, and at a fourth station, they obtained video and audio recordings of the instructional interaction. Afterwards, instructors and residents met in separate focus groups. The authors used qualitative content analysis to summarize the type and frequency of teaching behaviors and focus group information to clarify the analysis. We compared the frequency of the behaviors to an existing taxonomy of 16 operative teaching behaviors in open and laparoscopic surgery. RESULTS: Robotic instructors used 11 of the 16 behaviors previously described for surgical instruction. Frequency of use differed in the robotic environment due to relevance and application of new techniques. New, unique robotic teaching behaviors involved disengaging the resident from the operative console for either onscreen direction or for gesturing with verbal instruction. Focus group participants highlighted these behaviors as essential. CONCLUSION: Robotic instruction uses a different set of instructional approaches compared to open and laparoscopic surgery. New teaching behaviors emerged driven by physical separation within the robotic environment. Robotic faculty development should emphasize these unique features.

Integrating Robotic Technology Into Resident Training: Challenges and Recommendations From the Front Lines.

PURPOSE: To develop recommendations for improving the integration of robotic technology into today's apprentice-based resident training. METHOD: During a national meeting in 2017, 24 robotic surgeons were interviewed about their experiences integrating robotic technology into resident training. Qualitative thematic analysis of interview notes and recordings revealed themes related to challenges and recommendations. RESULTS: Four themes emerged, each corresponding to a general recommendation for integrating robotic technology into training. The first, surgical techniques versus tools, contrasts faculty's sequential mastery-surgical techniques first, then the robotic tool-with residents' simultaneous learning. The recommendation is to create separate learning opportunities for focused skill acquisition. The second theme, timing of exposure to the robotic tool, describes trainees' initial focus on tool use for basic surgical steps. The recommendation is to increase access to basic robotic cases. The third theme covers the relationship of laparoscopic and robotic surgery. The recommendation is to emphasize similar and dissimilar features during all minimally invasive surgical cases. The fourth theme, use of the dual console (which enables two consoles to operate the robot, the primary determines the secondary's functionality), highlights the unique teaching opportunities this console creates. The recommendation is for surgeons to give verbal guidance so residents completely understand surgical techniques. CONCLUSIONS: Surgical educators should consider technique versus tool, timing of exposure to the tool, overlapping and varying features of robotic and laparoscopic surgery, and use of the dual console as they develop curricula to ensure thorough acquisition and synthesis of all elements of robotic surgery.

A robotic teaching session: separating tool from technique to emphasize a cognitive focused teaching environment.

Most robotic curriculum requires simulation on a console prior to operative exposure. This practice does not permit experiencing the physical collisions with the robotic tools, which occurs during surgery. We designed and evaluated an innovative curriculum to address cognitive components and trouble-shoot robotic collisions when the surgeon lacks haptic feedback. We adapted our previous curriculum, designed to teach and document proficiency of robotic docking and instrument exchange, to include robotic collisions. Participants received a 10-min, didactic presentation describing finger grips, internal and external collisions, and instruction on how to trouble-shoot each type. Residents worked in pairs, one at the console and the other at bedside, to complete two simulation exercises. Participants manipulated the robot to determine how best to resolve the situations. Residents completed retrospective post-course surveys and instructors completed a final survey. For comparison, non-participants, PGY-matched surgical trainees, also completed a survey. All participants demonstrated proficiency in docking and instrument exchange. Compared to pre-session, post-session knowledge and confidence improved in five domains reflecting session objectives (p < 0.05). Participants could list and troubleshoot collisions more than the non-participant matched peers (p < 0.05). Instructors supported the additional collision components, but noted learners needed more time. Two of three non-participants expressed interest in a teaching session to address these components. Collisions occur using robotic technology and rarely get addressed in surgical training. We describe an opportunity for surgeons to trouble-shoot robotic collisions in a safe, simulated environment. This easily transferable curriculum represents one of the first industry-independent robotic teaching sessions for surgical trainees.

Microanalysis of video from a robotic surgical procedure: implications for observational learning in the robotic environment.

Without haptic feedback, robotic surgeons rely on visual processing to interpret the operative field. To provide guidance for teaching in this environment, we analyzed intracorporeal actions and behaviors of a robotic surgeon. Six hours of video were captured by the intracorporeal camera during a robot-assisted lower anterior resection. After complete review, authors reduced the video to a consecutive 35 min of highly focused robotic activity and finally, a 2-min clip was subjected to microanalysis. The clip was replayed multiple times (capturing 1, 2, 10, 60 and 120 s intervals) and activities were identified, such as right and left hand motion, tissue handling and camera adjustments recorded using a software program. Activity patterns were categorized into two main themes: change in operative focus occurs when there is an inability to obtain adequate tension, and observation of robot-assisted surgery is based on an incomplete visual framework. The surgeon manipulated tissue predominantly using blunt adjustments and rarely grasped it, likely as a way to avoid tissue trauma. A magnified operative field required precise dissection, which occurs robotically with movement of a single instrument against a static field (motionless second robotic arm). This meticulous technique is unlike the bimodal manipulation often used for laparoscopic dissection. Since residents have limited active participation in robotic cases, and therefore, rely heavily on the captured image for skill acquisition, we recommend surgeons to use focus shifts as an opportunity to describe their operative decision-making and highlight instrument manipulations specific to operating with robotic technology.

Using Technological Advances to Improve Surgery Curriculum: Experience With a Mobile Application.

OBJECTIVE: Our previous home-video basic surgical skills curriculum required substantial faculty time and resources, and was limited by delayed feedback and technical difficulties. Consequently, we integrated that curriculum with a mobile application platform. Our purpose is to describe this application and learner satisfaction. MATERIALS AND METHODS: The mobile platform incorporates a patented pedagogical design based on Ericsson's deliberate practice and Bandura's social learning theory. Instructors built step-wise skills modules. During the challenge phase, learners watched a video of surgical tasks completed by experts and uploaded a video of themselves performing the same task. In the Peer Review phase, they used a grading rubric to provide feedback. In the Recap stage, learners received individual feedback and could review their own videos. Two groups of learners, graduating medical students and matriculating surgical residents, participated in this independent learning platform, along with 2 to 4 laboratory sessions, and completed a survey about their experience. Survey responses were summarized descriptively and comments analyzed using content analysis. RESULTS: Fifty learners submitted videos of assigned tasks and completed peer reviews. Learners reported positive experiences specifically for the Peer Review Stage, structured home practice, ease of mobile access to submit and review videos, and ongoing immediate feedback. Over half of the learners reported spending at least 10 to 30 minute practicing skills before recording their videos and over 80% rerecorded at least 2 times before submission. Content analysis revealed learners engaged with the educational concepts designed into the platform. CONCLUSION: Learners easily used and were satisfied with a mobile-technology teaching platform that maintained the fundamental content, educational theories, and organizational structure of our previously effective surgical skills curriculum. Prior challenges were directly addressed through the mobile application's ease of use, support of deliberate practice, and improved timeliness of feedback.

Technical skill improvement with surgical preparatory courses: What advantages are reflected in residency?

INTRODUCTION: Sustainability of skill acquisition gained from graduating medical student (GMS) preparatory courses remains uncertain. GMS skills were assessed before (T1) and after a preparatory course (T2) and then again 2 (T3) and 4 (T4) months into residency and compared to surgical interns without such a course. METHODS: In April, GMS took the preparatory course. In July-August all interns participated in a basic skills curriculum. Learners completed four technical exercises pre/post each course. Three surgeons scored performances. GMS scores were compared across the 4 time points. Control interns were compared at T3 and T4. RESULTS: Thirty-two interns completed all pre/post course assessments (T3 and T4); seven of those were GMSs. GMS scores increased from 74.5%(T1) to 94.2%(T2) (p < 0.001), and were maintained into residency. Control interns also improved (65.8%(T3) to 91.8%(T4), p < 0.001). GMS-interns scored higher starting residency compared to control interns (T3, 89.08% vs 65.03%, p < 0.001). CONCLUSIONS: These findings support existing literature and demonstrate that students maintain their skills into residency. Preparatory courses provide a head start. Without such course, interns require a steep learning curve.

Current robotic curricula for surgery residents: A need for additional cognitive and psychomotor focus.

BACKGROUND: Current robot surgery curricula developed by industry were designed for expert surgeons. We sought to identify the robotic curricula that currently exist in general surgery residencies and describe their components. METHODS: We identified 12 residency programs with robotic curricula. Using a structured coding form to identify themes including sequence, duration, emphasis and assessment, we generated a descriptive summary. RESULTS: Curricula followed a similar sequence: learners started with online modules and simulation exercises, followed by bedside experience during R2-R3 training years, and then operative opportunities on the console in the final years of training. Consistent portions of the curricula reflect a device-dependent training paradigm; they defined the sequence of instruction. Most curricula lacked specifics on duration and content of training activities. None clearly described cognitive or psychomotor skills needed by residents and none required a proficiency assessment before graduation. CONCLUSIONS: Resident-specific robotic curricula remain grounded in initial industrial efforts to train experienced surgeons, are non-specific regarding the type and nature of hands on experience, and do not include discussion of operative technique and surgical concepts.

Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies.

BACKGROUND: Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students' readiness for surgical internship. This study addresses the feasibility and outcomes of this course. MATERIALS AND METHODS: A curriculum was designed based on ACGME surgical milestones. Students participated in 8 (3h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 = high confidence). Faculty graded students' technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α = 0.05). RESULTS: A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation = 0.49, 0.35; p < 0.05). Students' scores on all 5 suturing tasks increased (p < 0.05). CONCLUSIONS: We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while maximizing resources.

Descending necrotizing mediastinitis: a modified algorithmic approach to define a new standard of care.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process. METHODS: We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges. RESULTS: From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections. CONCLUSIONS: We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.

Complex trait analysis of ventricular septal defects caused by Nkx2-5 mutation.

BACKGROUND: The occurrence of a congenital heart defect has long been thought to have a multifactorial basis, but the evidence is indirect. Complex trait analysis could provide a more nuanced understanding of congenital heart disease. METHODS AND RESULTS: We assessed the role of genetic and environmental factors on the incidence of ventricular septal defects (VSDs) caused by a heterozygous Nkx2-5 knockout mutation. We phenotyped >3100 hearts from a second-generation intercross of the inbred mouse strains C57BL/6 and FVB/N. Genetic linkage analysis mapped loci with lod scores of 5 to 7 on chromosomes 6, 8, and 10 that influence the susceptibility to membranous VSDs in Nkx2-5(+/-) animals. The chromosome 6 locus overlaps one for muscular VSD susceptibility. Multiple logistic regression analysis for environmental variables revealed that maternal age is correlated with the risk of membranous and muscular VSD in Nkx2-5(+/-) but not wild-type animals. The maternal age effect is unrelated to aneuploidy or a genetic polymorphism in the affected individuals. The risk of a VSD is not only complex but dynamic. Whereas the effect of genetic modifiers on risk remains constant, the effect of maternal aging increases over time. CONCLUSIONS: Enumerable factors contribute to the presentation of a congenital heart defect. The factors that modify rather than cause congenital heart disease substantially affect risk in predisposed individuals. Their characterization in a mouse model offers the potential to narrow the search space in human studies and to develop alternative strategies for prevention.

The significant impact of a competency-based preparatory course for senior medical students entering surgical residency.

PURPOSE: Previous data suggest that formal, structured preparation might improve knowledge and skills of senior medical students (SMSs) as they transition to surgical residency. However, subsequent impact on clinical performance has not been demonstrated. METHOD: The authors developed a comprehensive course for SMSs entering surgical residencies and studied the impact of the course on the subsequent performance of 2010 graduates (n = 22) compared with matched peers (16 nonparticipant controls at authors' home institution and 24 nonparticipant peer controls at outside institutions; total n = 62). Through pre- and postcourse surveys, knowledge tests, and technical examinations, they measured confidence and skill acquisition in 32 specific, job-related tasks. They followed participants and matched peers into internship and collected performance evaluations from supervising senior residents to determine whether course graduates would display performance advantages in these same tasks. The authors used t tests for all comparisons, α = 0.05. RESULTS: Participants demonstrated marked improvement in task-specific confidence in all 32 tasks from course beginning to end, with improved scores on written and technical skill examinations. Further, course participants outperformed peers in all 32 tasks in July, with their performance advantage predictably dissipating into the third month of residency. There was a marked correlation between confidence and competence in all tasks. CONCLUSIONS: Competency-based preparation for surgical internship resulted in objective gains in task-specific confidence and test performance at course conclusion, translating to improved performance and better patient care upon residency matriculation. These data emphasize the significant impact of formally preparing SMSs before graduation.

Heterogeneity of genetic modifiers ensures normal cardiac development.

BACKGROUND: Mutations of the transcription factor Nkx2-5 cause pleiotropic heart defects with incomplete penetrance. This variability suggests that additional factors can affect or prevent the mutant phenotype. We assess here the role of genetic modifiers and their interactions. METHODS AND RESULTS: Heterozygous Nkx2-5 knockout mice in the inbred strain background C57Bl/6 frequently have atrial and ventricular septal defects. The incidences are substantially reduced in the Nkx2-5(+/-) progeny of first-generation (F1) outcrosses to the strains FVB/N or A/J. Defects recur in the second generation (F2) of the F1 X F1 intercross or backcrosses to the parental strains. Analysis of >3000 Nkx2-5(+/-) hearts from 5 F2 crosses demonstrates the profound influence of genetic modifiers on disease presentation. On the basis of their incidences and coincidences, anatomically distinct malformations have shared and unique modifiers. All 3 strains carry susceptibility alleles at different loci for atrial and ventricular septal defects. Relative to the other 2 strains, A/J carries polymorphisms that confer greater susceptibility to atrial septal defect and atrioventricular septal defects and C57Bl/6 to muscular ventricular septal defects. Segregation analyses reveal that > or = 2 loci influence membranous ventricular septal defect susceptibility, whereas > or = loci and at least 1 epistatic interaction affect muscular ventricular and atrial septal defects. CONCLUSIONS: Alleles of modifier genes can either buffer perturbations on cardiac development or direct the manifestation of a defect. In a genetically heterogeneous population, the predominant effect of modifier genes is health. (Circulation. 2010;121:1313-1321.)