The training and assessment of surgical skills in robot assisted surgery
Authors:   , Beulens Alexander Jacobus Wilhelmus 
Published: May 2023

The introduction of the surgical robot resulted in increasing technical difficulty of these robot assisted surgeries (RAS). The qualification and certification of RAS skills are still in a preliminary phase within all surgical specialties, also in urology. New methods of training for novice surgeons (residents and fellows) in these highly specialised techniques should be implemented to guarantee patient safety. The challenge for novice surgeons is how to learn new surgical procedures and once the procedure is learned and they become experts how to analyse past performances and subsequently use this as a lesson for the future in order to improve postoperative outcome. In the first part of this these we explored the best methods to educate surgeons in robotic surgery. By using different modalities of training, (i.e., hands-on training combined with theoretical information of learning) we discovered (chapter 2) novice robot surgeons were too positive in the self-assessment of their own surgical skills after a training in RAS. To prevent overconfidence biases the novice surgeons should be provided with feedback (proctoring) to inform them about their results to enhance learning and inform them of their competence levels. Although results (chapter 3) show there is no significant difference in the acquisition of surgical skills between different types of proctoring provided to novice surgeons the participant satisfaction seems to be higher in the “human proctoring” group. Which could result in additional motivation for the participant to continue training in RAS.
Additional research (chapter 4) shows residents in urology are allowed to perform RAS during their residency, but criteria for starting RAS differ significantly among the teaching hospitals. This shows there is a need for the implementation of a (multi-step) training and certification program in the Dutch urology residency curriculum. The long-term effects of the structured fellowship in RAS were investigated in chapter 5. The results of the survey showed that most respondents still perform RAS after the fellowship, which matches results from other research into the impact of RAS fellowships.34,35 A remarkable finding of this study is that a large proportion of respondents is unaware of the oncological (33%) and functional outcomes (66%) of their patients. Thus, participants of RAS fellowships should be coached to review their own results to learn from their past performance and reduce their learning curve.
The second part of the thesis focuses the assessment of a robotic surgeon’s surgical performance. Different methods were used to identify which factors should be assed in surgical video analysis in order to ascertain a surgeon’s surgical skills. In robot assisted surgery. (Chapter 6 and 8). In addition, a research protocol is provided by which the non-technical skills can be assed in both laparotomic surgery and robot assisted surgery in order to discover the difference in non-technical skills between the two surgical modalities. The third part of the thesis focusses on the relation between a surgeon’s performance and postoperative outcome of patients. In this part multiple methods of surgical video analysis were used to identify factors which could influence the postoperative outcome of patients (Chapters 9, 10, 11, and 12). Results show the length of the urethral stump after dissection of the prostate could be a significant factor in the recovery of continence after prostatectomy.