**6. Training the robotic surgical team**

operative times diminish considerably and in many institutions may be quicker than the equivalent operation performed laparoscopically. The economic arguments are not therefore

Importantly, once the hospital has agreed that a budget is available and a sensible financial plan is in place, the early adopters of the robotic technology need to be identified and offered

Robot-assisted surgery is rapidly gaining popularity among urologists and is becoming subspecialised. Generally the three main categories that need fellowship or hands-on training are prostatectomy, partial nephrectomy, and radical cystectomy. It is not acceptable to begin robotic surgery without the appropriate training [7]. Currently, robot-assisted radical prostatectomy is the most commonly performed robotic procedure worldwide. There is mounting evidence that the robot assistance provides significant benefits to the patient and surgeon, especially shortening operating time and surgeon fatigue [2]. There has been a major shift of treatment of prostate cancer by surgery in wealthier countries from open to a laparoscopic approach, and now robotic. A modern comparison is with radical nephrectomy

The learning curve to deliver laparoscopic radical prostatectomy (LRP) is estimated at 40–60 cases with skilled surgeons and 80–100 cases, with inexperienced surgeons. The robot shortens the prostatectomy learning curve for all surgeons, particularly experienced open prostatectomists. Interestingly, a surgeon skilled in open surgery was able to transfer his open skills to robotic surgery in 8**–**12 cases [8]. However, currently we recommend fellowship training

A fellowship-trained laparoscopic surgeon has a similar, short learning curve for robotic prostatectomy compared to an experienced open surgeon. The data showed a safe and reproducible surgery, interestingly even during the learning curve. Importantly, the outcomes were the same for early robotic surgery and a large cohort of open prostate surgery [8]. There was an emphasis on having a good mentor, experienced in robotics being present during the

Animal model training in robotics, prior to human application, is effective. Most of all robotic surgeries were initially tested in an animal model. Sung et al. [9] in 1995 performed a porcine robotic pyeloplasty. As the learning curve associated with surgical robotic use is unknown, a safe and modular training programme in an animal model would result in measurable

constant or static but an ever-changing field.

**4. Robotic surgeon training**

226 Evolving Trends in Kidney Cancer

in the 1990s.

a curriculum-based training programme [7] (**Figure 1**).

such as the ERUS-approved programmes (**Figure 1**).

initiation of the programme.

**5. Animal model and training**

improvement in robotic surgical skills.

Curiosity and commitment to robotics are helpful when motivating a team. However, it helps to have the support and enthusiasm of your hospital, including the management through your clinical colleagues and team leaders (**Figure 2**).

The primary group to get on board are the surgeons committed to robotics. Importantly, robotic surgery programmes develop purposefully and often slowly. Each step requires audit cycles, critically analysing the robotic team performance and not simply the surgeon. Team leaders in the operating room should be empowered to feedback performance values at each step of the process for safe and effective outcomes. Once the team engages in this process, it is the most rewarding experience.

Training within a team is an early and crucial step. Using a standard learning tool such as an objective-based curriculum, which is visual and live, allows for the best results. This should allow foundation building from experiences, in a stepwise manner (modular). For the more specialized team member requiring understanding of specific operative nuances, a more specialized skill set is needed [12].

The generic robotic team should begin the process by understanding the set-up, draping, and both electrical and mechanical troubleshooting. These basic steps would suffice to then return

**Figure 2.** A happy and supportive robotic team is essential!

to the host hospital and apply the knowledge to the local robot surgery. Most teams learn the advanced objectives in their host institution.

Trainee surgeons believe that robotic training is necessary to their future [17], although we know that all will not be robotic surgeons in the current climate. Interesting issues are raised when these trainees only work in robotic centres, where they are only exposed to robotic

Robotic Surgery and Successful Set-Up: A Stepwise Approach

http://dx.doi.org/10.5772/intechopen.86026

229

The robot is a relatively easy tool to use, but the resident will still need the trainer and operating room team to support training, particularly with time pressures in a busy operating room. Incorporating training within the training programme is a significant challenge. The aim should be to train the doctor without lowering the standard of patient outcome. Robotics lends itself to this objective, with stepwise training and short learning curves. Currently, surgical training simulators are being used for teaching, but they only allow initial training [18, 19]. Newer, dual-console robots (dual control) allow the teacher a level of comfort while teaching, but without this there are a number of important teaching processes to assure safety, including combining virtual, augmented training with modular training. It is therefore essential that robotic surgical educators have a comfort level both with performing the surgical procedure

and communicating with the assistant to teach the procedure [12, 20] (see **Figure 4**).

**Figure 4.** Planning and training presurgery.

Sachdeva et al. [21] summarized three steps involved in trying to train with novel technologies: (i) perceptual awareness, incorporating cognitive understanding of the surgery and visualizing the surgery; (ii) guided learning, in a modular fashion, with immediate mentor feedback, in order to learn correctly; and (iii) autonomous refinement of learning, in which

surgery, effectively missing the opportunities to undertake open surgery.

Training programmes are now cross-specialty [13], with real surgery observation, didactic sessions, video-based modular training, dry laboratories, and cadaveric training access [14].

Non-technical skills are vitally important to develop as part of the team training programme [15]. These human factors are crucial to running a seamless patient journey through a roboticassisted surgery (or any other surgery).
