**7. Resident training**

While surgical educators in resident training centres in which robotic surgery has been adopted are still charged with the responsibility of teaching residents the surgical management (see **Figure 3a** and **b**), they now face a new challenge in how to teach a resident to assist at and perform a surgery when not physically standing at the operating room table [16].

**Figure 3.** Resident training. (a) Console training for the robot; (b) Patient-side robotic raining.

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 surgery, effectively missing the opportunities to undertake open surgery.

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**).

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

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

to the host hospital and apply the knowledge to the local robot surgery. Most teams learn the

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 robotic-

While surgical educators in resident training centres in which robotic surgery has been adopted are still charged with the responsibility of teaching residents the surgical management (see **Figure 3a** and **b**), they now face a new challenge in how to teach a resident to assist at and perform a surgery when not physically standing at the operating room

**Figure 3.** Resident training. (a) Console training for the robot; (b) Patient-side robotic raining.

advanced objectives in their host institution.

assisted surgery (or any other surgery).

**7. Resident training**

228 Evolving Trends in Kidney Cancer

table [16].


**Step Module Description Competency Sign off**

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Level Date

Level Date

Date

Date

Level Date

Level Date

Level Date

Level Date

Date

Level Date

Level Date

Level Date

Date

Date

Date

1a I Transperitoneal access—trocar

Retzius space

2 I Set-up of da Vinci robot Level

3 III Pelvic lymphadenectomy Level

fascia and dissection of puboprostatic ligaments

4 I Incision of endopelvic

6 III Posterior bladder neck dissection

5 II Anterior and lateral bladder neck dissection

7 I Dissection and division of vas deferens

9 III Incision/dissection of posterior

the rectum

10a III Dissection of prostatic pedicles (non-nerve spare)

10b V Dissection of prostatic pedicles (nerve spare)

11 II DVC ligation Level

12 IV Apical dissection Level

13a III Rocco stitch Level

8 III Dissection of seminal vesicles Level

Denonvillier's fascia and mobilization of prostate from

1b II Extraperitoneal access—trocar

placement, incision of ventral peritoneum, and dissection of

placement and dissection of preperitoneal space

Modified from Ref. [22].

**Table 1.** Modular steps for RARP.

precision and efficiency are improved. These steps are logical to any expert trainer, and they are incorporated in the ERUS host robotic training centre curriculum, which are based on modular training [22] (**Tables 1** and **2**).

At present, laboratory-based experience is available for training with the da Vinci Surgical System's inanimate, cadaveric, or animate models [23]. Beyond the point of training laboratories, residents are able to be fellowship train, under supervision by experts within real operating rooms, with the consent of the patients.

The ongoing issue about where robotic surgical training should be deployed (e.g. postbasic training or postgraduate training) continues among robotic trainers around the world. However, surgery in general is becoming more subspecialist, and therefore not all trainee doctors need robotic training.

In our opinion, placing robot-assisted surgery as a category like its predecessor, laparoscopy, is not appropriate. The robot is a facilitating tool, for treating a disease. It would be sensible to train surgeons in robotics as part of specializing in a disease process. The difficulty arises when surgery is superseded by the next iteration of treatments.


precision and efficiency are improved. These steps are logical to any expert trainer, and they are incorporated in the ERUS host robotic training centre curriculum, which are based on

At present, laboratory-based experience is available for training with the da Vinci Surgical System's inanimate, cadaveric, or animate models [23]. Beyond the point of training laboratories, residents are able to be fellowship train, under supervision by experts within real

The ongoing issue about where robotic surgical training should be deployed (e.g. postbasic training or postgraduate training) continues among robotic trainers around the world. However, surgery in general is becoming more subspecialist, and therefore not all trainee

In our opinion, placing robot-assisted surgery as a category like its predecessor, laparoscopy, is not appropriate. The robot is a facilitating tool, for treating a disease. It would be sensible to train surgeons in robotics as part of specializing in a disease process. The difficulty arises

modular training [22] (**Tables 1** and **2**).

Modified from Ref. [22].

230 Evolving Trends in Kidney Cancer

**Table 1.** Modular steps for RARP.

doctors need robotic training.

operating rooms, with the consent of the patients.

when surgery is superseded by the next iteration of treatments.


[5] Link RE, Bhayani SB, Kavoussi LR. A prospective comparison of robotic and laparo-

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[13] https://www.sages.org/publications/guidelines/consensus-document-robotic-surgery/

[14] www.baus.org.uk/\_userfiles/pages/files/Publications/Robotic%20Surgery%20

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Curriculum.pdf

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**Table 2.** Resident diary.
