The authors wish to thank medical simulation technician Jared Hammond for design of the modified torso, and the Summa Health, Akron Campus operating room personnel. There was no outside funding for this project.

The IRB determined that this project was exempt from IRB review in accordance with federally defined categories of exempt review per 45 CFR 46.101 Category 2.
1. Gather and Prepare Materials
<ol>
	<li>Collect materials for the training curriculum, including a robotic system with 2 training arms (see Table of Materials), 3 trocars, and a laparoscope.</li>
	<li>In the hollow training torso, create at least 3 separate incisions with a scalpel to place laparoscopic instrument trocars. Ensure that the incisions are consistent with those found in robotic surgery, i.e., one above the umbilicus, and one in each the right and left lower quadrant large enough to accommodate a trocar.</li>
	<li>To simulate a vessel and subsequent vessel injury, create a vessel using rubber tubing. Tubing from a water seal chest drain functions well.
	<ol>
		<li>Cut a separate tube for the vena cava and descending aorta.</li>
		<li>Connect two shorter pieces replicating the right and left common iliac veins and two shorter pieces replicating the common iliac arteries to the vena cava and aorta, respectively, using a Y-connector.</li>
		<li>Create a notch at the distal end of the common iliac artery to allow for simulated blood to escape in the case of a vessel injury.</li>
		<li>Place the vessels against the posterior wall of the torso and secure using glue. Protrude the access point to the vessel through the cephalad portion of the torso to allow for instillation of red food colored fluid.</li>
		<li>Color as necessary for realism with oil base red and blue paint for artery and vein respectively. Coat with a protective clear enamel spray for durability.</li>
	</ol>
	</li>
	<li>Obtain a 1-liter bag of IV fluid. Inject red food coloring until the fluid has a color consistent with blood. Hook this bag to the previously assembled vessel.</li>
	<li>Drape the torso with operating room drapes used for laparoscopic surgery or laparotomy. Ensure that the drape covers the entire OR table.</li>
	<li>Have embedded standardized persons (ESPs) or confederates fulfill the roles laid out in the emergency undocking protocol (Figure 2). A minimum of 4 individuals is required. Alternatively, OR personnel can be employed to perform their actual roles.</li>
</ol>
2. Setup of the Operating Room
<ol>
	<li>Place the training torso, complete with vessel and IV tubing, and connect it to an IV fluid bag on the OR table. Place the table in a steep trendelenburg position, then drape using OR drapes.</li>
	<li>Place the laparoscopic trocars into the training torso through the incisions made previously. Move the robotic patient side cart to the bedside, and attach robotic arms to trocars. Once attached, dock robotic training instrument and camera to torso using trocars.</li>
	<li>Place ESPs or OR staff in desired roles as described in Figure 2. Have the surgeon console on and ready for surgeon to assume control of robotic instruments.</li>
</ol>
3. Simulation and Debriefing
<ol>
	<li>Have the surgeon enter the room and position at the surgeon&#39;s console. Instruct the surgeon to adjust positional settings, but not take control of the instruments until completion of orientation to the case.</li>
	<li>Introduce the ESPs or OR staff to the surgeon. Read one of the case stems presented in Figure 3. Then, instruct the surgeon to take control of the instruments following completion of the case stem.</li>
	<li>Have the anesthesia ESP initiate bleeding from the vessel via pressure bag or manual pumping of fluid bag once the case stem is completed. The IV tubing should be wide open, allowing for brisk bleeding. Allow the surgeon up to 5 minutes to complete emergency undocking.</li>
	<li>Following the case (or after 5 minutes), proceed with debriefing and didactic component of the scenario and procedure. During the debriefing emphasize key points of personnel roles as listed in Figure 2, key equipment including instrument arms and patient side cart, and use of closed loop communication.</li>
	<li>Reposition ESPs or OR staff, and run a second case to reinforce the lessons taught during debriefing. Following the case, reiterate any points missed during the second case.</li>
</ol>

<ol>
	<li>Huser, A. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulated+life-threatening+emergency+during+robot-assisted+surgery.">Simulated life-threatening emergency during robot-assisted surgery.</a> J Endourol. 28 (6), 717-721 (2014).</li><li>Berry, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiac+resuscitation+in+the+operating+room:+reflections+on+how+we+can+do+better.">Cardiac resuscitation in the operating room: reflections on how we can do better.</a> Can J Anaesth. 59 (6), 522-526 (2012).</li><li>Shaligram, A., Meyer, A., Simorov, A., Pallati, P., Oleynikov, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Survey+of+minimally+invasive+general+surgery+fellows+training+in+robotic+surgery.">Survey of minimally invasive general surgery fellows training in robotic surgery.</a> J Robot Surg. 7 (2), 131-136 (2013).</li><li>Acero, N. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Managing+a+surgical+exsanguination+emergency+in+the+operating+room+through+simulation:+an+interdisciplinary+approach.">Managing a surgical exsanguination emergency in the operating room through simulation: an interdisciplinary approach.</a> J Surg Educ. 69 (6), 759-765 (2012).</li><li>Hoffman, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation+of+robotic+radical+hysterectomy+using+the+porcine+model.">Simulation of robotic radical hysterectomy using the porcine model.</a> J Robot Surg. 6 (3), 237-239 (2012).</li><li>Goonewardene, S. S., Cahill, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+surgery,+skills+and+simulation:+a+technical+sport.">Robotic surgery, skills and simulation: a technical sport.</a> J Robot Surg. 10 (1), 85-86 (2016).</li><li>Meier, M., Horton, K., John, H. D. a. V. i. n. c. i. &. #. 1. 6. 9. ;. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Skills+Simulator&#8482;:+is+an+early+selection+of+talented+console+surgeons+possible.">Skills Simulator&#8482;: is an early selection of talented console surgeons possible.</a> J Robot Surg. 10 (4), 289-296 (2016).</li><li>Gaba, D. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+future+vision+of+simulation+in+health+care.">The future vision of simulation in health care.</a> Qual Saf Health Care. 13, i2-i10 (2004).</li><li>Salas, E., Wilson, K. A., Burke, C. S., Priest, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+simulation-based+training+to+improve+patient+safety:+what+does+it+take?.">Using simulation-based training to improve patient safety: what does it take?.</a> Jt Comm J Qual Patient Saf. 31 (7), 363-371 (2005).</li><li>McGaghie, W. C., Siddall, V. J., Mazmanian, P. E., Myers, J., Committee, A. C. o. C. P. H. a. S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lessons+for+continuing+medical+education+from+simulation+research+in+undergraduate+and+graduate+medical+education:+effectiveness+of+continuing+medical+education:+American+College+of+Chest+Physicians+Evidence-Based+Educational+Guidelines.">Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines.</a> Chest. 135 (3 Suppl), 62S-68S (2009).</li><li>Paige, J. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High-fidelity,+simulation-based,+interdisciplinary+operating+room+team+training+at+the+point+of+care.">High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care.</a> Surgery. 145 (2), 138-146 (2009).</li><li>Moitra, V. K., Gabrielli, A., Maccioli, G. A., O'Connor, M. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthesia+advanced+circulatory+life+support.">Anesthesia advanced circulatory life support.</a> Can J Anaesth. 59 (6), 586-603 (2012).</li><li>Ziewacz, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Crisis+checklists+for+the+operating+room:+development+and+pilot+testing.">Crisis checklists for the operating room: development and pilot testing.</a> J Am Coll Surg. 213 (2), 212-217 (2011).</li><li>O'Sullivan, O. E., O'Sullivan, S., Hewitt, M., O'Reilly, B. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Da+Vinci+robot+emergency+undocking+protocol.">Da Vinci robot emergency undocking protocol.</a> J Robot Surg. 10 (3), 251-253 (2016).</li><li>Arriaga, A. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+trial+of+surgical-crisis+checklists.">Simulation-based trial of surgical-crisis checklists.</a> N Engl J Med. 368 (3), 246-253 (2013).</li></ol>

The authors have nothing to disclose.

Incorporating this curriculum into training necessitates adherence to the protocol as outlined previously. Ensuring practice through hands on training of both the technical aspects of emergency undocking, as well as delineation of roles of OR personnel, is essential towards successful training. All three sessions of pre-training simulation, debriefing, and post-training simulation are likely required to ensure maximal benefit to the learner.
An attempt should be made to create as realistic a learning environment as possible. Although use of an in-situ environment is not mandatory, it is encouraged in order to identify any logistical hurdles or latent safety threats in an actual OR environment that might inhibit completion of the emergency undocking. Another important detail is the vessel used during the training scenarios. Choosing a durable and realistic material is essential as the learners may try any number of techniques to obtain hemostasis depending on their skill level. An ideal vessel design should be able to withstand repeated simulations.
A major limitation to instituting this curriculum is lack of faculty or staff with training in simulation or debriefing. Part of the goal of this curriculum is to clearly layout what is required regarding material and set up to ensure a successful simulation. The availability of the OR to perform training may be a limitation, but the importance of in-situ practice for identifying unanticipated obstacles in the actual clinical environment in case of an emergency undocking is invaluable. The resource of a pelvic model could also be a limitation for some. Although the modification to the model was designed for repeated use, some institutions may not have a training model. There are a number of affordable alternatives to the one mentioned specifically in the study.
The significance of this training curriculum is that it is a single tool used to teach not only procedural skills for emergency undocking, but also establishment of roles for the entire interprofessional team. The in-situ environment adds a level of realism to the simulation, and hands-on training provides a proven tool for solidifying knowledge of the procedure.
This curriculum can be used for future applications including modification for use with other case scenarios involving catastrophic events in robotic surgery. Although this curriculum was focused towards OBGYN robotic surgeons, it can be expanded to use with urology and general surgery robotic surgeons. The modified torso can be used for teaching OR emergencies for any laparoscopic surgery, not only robotic surgery.

The purpose of this training is to improve robotic surgeons&#39; confidence, knowledge, and proficiency of performing an emergency undocking of the robotic system, and to improve the surgeon&#39;s ability to lead an interprofessional team through effective communication of clearly delineated roles in the event of an emergency undocking. Despite the abundance of personnel and equipment in the operating room, there is a lack of experience managing these crises1,2. Current training requirements of online course work and a short period of proctored cases leave many surgeons feeling their training is inadequate3. Regardless of these feelings of inadequacy, prior studies have established that surgeons will encounter at least 1 OR emergency in their career4. Strategies to improve on these feelings of inadequacy include increasing usage of simulation training5. It is well established that simulation training is becoming inseparable from surgical education6. Prior studies have determined that simulation-based team training is an invaluable tool in helping learners overcome cognitive and behavioral gaps in surgical education and is useful as a tool to allow trainees in sessions with other team members the ability to demonstrate baselines for knowledge and communication skills, while improving performance following combining simulation exercises and debriefing4,7,8,9,10,11.
To improve robotic crisis management, various simulator-training scenarios have been developed1,12,13. While there have been numerous studies examining the effects of team training, there is a dearth of research analyzing training on complex OR scenarios4. During complex OR emergencies, checklists and the clear delineations of roles through effective communication are of paramount importance. In robotic surgery, there is a paucity of literature available outlining protocols or training for this procedure14. Simulation has proven effective in validating checklists for use during operating-room crises to improve surgical care15. Here, we present a training curriculum to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in an emergency undocking of a robotic system. Implementation of this curriculum takes place over three sessions in an in-situ environment, as laid out in Figure 1, and can be used to provide training, demonstrate skills for credentialing, and is easily reproducible in any hospital with a robotic system.

<table><tbody><tr><td>ZOE Gynecologic Simulator</td><td>Gaumard</td><td>S504.100</td><td>Incisions placed above umbilicus and in right and left lower quadrants large enough to pass trochars through. Vessels as detailed below. Tubing used to make aorta spliting into common iliacs as well as inferior vena cava.&amp;nbsp;</td></tr><tr><td>da Vinci Si Robotic System</td><td>Intuitive Surgical</td><td></td><td></td></tr><tr><td>Tubing from Atrium Water Seal Chest Drain</td><td>Atrium</td><td></td><td>Suction tubing removed an colored</td></tr><tr><td>Chest Tube Y-connector&amp;nbsp;</td><td>Sorin Group</td><td>050525-000</td><td>Connected to suction tubing for split from descending aorta to right and left iliac vessels</td></tr><tr><td>Reeve&#039;s Oil Colour Paint Set</td><td>Reeves</td><td></td><td>Coloring for venous and arterial vessel (Red and Blue)</td></tr><tr><td>Rust-oleum Clear Coat Enamel Spray</td><td>Rust-oleum</td><td></td><td>Coating for protection of vessels coloring</td></tr></tbody></table>

emergency undocking in robotic surgery: a simulation curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

By incorporating this curriculum as outlined in Figure 1 and the undocking protocol outlined in Figure 2 during training in robotic-assisted surgery, our study demonstrated an overall improvement in the confidence, knowledge, and critical actions performed by the surgeon as demonstrated in Figure 3. Baseline measurements in knowledge and confidence were collected on all participants immediately prior to participation in the curriculum. A 20 question multiple-choice exam and a 6-item Likert confidence scale ranging from very uncomfortable to very comfortable provided this baseline. This was illustrated by the significant increase in the baseline level of knowledge of robotic surgeons after our training curriculum was implemented (p = 0.001; Wilcoxon signed rank test of median change equal to 0), and our results also demonstrated an increase in the confidence of surgeons when faced with an emergency undocking after completion of our curriculum (p = 0.003) (Table 1, Figure 4). This may indicate that utilizing robotic surgery simulation during training can be advantageous to robotic surgeons by boosting confidence and familiarity with the emergency protocol. There was also an improvement in the undocking times (p &#60;0.001) and increase in the critical actions performed out of 7 possible measured actions (p = 0.002) (Table 2, Figure 4). This likely represents a combination of the robotic surgeon&#39;s ability to recognize the need for an emergency undocking sooner and having the opportunity to simulate the entire emergency undocking process while leading a team in an in situ environment with immediate feedback from content experts after completing the curriculum. It is important to be consistent in training personnel in the execution of this protocol in order to ensure consistency among surgeons and to maximize effectiveness in a real life scenario.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57286/57286fig1.jpg" /> 
Figure 1: Curricular outline of the pre-training simulation, debriefing and didactic component, and post-training simulation. <a href="/files/ftp_upload/57286/57286fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57286/57286fig2.jpg" /> 
Figure 2: Emergency undocking roles. <a href="/files/ftp_upload/57286/57286fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57286/57286fig3.jpg" /> 
Figure 3: Case stems read to initiate simulation. <a href="/files/ftp_upload/57286/Case_Stems.pdf">Please click here to download this file.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57286/57286fig4.jpg" /> 
Figure 4: Summary graph of statistically significant results (median &#177; interquartile range). <a href="/files/ftp_upload/57286/57286fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Study Cohort</td>
		</tr>
		<tr>
			<td>Variable/Statistic</td>
			<td>(n = 21)</td>
		</tr>
		<tr>
			<td>Baseline Knowledge Score (out of 20)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>10.0 (1.82)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>10 (8.5 - 11.5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>7 - 13</td>
		</tr>
		<tr>
			<td>Post-Baseline Knowledge Score (out of 20)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>12.4 (1.29)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>13 (12 - 13)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>9 - 14</td>
		</tr>
		<tr>
			<td>Change in Knowledge Score</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>2.4 (2.20)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>3 (1 - 4.5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>-2 - 5</td>
		</tr>
		<tr>
			<td>p</td>
			<td>0.001</td>
		</tr>
		<tr>
			<td>Baseline Total Confidence (maximum 75)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>38.5 (12.43)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>40 (33 - 48)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>15 - 62</td>
		</tr>
		<tr>
			<td>Post-Baseline Total Confidence (out of 75)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>58.9 (13.65)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>61.5 (53.75 - 69.25)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>25 - 74</td>
		</tr>
		<tr>
			<td>Change in Total Confidence</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>20.1 (19.93)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>18 (6 - 30.5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>-15 - 58</td>
		</tr>
		<tr>
			<td>p</td>
			<td>0.003</td>
		</tr>
	</tbody>
</table>
Table 1: Baseline/Post-simulation knowledge and total confidence of participants. p from Wilcoxon signed rank test of median change equal to 0.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Study Cohort</td>
		</tr>
		<tr>
			<td>Variable/Statistic</td>
			<td>(n = 21)</td>
		</tr>
		<tr>
			<td>Baseline Undocking Time (secs)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>146.1 (40.01)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>139 (116.5 - 169)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>88 - 254</td>
		</tr>
		<tr>
			<td>Post-Baseline Undocking Time (secs)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>89.6 (18.20)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>89 (76 - 104.5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>59 - 120</td>
		</tr>
		<tr>
			<td>Change in Undocking Time (secs)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>-56.5 (41.95)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>-50 (-81.5 - -23.5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>-151 - -2</td>
		</tr>
		<tr>
			<td>p</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td colspan="2">Baseline Critical Actions Performed (out of 7)</td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>4.3 (1.06)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>4 (3 - 5)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>3 - 6</td>
		</tr>
		<tr>
			<td>Post-Baseline Critical Actions Performed (out of 7)</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>5.3 (0.78)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>5 (5 - 6)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>3 - 6</td>
		</tr>
		<tr>
			<td>Change in Critical Actions Performed</td>
			<td></td>
		</tr>
		<tr>
			<td>Mean (SD)</td>
			<td>1.0 (1.05)</td>
		</tr>
		<tr>
			<td>Median (IQR)</td>
			<td>1 (0 - 2)</td>
		</tr>
		<tr>
			<td>Range</td>
			<td>-1 - 3</td>
		</tr>
		<tr>
			<td>p</td>
			<td>0.002</td>
		</tr>
	</tbody>
</table>
Table 2: Baseline/Post-simulation undocking times and completion of critical actions. p from Wilcoxon signed rank test of median change equal to 0.

Watch this Scientific Journal Video about Emergency Undocking in Robotic Surgery: A Simulation Curriculum at JoVE.com

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

emergency-undocking-in-robotic-surgery-a-simulation-curriculum

Nanyang Technological University

Research

JoVE Journal

Medicine

9.1K Views.  Summa Health. This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

Video: Emergency Undocking in Robotic Surgery: A Simulation Curriculum

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

Cancer Research

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. Transiliac-transsacral screws provide a longer lever arm to withstand the perpendicular vertical shear forces. However, the screw channel is so long that a minor discrepancy can lead to iatrogenic neurovascular injuries. The development of medical robots has improved the precision of surgery. The present protocol describes how to use a new teleoperated robotic system to execute transiliac-transacral screw fixation. The Robot was operated remotely to position the entry point and adjust the orientation of the sleeve. The screw positions were evaluated using postoperative computed tomography (CT). All the screws were safely implanted, as confirmed using intraoperative fluoroscopy. Postoperative CT confirmed that all the screws were in the cancellous bone. This system combines the doctor's initiative with the Robot's stability. The remote control of this procedure is possible. Robot-assisted surgery has a higher position-retention capacity compared with conventional methods. In contrast to active robotic systems, surgeons have full control over the operation. The robot system is fully compatible with operating room systems and does not require additional equipment.

Teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation is a feasible technique. Screw channels can be implemented with high accuracy owing to the excellent freedom of movement and stability of the robotic arms.

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

Engineering

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

Neuroscience

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robotized Testing of Camera Positions to Determine Ideal Configuration for Stereo 3D Visualization of Open-Heart Surgery

Stereo 3D video from surgical procedures can be highly valuable for medical education and improve clinical communication. But access to the operating room and the surgical field is restricted. It is a sterile environment, and the physical space is crowded with surgical staff and technical equipment. In this setting, unobscured capture and realistic reproduction of the surgical procedures are difficult. This paper presents a method for rapid and reliable data collection of stereoscopic 3D videos at different camera baseline distances and distances of convergence. To collect test data with minimum interference during surgery, with high precision and repeatability, the cameras were attached to each hand of a dual-arm robot. The robot was ceiling-mounted in the operating room. It was programmed to perform a timed sequence of synchronized camera movements stepping through a range of test positions with baseline distance between 50-240 mm at incremental steps of 10 mm, and at two convergence distances of 1100 mm and 1400 mm. Surgery was paused to allow 40 consecutive 5-s video samples. A total of 10 surgical scenarios were recorded.

The human depth perception of 3D stereo videos depends on the camera separation, point of convergence, distance to, and familiarity of the object. This paper presents a robotized method for rapid and reliable test data collection during live open-heart surgery to determine the ideal camera configuration.

Stereo 3D video from surgical procedures can be highly valuable for medical education and improve clinical communication. But access to the operating room ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

Robotic Cochlear Implantation for Direct Cochlear Access

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of the clinical workflow for robotic cochlear implantation using a robotic system specifically developed for a minimally invasive, direct cochlear access. The clinical workflow involves experts from various disciplines and requires training to ensure a smooth and safe procedure. The protocol briefly summarizes the history of robotic cochlear implantation. The clinical sequence is explained in detail, beginning with the assessment of patient eligibility and covering surgical preparation, preoperative planning with the special planning software, drilling of the middle ear access, intraoperative imaging to confirm the trajectory, milling of the inner ear access, insertion of the electrode array, and implant management. The steps that require special attention are discussed. As an example, the postoperative outcome of robotic cochlear implantation in a patient with advanced otosclerosis is presented. Finally, the procedure is discussed in the context of the authors' experience.

Robotic cochlear implantation is a procedure for minimally invasive inner ear access. Compared to conventional surgery, robotic cochlear implantation involves additional steps that need to be carried out in the operating room. In this article we give a description of the procedure and highlight the important aspects of robotic cochlear implantation.

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of ...

Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

This protocol presents a case of a robotic partial duodenal resection with primary side-to-side duodeno-jejunal reconstruction in a patient with a 5 cm duodenal stenosis. This is done at the third duodenal segment (D3) after an endoscopic mucosal resection (EMR) for a duodenal polyp.