From the Journals

‘Stepping’ up to a better way to teach robotic lobectomy

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Learning tool in 19 steps

Inderpal S. Sarkaria, MD, of the University of Pittsburgh acknowledged in his invited commentary how “metric-driven patient outcomes” have changed cardiothoracic surgical training (J Thorac Cardiovasc Surg. 2016;152:998).

But Dr. Sarkaria questioned the validity of using time performed as a metric in this study to evaluate a trainee’s competency. “Although ‘time’ is an important component, should not the primary focus be on ‘quality’ of the trainee’s work?” Dr. Sarkaria asked.

Dr. Inderpal S. Sarkaria

Dr. Inderpal S. Sarkaria

Despite these questions and the limitations of the study, he found the approach to surgical training “laudable.” Said Dr. Sarkaria: “It is arguable that the limitations of the study speak more to a common wisdom that certain aspects of surgical education remain an art to a greater or lesser extent, not easily amenable to our efforts to discretely compartmentalize and quantify the process.”
While the premise demands further study, Dr. Cerfolio and his coauthors “have laid a solid foundation on which further to build, explore, and potentially improve the science and art of teaching complex operations to our surgical residents,” Dr. Sarkaria said.

Dr. Sarkaria had no relationships to disclose.



Teaching minimally invasive robotic surgery to residents can be difficult in a health care environment obsessed with quality outcome measures and under scrutiny by hospital administrators and payers, but researchers at the University of Alabama at Birmingham may have devised a method to instruct residents in robotic lobectomy without compromising patient outcomes, according to a study published in the October issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:991-7).

Robert J. Cerfolio, MD, MBA, and his coauthors divided the procedure into 19 sequential, teachable steps and allowed residents to perform selected steps during operations that Dr. Cerfolio directed. “We then applied simulation training, coaching techniques, and video review of each step to help improve the steps that residents could not complete,” Dr. Cerfolio and his coauthors said.

Dr. Robert J. Cerfolio

Dr. Robert J. Cerfolio

Surgeons in academic centers face the challenge of teaching “the art and science of surgery,” Dr. Cerfolio and his colleagues said, while maintaining quality outcomes. “Teaching minimally invasive surgery, especially robotic surgery, is challenging given the risks and the limited availability of the robot.”
The researchers acknowledged that other groups have taken a similar approach to training, but this is the first study that included video review, coaching, and instruction tied to time constraints, they said. “A major concern is that while teaching robotic surgery, patients can be injured, care is worse, and metrics that are increasingly used as surrogates for quality outcomes suffer,” they noted.

They allotted each step in the procedure a set amount of time in which the resident had to complete it, totaling 80 minutes for all 19 steps and ranging from 1 minute to inspect the pleura after placing ports (9 minutes) to 20 minutes to close the five incisions. If the resident completed the task in the allotted time, it was recorded as “performed.”

Between February 2010 and December 2010 Dr. Cerfolio performed 520 robotic lobectomies, and over time the percentage of successful steps per resident improved. For example, in the first year, 50% of thoracic surgery residents completed the first five steps (mark and place ports, inspect pleura, resect the inferior pulmonary ligament, and remove three lymph nodes), but by the last year of the study 90% of them successfully completed the five steps.
Dr. Cerfolio and coauthors acknowledged “many flaws” in their study, but the study also had strengths: It involved only one operation and corroborated the database with each resident’s own surgical logs.
“Operations such as robotic lobectomy can be successfully taught by dividing them into a series of surgical maneuvers or steps,” the researchers noted. Recording what residents can and can’t do, reviewing video, and coaching contribute to the process to improve their skills. “Further studies that scientifically measure ‘ways to teach’ and ways to coach and mentor are needed,” they said.

Dr. Cerfolio disclosed relationships with Intuitive Surgical, Ethicon, Community Health Services, KCL, Bovie and C-SATS. Coauthor Douglas Minnich, MD, is a consultant to Medtronic. The other co-authors had no financial relationships to disclose.

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