Factors affecting workflow in robot-assisted surgery: a scoping review.

One of the innate qualities of all doctors is the desire to do what is best for the ailing patient. This quality then becomes an objective sought by all clinical physicians to improve medical standards as they try to find better ways of delivering healthcare to their patients. Although incorporation of minimally invasive laparoscopic, robotic, and endo-operative techniques into mainstream care has proved disruptive, our patients are demanding effective yet minimally invasive approaches to their healthcare needs. Accompanying these advances and advantages are the challenges and ethics of applying surgical technology to our respective patients. Currently, in the United States, every individual hospital is required to develop criteria and policies for granting clinical privileges to surgeons operating in their hospital. This task is usually assigned either to the medical director or the chief of each particular surgical service, who verifies whether the respective surgeon is “credentialed” for that procedure. The hospital, compromised by the medical staff office, is, in turn, required by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) to verify the credentials and training of their practitioners to delineate clinical privileges. One areas in which this process came into existence was credentialing aged surgeons. It is well known that fine motor skills wane as one ages. It was, therefore, recommended that “as age advances, a physician should, from time to time scrutinize impartially, the state of his faculties; that he may determine, bona fide, the precise degree in which he is qualified to execute the active and multifarious offices of his profession” [1]. Clearly, the above-mentioned process that materialized, which is generally standard across the nation, was not designed to address the introduction of new revolutionary surgical techniques and machinery. What remains is the question—how do we credential surgeons with new surgical technology, in particular robot assisted surgery? Robot-assisted surgery is the application of advanced computerized technology in the planning, performance, and follow-up of invasive surgical procedures. The Food and Drug Administration (FDA) approved the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA) April 2004 for use in several surgical disciplines, including cardiac, urologic, and gynecologic surgery. The da Vinci telerobotic surgical system consists of a three dimensional laparoscopic vision system and two or three robotic arms that can perform high-precision articulating movements with a variety of instruments. Both the vision system and the robotic arms are controlled by the surgeon in a “master/slave” relationship via a remote surgeon’s console that houses the vision system and the telemanipulators for the robotic arms. The technology enables for more precise and anatomical dissection with outcomes equal to or better than conventional techniques in both academic and private practice-based settings [2–6], for both laparoscopic and non-laparoscopic trained surgeons [7, 8]. Robot-assisted surgery is not a mere extension of one’s innate ability to perform open or laparoscopic surgery. The appropriate and safe use of this technology requires specialized training and experience. Although the FDA reviews the results of laboratory, animal, and human clinical testing, it does not develop or test products. The FDA does not, moreover, regulate who buys or uses the product, or whether a physician is qualified to use the equipment. The ability to perform a surgical procedure is regulated by hospital-based credentialing policy. Credentialing is the systematic approach to the collection, review, and verification of a practitioner’s professional qualification. Robot-assisted surgery may not be learned safely during a weekend course. Dedication, commitment, and unique cognitive and technical skills are required to transfer skills from an open or laparoscopic setting to a robotic setting. There are no widely accepted guidelines that define appropriate credentialing for robot-assisted urologic surgery. This group was formed in response to a need to establish prudent and fair guidelines for credentialing robotic surgery at our respective institutions. Electively we tried to formulate a policy for credentialing and maintenance of credentials for robot-assisted radical prostatectomy. The guidelines herein are proposed for obtaining privileges and performing robot-assisted radical prostatectomy using the da Vinci telerobotic surgical system. Use of this technology should be limited to the level of intervention already granted under the same privileges for open and advanced laparoscopic procedures. Special circumstances may arise where robot-assisted surgery may be appropriate for non-laparoscopic open surgical procedures. Credentialing is considered on a case-by-case basis. Our consensus is given in the Appendix. We believe that every institution that invests in the da Vinci telerobotic surgical system should consider establishing a robot-assisted surgical subcommittee of their existing credentialing committee. As with any surgical procedure, credentialing should be dictated by the policies of the local hospital or institution. To the best of our knowledge, most institutions have embarked on robot-assisted surgical programs without the benefit of procedural guidelines for obtaining surgical privileges and credentialing of physicians for robot-assisted surgery because of the newness of the technology. The suggested guidelines can serve as a template to such committees in an effort to provide direction for a successful launch of a new program or facilitation of a successful ongoing program. Based on a collaborative experience of 1,500 cases and numerous proctoring experiences at various institutions, we recommend the following guidelines. A minimum of four cases be proctored before performing robotic surgery independently. Based on consensus opinion four cases seems practical but each credentialing committee should consider a surgeon’s past operative experience and availability of appropriate proctors. More importantly, each proctor and trainee must determine if additional cases may be required before performing these procedures independently. In an era of evidence-based medicine, surgical competence is being defined by some as a measure of quantity by using “volume” of a procedure to ensure acceptable outcomes. In urology, the prototype has been the conventional radical retropubic prostatectomy [9–12]. Occurrence of postoperative and late urinary complications was reduced if the procedure was performed in a high-volume hospital and by a surgeon who performs a large number of such procedures. However, significant variations occurred among surgeons that suggested technical details were critical for favorable outcomes [9, 10, 12]. In addition, post-operative mortality was low and similar among surgeons and hospitals with different volumes of radical prostatectomies [9–12]. Other disciplines require a minimum number of procedures to obtain and/or maintain surgical privileges, because studies demonstrated that a caseload threshold exists whereby surgical outcomes decline for hospitals or surgeons [11, 13–15]. The Society for Bariactric Surgery requires a 150-case minimum per year/per institution and a 50-case minimum per year/per surgeon for recognition as a center of excellence [11, 13–17]. The American Society for Gastrointestinal Endoscopy (ASG guidelines) recommends a minimum number for each endoscopic procedure performed before competence can be assessed [18]. Although many believe there is inherent quality in quantity, the frequency of a procedure is more than just a marker of quality. Experience gained by repetition may be an underrated aspect of a surgeon’s technical ability. We recommend by consensus that a minimum number of robot-assisted cases be performed on an annual basis, although data that enable scientific validation of this opinion are not currently available [12]. Although the benefits of quantity of surgical procedures remain controversial, idle motor skills wane faster than memories. “Pay-for-performance” may soon require that urologists track outcomes. The higher than expected variability in outcome for radical prostatectomy performed by high volume surgeons led to the appropriate recommendation for monitoring of individual surgeon performance [10, 12]. High-quality surgical care is everyone’s objective. Periodic review is mandatory to expose deficiencies and improve quality outcomes. Procedural credentialing is a privilege—not a right that serves to protect patients from practitioners whose skills are less than otherwise available. We suggest these guidelines to assist urologists and their medical institutions with commencing a successful and safe transition from open to robot-assisted radical prostatectomy.

BackgroundUndeniably, robotic-assisted surgery (RAS) has become very popular in recent decades, but it has introduced challenges to the workflow of the surgical team. Non-technical skills (NTS) have received less emphasis than technical skills in training and assessment. The systematic review aimed to update the evidence on the role of NTS in robotic surgery, specifically focusing on evaluating assessment tools and their utilisation in training and surgical education in robotic surgery.MethodsA systematic literature search of PubMed, PsycINFO, MEDLINE, and EMBASE was conducted to identify primary articles on NTS in RAS. Messick’s validity framework and the Modified Medical Education Research Study Quality Instrument were utilised to evaluate the quality of the validity evidence of the abstracted articles.ResultsSeventeen studies were eligible for the final analysis. Communication, environmental factors, anticipation and teamwork were key NTS for RAS. Team-related factors such as ambient noise and chatter, inconveniences due to repeated requests during the procedure and constraints due to poor design of the operating room may harm patient safety during RAS. Three novel rater-based scoring systems and one sensor-based method for assessing NTS in RAS were identified. Anticipation by the team to predict and execute the next move before an explicit verbal command improved the surgeon’s situational awareness.ConclusionThis systematic review highlighted the paucity of reporting on non-technical skills in robotic surgery with only three bespoke objective assessment tools being identified. Communication, environmental factors, anticipation, and teamwork are the key non-technical skills reported in robotic surgery, and further research is required to investigate their benefits to improve patient safety during robotic surgery.

ABSTRACTDeficiency of non-technical skills may increase the number of adverse events in the operating room. Sustained life-threatening hypotension due to intraoperative cardiac tamponade during robot-assisted thoracic surgery is rare, requiring prompt assessment and swift decision-making. A 54-year-old woman was scheduled to undergo robot-assisted thoracic surgery for an anterior mediastinal tumor. During the operation, hemodynamic instability occurred despite the administration of a high dose of vasopressor. Anesthesiologists and thoracic surgeons shared information regarding the situation, and decided to perform echocardiography and call other physicians for assistance. Cardiac tamponade was diagnosed during echocardiography, and an incision was made in the pericardium. The patient recovered from the critical situation and was extubated in the operating room. Particularly in robot-assisted surgery, non-technical skills are indispensable to enable the anesthesiologist to successfully manage critical hemodynamic instability owing to unexplained causes.

Core trainee boot camp, a method for improving technical and non-technical skills of novice surgical trainees. A before and after study

The command team as a decision-making team under the complex task environment is required both the simple technical skills and the non-technical skills including the managerial skills and the social skills to manage the group process effectively and efficiently. However, little is known about how the Japanese command team members recognize the value of those non-technical skills and whether the non-technical education is needed or not, in the context of the actual field operation requirements. This paper is intended as an investigation of the Japanese command team. This study conducted a case study about the 3 command teams, 21 members, of the fire department of Kyoto city and employed the 8 individual interviews, the 5 group interviews, the document analysis, and the questionnaire using NOTECHS (a behavioral marker system of the non-technical skills). The questionnaire contained 3 phases. At the first phase, team members evaluated the degree of the change on their task environment because the change of the task environment indicates the potential the needs for new skills to adapt the changed task requirements. The next phase, they evaluated the importance of the non-technical skills. These non-technical skills were identified by referring to the NOTECHS and categorized "cooperation" "leadership and management" "situation awareness" "decision making". Finally, it surveyed the needs of technical, non-technical, procedural educations. As a result, in general, high evaluations were dominant on both changes of the task environment and needs of the non-technical skills and they recognized the needs of the non-technical skills education as well as the technical and the procedural educations. In detail, however, we can see some items which have the low agreement levels in 3 non-technical skills categories except "situation awareness". This shows the NOTECHS might be an inappropriate measure system to Japanese command team, or this team member should construct the higher agreement level. It remains as a matter to be discussed further.

• Changes to working hours, new technologies and increased accountability have rendered the need for alternative training environments for urologists. • Simulation offers a promising arena for learning to take place in a safe, realistic setting. • Despite its benefits, the incorporation of simulation into urological training programmes remains minimal. • The current status and future directions of simulation for training in technical and non-technical skills are reviewed as they pertain to urology. • A framework is presented for how simulation-based training could be incorporated into the entire urological curriculum. • The literature on simulation in technical and non-technical skills training is reviewed, with a specific focus upon urology. • To fully integrate simulation into a training curriculum, its possibilities for addressing all the competencies required by a urologist must be realized. • At an early stage of training, simulation has been used to develop basic technical skills and cognitive skills, such as decision-making and communication. • At an intermediate stage, the studies focus upon more advanced technical skills learnt with virtual reality simulators. • Non-technical skills training would include leadership and could be delivered with in situ models. • At the final stage, experienced trainees can practise technical and non-technical skills in full crisis simulations situated within a fully-simulated operating rooms. • Simulation can provide training in the technical and non-technical skills required to be a competent urologist. • The framework presented may guide how best to incorporate simulation into training curricula. • Future work should determine whether acquired skills transfer to clinical practice and improve patient care.

Non-technical skills in oral and maxillofacial and head and neck surgery: systematic review

PD41-06 ROBOT-ASSISTED TRAINING - EXPERT PERFORMANCE IN FULL IMMERSION SIMULATION, SETTING THE BENCHMARK (CONCURRENT VALIDITY)

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.

Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life shoulder dystocia is limited, and the impact of non-technical skills has not been adequately evaluated. We aimed to analyze videos of teams managing real-life shoulder dystocia to identify clinical challenges associated with correct management and particular non-technical skills correlated with high technical performance. We included 17 videos depicting teams managing shoulder dystocia in two Danish delivery wards, where deliveries were initially handled by midwives, and consultants were available for complications. Delivery rooms contained two or three cameras activated by Bluetooth upon obstetrician entry. Videos were captured 5 min before and after activation. Two obstetricians assessed the videos; technical performances were scored as low (0-59), average (60-84), or high (85-100). Two other assessors evaluated non-technical skills using the Global Assessment of Team Performance checklist, scoring 6 (poor) to 30 (excellent). We used a spline regression model to explore associations between these two score sets. Inter-rater agreement was assessed using interclass correlation coefficients. Interclass correlation coefficients were 0.71 (95% confidence interval 0.23-0.89) and 0.82 (95% confidence interval 0.52-0.94) for clinical and non-technical performances, respectively. Two teams had low technical performance scores; four teams achieved high scores. Teams adhered well to guidelines, demonstrating limited head traction, McRoberts maneuver, and internal rotation maneuvers. Several clinical skills posed challenges, notably recognizing shoulder impaction, applying suprapubic pressure, and discouraging women from pushing. Two non-technical skills were associated with high technical performance: effective patient communication, with teams calming the mother and guiding her collaboration during internal rotational maneuvers, and situation awareness, where teams promptly mobilized all essential personnel (senior midwife, consultant, pediatric team). Team communication, stress management, and task management skills were not associated with high technical performance. Videos capturing teams managing real-life shoulder dystocia are an effective tool to reveal challenges with certain technical and non-technical skills. Teams with high technical performance are associated with effective patient communication and situational awareness. Future training should include technical skills and non-technical skills, patient communication, and situation awareness.

ObjectiveComprehensive analyses specifically comparing robot-assisted surgery(RS) and laparoscopic surgery(LS) for choledochal cyst(CC) in children remained scarce. This study aimed to evaluate the safety and efficacy of RS vs. LS for pediatric CC.MethodsA systematic search of PubMed, Embase, Web of Science, and the Cochrane Library was conducted to identify studies published up to December 31, 2025, that compared laparoscopic and robot-assisted surgery for CC in children. Meta-analysis was performed using Stata 18.ResultsA total of 19 retrospective studies were included. Meta-analysis results demonstrated that the RS group had significantly lower incidences of postoperative biliary stones (OR = 0.10, 95% CI: 0.01–0.89), bile leakage (OR = 0.28, 95% CI: 0.11–0.70), anastomotic stricture (OR = 0.27, 95% CI: 0.12–0.65), and overall complications (OR = 0.26, 95% CI: 0.13–0.51) compared to the LS group. Total operative time was longer in the RS group (SMD = 1.02; 95% CI: 0.30–1.74), whereas intraoperative blood loss was significantly lower (SMD = −1.22; 95% CI: −2.19 to −0.24). Additionally, the RS group exhibited shorter hepaticojejunostomy time (SMD = −1.43; 95% CI: −2.30 to −0.56), drainage tube indwelling time (SMD = −0.74; 95% CI: −1.01 to −0.47), postoperative fasting time (SMD = −0.80; 95% CI: −1.11 to −0.50), and hospital stay (SMD = −1.16; 95% CI: −2.08 to −0.23). No significant differences were observed in other outcomes, including postoperative cholangitis (OR = 0.59, 95% CI: 0.22–1.57), residual cyst (OR = 0.22, 95% CI: 0.02–1.94), incision infection (OR = 0.17, 95% CI: 0.02–1.41), intestinal obstruction (OR = 0.97, 95% CI: 0.40–2.33), pancreatitis (OR = 0.74, 95% CI: 0.08–6.47), pancreatic leakage (OR = 0.43, 95% CI: 0.10–1.92), and conversion to open surgery (OR = 0.79, 95% CI: 0.36–1.75). Furthermore, no statistically significant difference was found in cyst excision time between the two groups (SMD = −1.77; 95% CI: −3.91 to −0.77).ConclusionIn the treatment of pediatric CC, RS offered potential advantages over LS in terms of reducing postoperative biliary-related complications, decreasing intraoperative blood loss, accelerating postoperative gastrointestinal function recovery, and shortening hospital stay. Although RS required longer operative time, this limitation might be mitigated with accumulated surgical experience and technological advancements. However, current evidence is primarily derived from retrospective studies conducted in Asian countries and lacked long-term follow-up data. Well-designed multicenter prospective studies or randomized controlled trials were urgently needed to provide higher-level evidence and further validate our findings.

Job description parsing with explainable transformer based ensemble models to extract the technical and non-technical skills

Non-technical skills are interpersonal and cognitive skills involved in safe performance and preventing adverse events during surgery. it is necessary to dominate the non-technical skills to ensure patient safety. This study has aimed to assess the validity and reliability of Oxford Non-technical skills 2 system (Oxford NOTECHS 2) in Iran and to evaluate surgical teams' non-technical skills in orthopedic surgery wards. This cross-sectional study was conducted in Tehran, Iran during 2015. The level of evidence is III based on Canadian Task Force on the Periodic Health Examination. We followed the Beaton's guideline for Persian translation and cross-cultural adaptation of the checklist. In this study, 60 orthopedic surgical team members working in two selected public hospitals were selected by cluster random sampling method.Oxford NOTECHS 2 system which is consisted of four subscales including leadership and management, teamwork and collaboration, decision-makingand problem-solving, and situational awareness was used to collect the data. The overall mean score of non-technical skills was 69.52±6.64. The mean score for surgery, anesthesia, and nursing sub-teams were 24.98±3.71, 21.12±4.29, and 23.42±3.60, respectively. The teams' scores in total, leadership and management, teamwork and collaboration, problem solving and decision making, and situational awareness at the standard level were 74.70%, 76.95%, 73.75%, 66.87%, and 74.70% of maximum score, respectively. The validity and reliability of the Persian version of Oxford NOTECHS 2 scale in Iran was confirmed. The results of this study showed that surgical teams' non-technical skills were at a moderate level in orthopedic surgery wards. The minimum score of the surgical teams' non-technical skills belonged to anesthesia and maximum to surgery sub-team. Using the training programs and setup workshop is recommended to improve the surgical teams' non-technical skills, especially surgery-nursing sub-team.

Circulating nurses are important members of surgical teams. They need to use nontechnical skills to work safely. This study aims to review the existing observational tools for the assessment of circulating nurses' nontechnical skills. Electronic resources, including Web of Sciences, PubMed, Scopus, ProQuest, CINAHL, Embase, and Google Scholar, were searched, including studies using tools for observational assessment of nontechnical skills in surgery published up to September 2019. The search process relied on the following keywords: circulating/scout/operating room nurse, observational, assessment tools, operating room nontechnical skills, task management, teamwork, communication, situational awareness, leadership, and decision making. The data were pooled from 30 eligible studies using tools for assessment of nontechnical skills in surgeries. Eight tools were found to assess nontechnical skills for the whole surgical team or individuals, including circulating nurses. Although general behaviors for all surgical team members within the tools have been recognized, there is no specific observational tool for the assessment of circulating nurses' nontechnical skills.

Trainee pilots are expected to be thoroughly trained on both technical and nontechnical skills. Technical skills are relatively easy to evaluate. However, non-technical skills are hard to monitor and assess. This study investigates the feasibility of providing a smart evaluation technique that can generate feedback on trainee pilots’ instrument scan behavior. The authors conducted gaze monitoring experiments with a number of trainee pilots while operating a flight simulator in order to isolate patterns of behavior associated with Situation Awareness (SA). Recorded data on eye movements are then processed and transitions are extracted using a state transition model. The sequence of transitions are then processed to retrieve repeated instrument scan pattern. The results are verified using chart visualizations.