ORIGINAL ARTICLE
Robotic thyroidectomy learning curve for beginning surgeons with little or no experience of endoscopic surgery Jae Hyun Park, MD,1 Jandee Lee, MD,2 Nor Azham Hakim, MD,3 Ha Yan Kim,4 Sang-Wook Kang, MD,2 Jong Ju Jeong, MD,2 Kee-Hyun Nam, MD,2 Keum-Seok Bae, MD,1 Seong Joon Kang, MD,1 Woong Youn Chung, MD2* 1
Department of Surgery, Yonsei University Wonju College of Medicine, Kangwon, Korea, 2Department of Surgery, Yonsei University College of Medicine, Seoul, Korea, Department of Surgery, Putrajaya Hospital, Putrajaya, Malaysia, 4Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea.
3
Accepted 27 June 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23824
ABSTRACT: Background. This study assessed the results of robotic thyroidectomy by fellowship-trained surgeons in their initial independent practice, and whether standard fellowship training for robotic surgery shortens the learning curve. Methods. This prospective cohort study evaluated outcomes in 125 patients who underwent robotic thyroidectomy using gasless transaxillary singleincision technique by 2 recently graduated fellowship-trained surgeons. Learning curves were analyzed by operation time, with proficiency defined as the point at which the slope of the time curve became less steep. Results. Of the 125 patients, 113 underwent robotic less-than-total thyroidectomy, 9 underwent robotic total thyroidectomy and 3 underwent robotic total thyroidectomy with modified radical neck dissection. Mean
total times for these 3 operations were 100.8 6 20.6 minutes, 134.2 6 38.7 minutes, and 284.7 6 60.4 minutes, respectively. For both surgeons, the operation times gradually decreased, reaching a plateau after 20 robotic less-than-total thyroidectomies. Conclusion. The surgical learning curve for robotic thyroidectomy performed by recently graduated fellowship-trained surgeons with little or no experience in endoscopic surgery showed excellent results compared C 2014 Wiley with those in a large series of more experienced surgeons. V Periodicals, Inc. Head Neck 00: 000–000, 2014
INTRODUCTION
thyroidectomy, little is known about the robotic thyroidectomy learning curves for beginning surgeons with little or no prior experience with endoscopic surgery.14,15 This first insight into the learning curve for robotic thyroidectomy emphasized the importance of specialized training programs. Systematic training using a surgical robotic system on animals has been shown to result in a quantifiable improvement in surgical skills.16–18 Moreover, in addition to improving the quality of care, systematic training was shown to be cost-effective.19,20 The standard training program for surgeons learning robotic thyroid surgery in our institution includes supervision by an experienced surgeon and use of animal models. To assess the effects of this training program on the learning curve of beginning surgeons, we evaluated the clinical outcomes of initial robotic thyroidectomy, with or without radical neck dissection, procedures performed by 2 surgeons who had recently graduated from a standard fellowship-training program in our institution but had little or no prior experience with endoscopic surgery. Our primary purpose was to assess whether specialized training in robotic thyroid surgery shortens the learning curve previously reported for more experienced surgeons.
The robotic approach is the new frontier of thyroid surgery, with several advantages over conventional open and endoscopic techniques. Since our group first demonstrated the feasibility of robotic thyroidectomy in 2009, many other centers have adopted a robotic platform, with many studies reporting that robotic thyroidectomy is feasible and safe when compared to conventional open surgery.1–9 Any new surgical procedure is subject to a learning curve. Robotic thyroid surgery can overcome some of the limitations imposed by traditional endoscopic instrumentation, including counterintuitive hand movements, 2D visualization, limited degrees of instrument motion within the body, and ergonomic difficulties and tremor amplification.10,11 Therefore, robotic thyroidectomy was associated with a shorter operation time than conventional endoscopic thyroidectomy and learning robotic surgical techniques was less complicated than adapting conventional endoscopic techniques.6,12,13 Studies have assessed the learning curves for robotic thyroidectomy by surgeons with prior experience in performing endoscopic thyroidectomy.6 Although prior experience in advanced endoscopic techniques can improve the learning curves for robotic
KEY WORDS: robotic thyroidectomy, robot, thyroidectomy, learning curve, beginners, trainer, trainee, robot training, training program
PATIENTS AND METHODS Surgical prerequisites *Corresponding author: W. Y. Chung, Department of Surgery, Yonsei University College of Medicine, C.P.O. Box 8044, 250 Seongsanno, Seodaemun-gu, Seoul 120–752, South Korea. E-mail: [email protected]
All surgeon candidates were required to have sufficient experience with open thyroidectomy procedures before HEAD & NECK—DOI 10.1002/HED
MONTH 2014
1
PARK ET AL.
starting the robotic procedure. Surgeons in our thyroid cancer clinic usually perform more than 50 thyroidectomies per week, 60% using an open approach, and 40% using a robotic approach. Because there are usually 4 fellows per term, each could assist at more than 15 thyroidectomies per week; after 3 months of training, each can independently perform open thyroidectomy under supervision. Because of this high volume, a period of 6 months was deemed sufficient for each beginning surgeon to acquire sufficient experience with robotic thyroid surgery. To begin to understand the complexities of robotic thyroid surgery, surgeons must first comprehensively review the overall anatomy of the thyroid gland and adjacent regional lymph node compartments. They must also be able to describe the step-by-step thyroidectomy procedure in detail. In our institution, training in robotic thyroidectomy is incorporated into the 6-month or 12-month International Robotic Thyroid Surgery Fellowship Program. These programs include lectures by specialists, case discussions, observation of live surgery, hands-on sessions, and individual fellowships for mastering these surgical skills. After completing the fellowship training course, supervising consultants decide whether a candidate can perform robotic thyroidectomy independently.
Introduction to the robotic console (weeks 13–16). The candidate participates in a “dry-lab” session, in which he/she is able to practice simple nonclinical tasks using the training sets on the robotic system. The candidate is then provided opportunities to practice on the robotic console during actual operations. These sessions usually occur at the end of the procedure during the final inspection before undocking the robotic system from the patient. Independent practice under supervision (weeks 17–24). This phase is divided into 3 segments: (1) upper pole dissection; (2) lower pole dissection and central compartment neck dissection with recurrent laryngeal nerve (RLN) identification; and (3) RLN tracing and Berry’s ligament dissection. Each candidate starts by performing upper pole dissection, gradually progressing when the supervisor is satisfied that the candidate is able to complete each step correctly. Throughout the 6-month training period, each candidate would have accumulated sufficient experience to be able to perform open thyroidectomies competently. After a final determination by the training surgeon, the candidate is then allowed to perform complete robotic thyroidectomies under supervision.
Selection of patients Standard fellowship training program for robot thyroidectomy Training in robotic thyroidectomy starts at the commencement of the fellowship training program and can be divided into 5 phases: (1) observation; (2) assistance; (3) creation of a working space; (4) introduction to the robotic console; and (5) independent practice under supervision. The duration of each phase depends on the candidate’s ability to master it, a determination made by the supervising surgeon. Observation phase (weeks 1–4). The observation phase usually lasts 1 month or less. During this period, the candidate is expected to observe all open, endoscopic, and robotic thyroidectomies. Observation allows the candidate to become familiar with the procedure, setup, and environment, providing a broad overall view on the performance of robotic thyroidectomy, particularly on the role of each of the personnel involved, the system setup, and the actual surgical procedure. Assisting phase (weeks 5–12). A candidate starts by assisting in the creation of the working space, after which the candidate assumes the role of the patient-side assistant during robotic thyroidectomies. The candidate is also expected to be involved in performing open and endoscopic thyroidectomies. By the end of this phase, the candidate would have observed and/or assisted in more than 30 to 50 working space dissections and robotic thyroidectomies, and should therefore be familiar, at least theoretically, with the steps in each procedure. Creating a working space phase (weeks 12–16). After 3 or 4 months, the candidate starts training in working-space dissection under the supervision of an experienced surgeon. The training continues until the supervisor is satisfied that the candidate can satisfactorily and safely complete the procedure. 2
HEAD & NECK—DOI 10.1002/HED
MONTH 2014
This study was approved by the institutional review board. The study involved 125 consecutive patients who underwent robotic thyroid surgery by 2 fellowship-trained surgeons in their initial independent practice from September 2010 to October 2011. Both candidates were enrolled in the training program described above. Surgeon 1 (J. H. P.) was a domestic fellow; his experience before starting robotic thyroidectomy included 47 open conventional thyroidectomies but no experience in endoscopic thyroidectomy. Surgeon 2 (N. A. H.) was an international fellow; his experience before starting robotic thyroidectomy included more than 200 open conventional thyroidectomies but participated in only 5 endoscopic thyroidectomies. The 2 surgeons completed the fellowship training course at the same time. The trainer (W. Y. C.) was a pioneering surgeon in the field of robotic thyroid surgery. He had performed more than 3000 robotic thyroidectomies and has already described his operative technique and critical operative tips several times. Both candidates started their initial robotic total thyroidectomy after independently performing robotic less-than-total thyroidectomy in more than 30 patients. Patient selection is of the utmost importance when considering the use of robotic surgery. Accurate preoperative evaluation of thyroid cancer aggressiveness included tumor size, location, presence of extrathyroidal invasion, multiplicity, bilaterality, and presence of cervical lymph node metastasis. In accordance with American Thyroid Association guidelines, less-than-total thyroidectomy was performed in patients
Robotic thyroidectomy learning curve for beginning surgeons with little or no experience of endoscopic surgery Jae Hyun Park, MD,1 Jandee Lee, MD,2 Nor Azham Hakim, MD,3 Ha Yan Kim,4 Sang-Wook Kang, MD,2 Jong Ju Jeong, MD,2 Kee-Hyun Nam, MD,2 Keum-Seok Bae, MD,1 Seong Joon Kang, MD,1 Woong Youn Chung, MD2* 1
Department of Surgery, Yonsei University Wonju College of Medicine, Kangwon, Korea, 2Department of Surgery, Yonsei University College of Medicine, Seoul, Korea, Department of Surgery, Putrajaya Hospital, Putrajaya, Malaysia, 4Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea.
3
Accepted 27 June 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23824
ABSTRACT: Background. This study assessed the results of robotic thyroidectomy by fellowship-trained surgeons in their initial independent practice, and whether standard fellowship training for robotic surgery shortens the learning curve. Methods. This prospective cohort study evaluated outcomes in 125 patients who underwent robotic thyroidectomy using gasless transaxillary singleincision technique by 2 recently graduated fellowship-trained surgeons. Learning curves were analyzed by operation time, with proficiency defined as the point at which the slope of the time curve became less steep. Results. Of the 125 patients, 113 underwent robotic less-than-total thyroidectomy, 9 underwent robotic total thyroidectomy and 3 underwent robotic total thyroidectomy with modified radical neck dissection. Mean
total times for these 3 operations were 100.8 6 20.6 minutes, 134.2 6 38.7 minutes, and 284.7 6 60.4 minutes, respectively. For both surgeons, the operation times gradually decreased, reaching a plateau after 20 robotic less-than-total thyroidectomies. Conclusion. The surgical learning curve for robotic thyroidectomy performed by recently graduated fellowship-trained surgeons with little or no experience in endoscopic surgery showed excellent results compared C 2014 Wiley with those in a large series of more experienced surgeons. V Periodicals, Inc. Head Neck 00: 000–000, 2014
INTRODUCTION
thyroidectomy, little is known about the robotic thyroidectomy learning curves for beginning surgeons with little or no prior experience with endoscopic surgery.14,15 This first insight into the learning curve for robotic thyroidectomy emphasized the importance of specialized training programs. Systematic training using a surgical robotic system on animals has been shown to result in a quantifiable improvement in surgical skills.16–18 Moreover, in addition to improving the quality of care, systematic training was shown to be cost-effective.19,20 The standard training program for surgeons learning robotic thyroid surgery in our institution includes supervision by an experienced surgeon and use of animal models. To assess the effects of this training program on the learning curve of beginning surgeons, we evaluated the clinical outcomes of initial robotic thyroidectomy, with or without radical neck dissection, procedures performed by 2 surgeons who had recently graduated from a standard fellowship-training program in our institution but had little or no prior experience with endoscopic surgery. Our primary purpose was to assess whether specialized training in robotic thyroid surgery shortens the learning curve previously reported for more experienced surgeons.
The robotic approach is the new frontier of thyroid surgery, with several advantages over conventional open and endoscopic techniques. Since our group first demonstrated the feasibility of robotic thyroidectomy in 2009, many other centers have adopted a robotic platform, with many studies reporting that robotic thyroidectomy is feasible and safe when compared to conventional open surgery.1–9 Any new surgical procedure is subject to a learning curve. Robotic thyroid surgery can overcome some of the limitations imposed by traditional endoscopic instrumentation, including counterintuitive hand movements, 2D visualization, limited degrees of instrument motion within the body, and ergonomic difficulties and tremor amplification.10,11 Therefore, robotic thyroidectomy was associated with a shorter operation time than conventional endoscopic thyroidectomy and learning robotic surgical techniques was less complicated than adapting conventional endoscopic techniques.6,12,13 Studies have assessed the learning curves for robotic thyroidectomy by surgeons with prior experience in performing endoscopic thyroidectomy.6 Although prior experience in advanced endoscopic techniques can improve the learning curves for robotic
KEY WORDS: robotic thyroidectomy, robot, thyroidectomy, learning curve, beginners, trainer, trainee, robot training, training program
PATIENTS AND METHODS Surgical prerequisites *Corresponding author: W. Y. Chung, Department of Surgery, Yonsei University College of Medicine, C.P.O. Box 8044, 250 Seongsanno, Seodaemun-gu, Seoul 120–752, South Korea. E-mail: [email protected]
All surgeon candidates were required to have sufficient experience with open thyroidectomy procedures before HEAD & NECK—DOI 10.1002/HED
MONTH 2014
1
PARK ET AL.
starting the robotic procedure. Surgeons in our thyroid cancer clinic usually perform more than 50 thyroidectomies per week, 60% using an open approach, and 40% using a robotic approach. Because there are usually 4 fellows per term, each could assist at more than 15 thyroidectomies per week; after 3 months of training, each can independently perform open thyroidectomy under supervision. Because of this high volume, a period of 6 months was deemed sufficient for each beginning surgeon to acquire sufficient experience with robotic thyroid surgery. To begin to understand the complexities of robotic thyroid surgery, surgeons must first comprehensively review the overall anatomy of the thyroid gland and adjacent regional lymph node compartments. They must also be able to describe the step-by-step thyroidectomy procedure in detail. In our institution, training in robotic thyroidectomy is incorporated into the 6-month or 12-month International Robotic Thyroid Surgery Fellowship Program. These programs include lectures by specialists, case discussions, observation of live surgery, hands-on sessions, and individual fellowships for mastering these surgical skills. After completing the fellowship training course, supervising consultants decide whether a candidate can perform robotic thyroidectomy independently.
Introduction to the robotic console (weeks 13–16). The candidate participates in a “dry-lab” session, in which he/she is able to practice simple nonclinical tasks using the training sets on the robotic system. The candidate is then provided opportunities to practice on the robotic console during actual operations. These sessions usually occur at the end of the procedure during the final inspection before undocking the robotic system from the patient. Independent practice under supervision (weeks 17–24). This phase is divided into 3 segments: (1) upper pole dissection; (2) lower pole dissection and central compartment neck dissection with recurrent laryngeal nerve (RLN) identification; and (3) RLN tracing and Berry’s ligament dissection. Each candidate starts by performing upper pole dissection, gradually progressing when the supervisor is satisfied that the candidate is able to complete each step correctly. Throughout the 6-month training period, each candidate would have accumulated sufficient experience to be able to perform open thyroidectomies competently. After a final determination by the training surgeon, the candidate is then allowed to perform complete robotic thyroidectomies under supervision.
Selection of patients Standard fellowship training program for robot thyroidectomy Training in robotic thyroidectomy starts at the commencement of the fellowship training program and can be divided into 5 phases: (1) observation; (2) assistance; (3) creation of a working space; (4) introduction to the robotic console; and (5) independent practice under supervision. The duration of each phase depends on the candidate’s ability to master it, a determination made by the supervising surgeon. Observation phase (weeks 1–4). The observation phase usually lasts 1 month or less. During this period, the candidate is expected to observe all open, endoscopic, and robotic thyroidectomies. Observation allows the candidate to become familiar with the procedure, setup, and environment, providing a broad overall view on the performance of robotic thyroidectomy, particularly on the role of each of the personnel involved, the system setup, and the actual surgical procedure. Assisting phase (weeks 5–12). A candidate starts by assisting in the creation of the working space, after which the candidate assumes the role of the patient-side assistant during robotic thyroidectomies. The candidate is also expected to be involved in performing open and endoscopic thyroidectomies. By the end of this phase, the candidate would have observed and/or assisted in more than 30 to 50 working space dissections and robotic thyroidectomies, and should therefore be familiar, at least theoretically, with the steps in each procedure. Creating a working space phase (weeks 12–16). After 3 or 4 months, the candidate starts training in working-space dissection under the supervision of an experienced surgeon. The training continues until the supervisor is satisfied that the candidate can satisfactorily and safely complete the procedure. 2
HEAD & NECK—DOI 10.1002/HED
MONTH 2014
This study was approved by the institutional review board. The study involved 125 consecutive patients who underwent robotic thyroid surgery by 2 fellowship-trained surgeons in their initial independent practice from September 2010 to October 2011. Both candidates were enrolled in the training program described above. Surgeon 1 (J. H. P.) was a domestic fellow; his experience before starting robotic thyroidectomy included 47 open conventional thyroidectomies but no experience in endoscopic thyroidectomy. Surgeon 2 (N. A. H.) was an international fellow; his experience before starting robotic thyroidectomy included more than 200 open conventional thyroidectomies but participated in only 5 endoscopic thyroidectomies. The 2 surgeons completed the fellowship training course at the same time. The trainer (W. Y. C.) was a pioneering surgeon in the field of robotic thyroid surgery. He had performed more than 3000 robotic thyroidectomies and has already described his operative technique and critical operative tips several times. Both candidates started their initial robotic total thyroidectomy after independently performing robotic less-than-total thyroidectomy in more than 30 patients. Patient selection is of the utmost importance when considering the use of robotic surgery. Accurate preoperative evaluation of thyroid cancer aggressiveness included tumor size, location, presence of extrathyroidal invasion, multiplicity, bilaterality, and presence of cervical lymph node metastasis. In accordance with American Thyroid Association guidelines, less-than-total thyroidectomy was performed in patients
