Name: emergency undocking in robotic surgery: a simulation curriculum
Uploaded: 2018-05-20T14:00:00
Description: Watch this Scientific Journal Video about Emergency Undocking in Robotic Surgery: A Simulation Curriculum at JoVE.com

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 tr...

<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>

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 l...

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 border="0" cellpadding="0" cellspacing="0" width="573">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">ZOE Gynecologic Simulator</td>
			<td style="width:71px;">Gaumard</td>
			<td style="width:119px;">S504.100</td>
			<td style="width:167px;">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.&#160;</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">da Vinci Si Robotic System</td>
			<td style="width:71px;">Intuitive Surgical</td>
			<td style="width:119px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Tubing from Atrium Water Seal Chest Drain</td>
			<td style="width:71px;">Atrium</td>
			<td style="width:119px;"></td>
			<td>Suction tubing removed an colored</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Chest Tube Y-connector&#160;</td>
			<td style="width:71px;">Sorin Group</td>
			<td style="width:119px;">050525-000</td>
			<td>Connected to suction tubing for split from descending aorta to right and left iliac vessels</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:216px;">Reeve&#39;s Oil Colour Paint Set</td>
			<td style="width:71px;">Reeves</td>
			<td style="width:119px;"></td>
			<td>Coloring for venous and arterial vessel (Red and Blue)</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:216px;">Rust-oleum Clear Coat Enamel Spray</td>
			<td style="width:71px;">Rust-oleum</td>
			<td style="width:119px;"></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...

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 ...

The overall goal of this simulation curriculum is to better prepare robotic surgeons for this potentially life-threatening scenario. This method can help prepare operating room personnel and robotic surgeons for emergency undocking. The main advantage of this technique is that it focuses on team roles for reducing time until intervention can be performed for the patient.This method can provide insight into proper allocation of resources in an emergency undocking, as well as other operating room emergencies, such as cardiac arrest. Generally, individuals new to this method will struggle because they may have never encountered this scenario. We first had the idea for this curriculum when we discovered learners had a limited knowledge of the emergency undocking process.Visual demonstration of the undocking steps is critical for long-term retention of the skills. After collecting the materials, use a scalpel to make one incision above the umbilicus and one each in the right and lower left quadrants of a hollow, draining torso large enough to accommodate a laparoscopic instrument trocar. To simulate a vessel and subsequent vessel injury, cut one piece of rubber tubing from a water seal chest drain for the vena cava and one for the descending aorta.Using Y-connectors, connect two approximately 12-inch pieces of tubing for the right and left common iliac veins, and two approximately 12-inch tubes for the common iliac arteries to the vena cava and aorta. Create a notch at the distal end of the common iliac artery to allow the simulated blood to escape in the case of a vessel injury, and glue the mock vessels against the posterior wall of the torso. Then, protrude the access point to the vessel through the cephalad portion of the torso.After painting, coat the vessels with a clear enamel spray, and inject red food dye into a one liter bag of IV fluid until the fluid has a color consistent with blood. Then hook the bag to the vessel and place the table in a steep Trendelenburg position. Next, drape the torso with operating room drapes used for laparoscopic surgery or laparotomy, so that the entire table is covered, and place laparoscopic trocars into the training torso through the incisions.Move the robotic patient side cart to the bedside and attach robotic arms to the trocars. Using the trocars, dock the robotic training instrument and camera to the torso, and direct at least four embedded standardized persons to their appropriate positions around the table according to their roles. Then start up the surgeon console so that it is ready for the surgeon to assume control of the robotic instruments.When the console is ready, instruct the surgeon to adjust the positional settings of the console without taking control of the instruments. Introduce the embedded standardized persons to the surgeon and read a case stem. At the end of the case orientation, instruct the surgeon to take control of the instruments and have the anesthesia embedded standardized person initiate bleeding from the vessel.The IV tubing should be wide open, allowing for brisk bleeding. Allow the surgeon up to five minutes to complete the emergency undocking. Then debrief, emphasizing the key points of personnel roles, the key equipment used, including the instrument arms and patient side cart and the use of closed loop communication.The embedded standardized persons can then be repositioned for a second case to reinforce the lessons learned during the debriefing. After incorporating this training curriculum as just demonstrated, robotic surgeons who completed the curriculum reported an increase in confidence when faced with an emergency undocking, compared to their reported baseline levels of confidence and knowledge about the procedure. Undocking times and critical actions performed out of seven possible measured actions, also improved, likely representing a combination of the robotic surgeon's ability to recognize the need for an emergency undocking sooner and having the opportunity to simulate the entire emergency undocking process in an in situ environment with immediate feedback from content experts.Once mastered, this curriculum can be completed in under one hour if it is performed properly. While attempting this procedure, it is important to remember to clearly assign the roles using closed loop communication. Following this procedure, other scenarios can be run to further emphasize the learning.After its development, this technique paved the way for other quality improvement projects within the operating room, including Code Blue drills to maximize patient care. After watching this video, you should have a good understanding of how to perform an emergency undocking of the robot. Don't forget that working with surgical equipment poses an innate risk and that care should always be taken to avoid injury.

Research

JoVE Journal

Medicine

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

An Anesthesia, Surgery, and Harvest Method for the Evaluation of Transpedicular Screws Using an In Vivo Porcine Lumbar Spine Model

Pedicle screw fixation is the gold standard for the treatment of spinal diseases. However, many studies have reported the issue of loosening pedicle ...

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased ...

Robotic Enucleation of an Intra-Pancreatic Insulinoma in the Pancreatic Head

Pancreatic parenchyma sparing surgery for insulinomas avoids the risk of endocrine and exocrine insufficiency, and potential high-risk anastomoses ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

A Rat Carotid Artery Pressure-Controlled Segmental Balloon Injury with Periadventitial Therapeutic Application

Cardiovascular disease remains the leading cause of death and disability worldwide, in part due to atherosclerosis. Atherosclerotic plaque narrows the ...

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and ...

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), ...

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 ...

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 ...