The study shows that surgeons begin at different levels, and it may take a different path of commitments to gain competence on the robot. In other words, it proves that some surgeons need to work harder than others to gain proficiency. Some understand the mechanics of the robot right away, while others need more time on the simulator.
A Methodology That Stands Out
We have not seen a model showing competence in live surgery because such a model is logistically difficult, requiring necessary attention to scheduling, time, and effort. Culligan’s commitment to solving the question is appreciated by his peers. “This is the first study in gynecology that asks if simulation really improves performance in live surgery,” says Paul Tulikangas, MD, FACOG, FACS, an ob/gyn and urogynecologist affiliated with the University of Connecticut School of Medicine, who has adopted the new findings into his program. “Pat took it further than anyone when looking at expertise. He asked, ‘We think you’re better, but we don’t know for sure, so let’s examine live surgeries and see if the simulation program really improved performance.’”
What distinguishes this paper from previous studies is that it more carefully evaluates and then separates the various skill levels among the surgeons. “We used this study to set minimum skill levels that must be met before operating on live patients. This is important because surgeons develop their skills at different rates,” says Tulikangas. But in this latest study, the control group was experienced in robotics.
Surgeons who reviewed the study say it is the methodology that is different this time, because subjects are separated by skill level, which was not done in previous studies, such as the controversial 2013 JAMA study, which concluded that the surgical outcomes don’t justify the cost of the surgical robot.
John Lenihan, MD, who has publicly challenged studies based on poor methodologies, is also now using the Morristown protocol for new surgeons. He says the recent studies showing problems with the robot when compared with traditional laparoscopic surgery have been blown out of proportion. His remarks echo those of others who prefer the robot to standard laparoscopic surgery. “The da Vinci robot is not the problem,” he says. “Many of us have reviewed the literature. The number one cause of problems with the robot has to do with surgeons doing surgeries that they have not yet acquired the skills to do.” He claims that some surgeons have a lack of respect for the need for training in general.
This time, board-certified laparoscopic surgeons who had no prior experience with robotic surgery were, after the training, able to meet and even exceed the rigorous requirements of the study set by a team of experienced robotic surgeons who, according to researchers, averaged over 75 robotic cases each year. Study participants required between eight and 40 hours of simulation training to achieve the required benchmarks.