The necessity of adequate training in robotic surgery

We have been concerned this week by a high profile report in the news of a patient who died during a robotic mitral valve procedure in Newcastle in 2015.

Clearly our thoughts are with the patient’s family and friends, who have lost a man who the coroner said may have lived had the procedure been performed with the standard open approach. It was reported that the primary surgeon hadn’t completed much training and had received little one-to-one tuition, and that the two external mentors left part of the way through the operation. Open conversion occurred when the robotic procedure had to be abandoned due to bleeding obscuring the vision.

As a robotic trainer and mentor for urological surgery I was concerned about some of the background to the story. This was the one of the first times this procedure had occurred in the UK and certainly the first in this hospital.

As robotics expands into different specialties, the need for a more formal and standardised training programme is increasingly required. Unlike most large US hospitals there are only a few UK centres that have a formal credentialing process for new robotic surgeons. 

In urology we are lucky as we have established a more structured training programme and have many young fellowship trained surgeons. The penetration is such that over 80% of 7000 annual radical prostatectomies are carried out robotically – so most centres are now well established and well over their initial learning curves, with excellent national results.

As a result of the increasing uptake in robotic surgery now occurring in gynaecology, upper and lower GI surgery, ENT and thoracics, the UK needs a pan-speciality training and accreditation programme to ensure that minimum competencies are defined and patients are not placed at risk during initial cases. Without this there is a possibility that results may get worse before they get better. 

What are your thoughts? Is more training the solution to prevent future surgical tragedies? 

Comments (7) Add yours ↓
  1. Catherine Lovegrove FY2 Doctor

    Great comments. It’s a terrible scenario and evidence of Swiss Cheese in action; little training, little tutoring, suboptimal support…
    I agree, like any surgical technique or operation, robotic surgery needs training and mentoring and indeed there is a responsibility for regulatory bodies to be involved and for curricula to exist, as in urology. It’s important that events such as this are learned from and that training improve rather than let it marr training and opportunity for surgical innovation.

    November 12, 2018 Reply
  2. Greg Shaw Consultant Urologist

    Without pioneers, advances would not be made. That said, if you were the patient- about to sign the consent form, what would you want to know? Pioneering a new technique is challenging and if things go wrong those responsible are vulnerable to criticism.

    Developing a new technique should involve specialists with expertise to elements approximating that which is proposed. There should be careful thinking through of the steps involved and safety checks and technical rehearsal as well as contingency plans. These adaptations are usually best made through a series of small adaptations, rather than one major change. The patients should understand exactly what is being proposed and there should be regular and careful scrutiny of results. This might be best done within the context of a research study.

    November 12, 2018 Reply
  3. Christian Brown Consultant Urologist

    The story was hard to believe but it’s true. There are issues at the trust level and at the surgeon level. Greg’s right someone has to go first but not this way. Urology has paved the way for other specialities to see how robotic training can be delivered safely and in a timely way with no increased chance of poor outcome.

    As urologists we are fortunate to work in our speciality with robust training regimes to protect patients and indeed ourselves from ourselves.

    November 12, 2018 Reply
  4. Ravi Barod Consultant Urologist

    Agree entirely. When we started the robotic kidney transplant programme at The Royal Free, we kept patient safety at the centre of our business case. All robotic kidney transplant operations are performed by 2 consultants… an experienced robotic surgeon and an experienced transplant surgeon. Extensive training was carried out on pre-clinical models in the US and Belgium. Clinical observation of 4 cases occurred in India. Our first 2 cases were overseen by an experienced mentor. This level of attention to detail is what is required when pushing the boundaries of robotic surgery. Patient safety is paramount.

    November 13, 2018 Reply
  5. Louise de Winter Chief Executive, The Urology Foundation

    Without knowing the full details behind this case, what we read in the papers defies belief. How could a surgeon, seemingly cognisant of the fact that he could have done with more training and support, even begin to contemplate performing such an operation? To me this is not only an issue about training and its delivery and take up, but one of an over-inflated sense of confidence and ego. The facts also smack of poor communication and team work, from the proctors leaving the operation midway to the slow decision making within the surgical team. Urology surgeons are fortunate that thanks to BAUS and The Urology Foundation, there is a structured robotic training programme in place and TUF funds centres of excellence such as the Freeman in Newcastle to deliver training in robotic urological surgery. However, the technical aspect is only one, albeit very important aspect of being a surgeon. The other important, and in this case crucial lesson, is knowing when one is safe to operate and not being afraid to ask for help or support.

    November 15, 2018 Reply
  6. Peter Rimington Consultant Urologist

    It is hard to believe that his sort of thing could still happen.
    What sort of surgeon who has the interest of the patient as paramount concern, would proceed with a new procedure without undergoing rigorous training including watching a few procedures, building a relationship with the mentor, doing some animal work if it really is a ground breaking new procedure, ensuring there was adequate supervision of himself and the entire team on the day throughout the operation etc etc?!
    Where were the mentors? How on earth can they walk out during the procedure? Who appoints these mentors? How well trained are they in this surgery and in being mentors?
    Where was Intuitive in this whole thing? Judging by the numerous and well controlled hoops we had to pass through before attempting any robotic procedure, I cannot fathom how they let this happen on their watch (assuming of course it was a daVinci robot being used).
    Urology led the way to successful and safe laparoscopic surgery and now we have done the same for robotic surgery.
    There is absolutely no room at all for “having a go” or any type of “practice” in a human being. Lessons must be learnt and disseminated and if necessary, some heads must roll.

    November 15, 2018 Reply
  7. Simon Lord Patient

    It’s fair to compare robotic surgery with aviation in some respects. An aircraft captain will be examined on paper, orally and tested in a simulator before undertaking check flights until they satisfy the examiner. Only then will they take sole command.

    The Trust totally failed the patient in allowing the procedure to go ahead without written confirmation of the skills of the surgeon (which were nominal) and therefore those supervising him in theatre and in his department also bear a heavy burden.

    November 28, 2018 Reply

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