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The Importance of Proficiency in Robotic Surgery and the Training Implications

Over the past few months we have talked frequently about the importance of acquiring proficiency in robotic surgery. Although this may have been evident to many, the term proficient has been based on the Dreyfus Model of Skill Acquisition. This model, developed in the 1980’s, focuses on how students acquire skills through formal instruction and practice. It was developed by the brothers, Stuart and Hubert Dreyfus, out of the University of California, Berkeley.

The diagram below is a simple representation of the Dreyfus model:


The critical factor is being able to determine where individuals sit on this progression and what are the real objective boundaries between the different skill levels.

The concept of proficiency was taken up by surgeons when beginning to learn laparoscopic surgery and incorporated into the Fundamentals of Laparoscopic Surgery (FLS) where a proficiency level of 2 consecutive and 10 non-consecutive passes have to be achieved before certification is reached.

The da Vinci® surgical system is currently the main player in the computer-assisted surgical market. Over 3M procedures have been done with the system, of which some 650,000 were in the last 12 months. What does it take to become proficient at using a da Vinci system?

First and foremost, it is important to realize that surgery is a team activity and that while the role of the surgeon is vital in the ensuring the best outcomes for the patient, the surgeon can only do so if supported by a highly skilled OR team.

The da Vinci System was designed around three key principles, 3D visualization, dexterity, and control. This essentially means that the system allows the surgeon to see and move within the operative field in a way that they were not able to beforehand while building in safe guards to ensure patients could not be inadvertently harmed.

To achieve this, the surgeon is placed on a console outside the operative field where they can control a combination of instruments using their hands and their feet. Instruments are changed by an assistant who will replace the required instrument at the correct time.

When training to use the da Vinci system, it is not only important to ensure that the surgeon is proficient at controlling the system itself but that the whole team is also comfortable with working in this new environment. What does take some time getting used to is the fact that the team leader is no longer at the bed side but is now sitting apart outside of the sterile field immersed in the console. Given the high quality of the image, they can easily become immersed in the operative field.

How do hospitals therefore ensure that their surgeons and teams are proficient and ready to perform robotic surgery? Also how do they make sure that they after their initial training they are staying up to speed with evolutions in the technology and gaining enough exposure to the system?

The table below shows a typical case distribution by surgeon over a three year period. The X axis shows the average number of cases and the Y axis represents each surgeon ranked from lowest to highest volume.


Many hospitals will typically use a minimum case volume per year to decide whether or not a surgeon should maintain privileges on a robotic system. However, looking at the distribution of cases, can the number of cases alone really be used to determine whether or not a surgeon and team are performing as advanced beginners, competent users, or are really proficient?

Thanks to its 10 years of experience in the training of surgeons and teams to run effective robotic surgical programs, Mimic has the experience to help hospitals with this issue. MimicMED’s Consultancy Services can help organizations set their thresholds to distinguish between the different skill levels, evaluate their surgical staff, and see where they currently sit on the continuum as well as develop and implement training programs to ensure overall objectives are met.

Click here for more information on how MimicMED’s Consultancy Services could potentially help you.