Welcome to our live webcast, Robotic Surgical Training for Residents and Fellows. Thank you for joining us. My name is Jacob, and I will be the operator for the presentation today. Before we get started, I would like to take a moment to acquaint you with a few features of this web event technology. On the right-hand side of your screen, you will see the Q&A window. To send a question, click on the text box and type your text. And when finished, click the Send button or push Enter. All questions that you submit are only seen by today's presenters. Your questions will be responded to in the order in which they were received, and will be addressed throughout and at the end of the presentation. At the conclusion of today's program, we ask that you complete a brief post-event survey. Please take a moment to complete this survey, as it will help us plan future web events. We are joined today by our moderator, Leslie Rickey, and our speaker, Nazima Siddiqui. At this time, I would like to turn the microphone over to Leslie Rickey for opening remarks. Leslie? Thanks so much, Jacob. I would like to welcome all of you to our next installment of our AUG Virtual Forum web-based lecture series. This is a series of presentations by experts in our subspecialty from across the country, focused on topics based on the SDMRS learning objectives, as well as relevant practice-related topics. The virtual format also provides AUG members the opportunity to interact with the speakers in real time. This presentation will then be captured and made available for view at any time on the AUG website. Upon completion of this program, you will be given the opportunity to provide some feedback, which we value greatly in future programming. I do want to thank Intuitive, as this webinar is supported by generous educational grants from Intuitive Surgical. For this evening's presentation, it is my pleasure to introduce one of AUG's finest speakers, clinicians, and scholars, Dr. Nazima Siddiqui. She is an Assistant Professor of Obstetrics and Gynecology in the Division of Urogynecology and Reconstructive Pelvic Surgery at Duke University Medical Center. This webinar will introduce participants to web-based and simulation curricula for robotic surgical training. In addition, we will discuss training tools for specialized surgery, such as robotic sacral copepaxi. Her presentation today will be Robotic Surgical Training for Residents and Fellows. Thank you, Dr. Siddiqui. Well, thank you, Leslie, for that introduction. I have about 45 minutes of content here, including some videos, and then hopefully we'll be able to have some time for questions, as this tends to be a very thought-provoking topic that different people struggle with. In terms of our objectives today, I wanted to be able to discuss with you all some of the ways to optimize the training experience, particularly for residents and fellows. Think about where to focus dry lab practice, just because there are sometimes many opportunities, and it's hard to figure out where to prioritize time. And then also review some of the web-based and simulation curricula that are available that can be used by various trainees, and highlight some of the training tools that can also be utilized. One of the questions that does come up is actually, why do we need a training program? I suspect for many of you who have called in tonight, this is a little bit of an obvious question for you. But this does come up at the institutional level sometimes, and you all probably appreciate that robotic surgery continues to increase in multiple specialties, not just in OB-GYN. And there is a steep learning curve that is exclusive to robotic surgery, and that learning curve is really magnified in trainees, because they're not only learning robotic techniques, but they're also learning a procedure that they may not have as much experience with in the same way that faculty or attendings might. And so they're really learning multiple things and sort of drinking from a fire hose in those moments of time. And what we have seen is that along with the fact that you have all these learning challenges, there is a shift in caseload that has happened over time. And if trainees are not incorporated into robotic procedures, it can really translate into a loss of operative experience for them. So this is just an illustration of adoption of minimally invasive surgery for a hysterectomy, not necessarily sacrocopalpexy per se. But, you know, among hysterectomy, we can see that the open hysterectomy rate has gone down, and along with that, the robotic surgery rate has gone up. We've seen some small shifts in laparoscopy and vaginal as well. But if you think about all of those open surgeries turning into robotic surgeries, and if you were not to include trainees, then that really translates to surgeries that they are no longer participating in and missed opportunities for training. And this is now being borne out in the literature. So we do see that a shift in caseload is translating to a loss of operative experience for residents. In JMIG in 2014, Yamasoto et al. published some of these data where they showed that the abdominal hysterectomy rates went down, robotic surgical rates went up, laparoscopic and vaginal in their population stayed about the same. And Peter Jepson, one of our fairly recently, a few years ago, graduated FPMRS fellows, worked with the fellows' public research network to do a study that they published in 2015 that shows that in over 1,400 hysterectomies, the proportion of hysterectomies with resident involvement is lower with robotics than with any other route. And so these are very real concerns in the trainee population. So we see this sort of residency and fellowship program director's quandary, and this is probably more pronounced amongst residency directors, which is that robotic surgery is specialized and may not be useful for each trainee, particularly in a resident population. Obviously in a fellowship population of specialized surgery, it may actually be useful for all of your trainees. But we see that the loss of surgical numbers and training that happens unless residents and fellows are incorporated into these procedures. And so that program director may think about the fact that, you know, this kind of training may not be applicable for everybody, but we need to find a way to involve residents as much as possible to maintain operative experience, and also doing that in a way that is safe. And so how do we safely integrate trainees in robotic surgery? And all of us know that all of these concerns are balanced with the fact that time equals money, and we have to maintain operative efficiency. For those of us who are robotic surgeons, we know that our case times are being, you know, scrutinized and we tend to have the concerns about how incorporating trainees may also affect your robotic case efficiency. So I've thought about this a little bit over the last few years and have a couple of suggestions in terms of how to approach that problem. I do think that utilizing a standard training program is really helpful for initial practice, and this really pertains mostly to residents and perhaps fellows who are in their first or kind of incoming fellows who have not had robotic experience. Those fellows are getting fewer and fewer, at least in my experience these days. A lot of incoming fellows have had at least a little bit of experience with robotics while they're a resident. But, you know, for people who are naive to robotics, having a standardized training program is really very helpful to set expectations and allow them to understand what sorts of things they need to do before they can safely be integrated into the operating room sphere. I think it's also helpful, then, to provide opportunities for ongoing and advanced practice, and this is probably more relevant for upper-level residents or fellows, people who have demonstrated that they have, you know, reached some threshold where they're allowed or in a position where they can assist at the console, but then they will still need some ongoing practice. And then, as educators, it's helpful to periodically review systems and implementation. And, you know, for today's discussion, I don't have as many slides about that latter component, but certainly can talk or speak to that if there are questions at the end. We'll just see how the time goes. So, in terms of the initial training, I'm going to highlight one initial training program that's out there that some of you might have heard of. It's through the RTN, which is basically the Robotic Training Network, and here's the website for those of you who are not familiar with it. And the reason I'm highlighting this is twofold. Now, number one, I have to say that I have a huge conflict of interest here because I'm very involved in the RTN. But that being said, part of why I'm highlighting this program is because of the fact that it is a comprehensive program that is available that can make it so that people don't have to reinvent the wheel locally at their own institutions. And part of how this came about was that about six years ago, there were a number of robotic surgeons and educators who were struggling with this very problem of, you know, the need for having a standardized curriculum, and we were all individually working on things separately and thought that it was going to be much more helpful to collaborate and try to come up with something together. And you can see the founding members of the RTN actually include a fair number of people in the SPMRS sphere. For those of you who are looking at the pictures, you may recognize Liz Geller right here from UNC, Megan Tarr was at Cleveland Clinic at the time, now at Carolinas Medical Center. I'm there. But then there's also a number of minimally invasive gynecologists, GYN oncology, you know, people who are pretty prominent in the field. And so these were all surgeons who were struggling with this very question. We wanted to come together to create a standardized curriculum. And then we really felt that the important thing at that time was to develop a test to assess readiness to operate at the console. And that was something that we were all, you know, really struggling with, which is that you could send your trainees off to do some training, but then how do you really know that they're ready to assist in a live patient? And we also felt that we really felt strongly that we wanted to have some evidence-based metrics behind whatever we were to recommend. So about six years ago, everybody started working together and over time developed this curriculum. I have to give a lot of credit to both Isabel Green and Marty Martino. And I should actually give some shout-out also to both Intuitive Surgical and Mimic Technologies, who were very involved, especially in the early years, with helping to support all of us to come together and collaborate in a way where we could do so in person in a meaningful way. But, you know, so Isabel and Marty have been very integral in helping to develop the curriculum. Isabel has a master's in education and was instrumental in ensuring that the ACGME six-core competencies were covered within the curriculum. And so there's actually a blueprint that's available for residency and fellowship program directors. You know, this is particularly important now for urogynecology fellows because we are under the GME framework or ACGME framework. And so those competencies and learning objectives are there for program directors if they are seeking that information. But the curriculum does have an approach that kind of follows the milestone method, which is to say that the learner is really kind of going through the program in a couple of phases. The first phase is the bedside assistant training, and then they graduate into console training. And we've thought very critically about this over time because, depending on logistics, sometimes people come to one thing before the other, but I think that as robotic surgeons, a lot of us felt very strongly that trainees tend to gloss over the bedside assistant phase and want to get right on the console. And yet, being able to manage the bedside and help and assist there is a key and instrumental part of robotic surgery. And as you all know, you know, the minutes can add up to hours, and if your bedside assistant is not trained, then that can be a particular impediment for OR efficiency. And so we felt like it was especially important to incorporate that bedside assistant training early on. The RTN curriculum has a couple of components to it. Everybody takes a pretest. This is a web-based, or there's a web-based learning module that sort of guides you through the curriculum. And so everyone takes a pretest, and then they start in phase one. For both phase one and phase two, the structure is very similar, which is that there are some articles, and they sort of pertain to the phase, but these articles may include things like society statements that come from ACOG or AGL or AUGS or, you know, wherever they're relevant and pertain to robotics, we try to include those kinds of things. I shouldn't say AUGS. I'm sorry. I misspoke. It's actually there's an AUA statement, which we purposely included because we're trying to keep this curriculum available to trainees from multiple disciplines. Some of the articles do cover things related to cost and OR efficiency because that's a big component of robotic surgery as a robotic surgeon. And all of this is organized on the web with the articles and questions to help guide their learning. They also have web-based modules, and currently the trainees go out to the intuitive website, and that's particularly because the robotic technology that all of the trainees are using is the intuitive-based technology. We have always thought that if there were other robotic surgical systems available on the market, that we would try to facilitate having people select or go to the web-based modules that were more suitable for what they are going to be operating with. And after they go through that sort of article and web-based module component, for each phase, there's a key and critical dry lab, and that is a time where they get to essentially experiment, use the technology, and understand it without having a patient there. In phase one, the focus is really on the bedside assistant tasks, how to manage the camera, how to swap instruments, being able to understand the functionality of the camera and the things that they can do with the buttons. And in phase two, the dry lab is really focused on skill drills and the console test, or essentially the test of readiness to be able to assist at the console for live surgery. And then after each dry lab, we do incorporate some OR assessments. And while there are things about this curriculum that are not perfect, and so the OR assessment currently is not as well integrated as we would like it in terms of being able to marry with other existing technologies that people are using for assessment locally in their institutions, we do have a framework for OR assessments and some recommendations for how to do some objective assessments in the operating room. I wanted to just show a few of the components of this curriculum. So the phase one dry lab that I mentioned, we do utilize sort of an abdominal shell that allows practice with docking, practice with port placement, and how to select where things should go. This same abdominal shell on the interior houses drills that are used in the phase two dry lab and practice sessions. And for those sites that are joining the RTN now, the kit looks a little bit different than it did before. The outer shell looks more like a dome instead of what you saw in those other pictures, but it functions the same way, which is that there are places where people can place ports and learn about the remote center, and then on the interior area you can place the drills. As part of this curriculum, and I've kind of alluded to this, there was a lot of thought that went into developing a test of proficiency or competency, and I'm going to mess up the words. I apologize to the educators who are on the line here. But essentially a test of readiness to operate at the console. A number of members of the group about five years ago sat down with a whole bunch of dry lab skill drills and tried to figure out, you know, what is that minimal set that assesses a whole bunch of different kinds of robotic skills? And we came up with a series of five dry lab skill drills and associated assessment form. And we went on to essentially test that a little bit further in a study, which I'm going to show you in a moment. But before I show you those data, I just want to also show you how these skill drills function. So if we could queue up the first video. This is, I'm just going to hit play and talk while it goes. But essentially this is just showing how you can use that kit that I mentioned and dock the robot onto it. This is the first drill. And these are actually trainees working in these drills that you can see. But this is the first drill, which is the tower transfer drill, where some of you have done this. You have to pick up rubber bands. You have to transfer from one hand to another without dropping the rubber band. And then transfer that band to another tower of varying heights. That prior drill does a lot of camera manipulation. And this one as well requires a lot of camera manipulation and dexterity. This is the roller coaster drill, which for some residents is actually the hardest drill of the bunch. We have to move that rubber band around the wire ring. This one is the big dipper drill, which is one of the needlework drills where you have to pass a needle in various throws following these dots, which are in a big dipper formation. This one is the train tracks drill, which just mimics a running suture, but essentially also tests dexterity. You have to put the needle in and out where those dots are and also kind of forces some suture management. And this one is the suturing drill where the participant has to do a figure of eight. So a figure of eight and then tie a knot, which would be a surgeon's throw followed by three half hitches. So this one really tests suturing. And that final drill is actually the hardest thing to simulate in a virtual reality world. And part of why, and we can go back to the slides now, part of why we really wanted to develop these drills in a dry lab sphere was twofold. Number one, because not every program has a virtual reality simulator and not every program has the same virtual reality simulator. And then also because of the importance of suturing in many complex procedures and how, at the time, we weren't able to have great suturing drills in the VR world. So our group did validate, assess the validity and reliability of this framework, those five drills, with the assessment tool in a study of 105 participants. And then we also went on to publish the benchmark. So we did a separate study where we established what is the minimum benchmark for competency. And this is minimum competence because we're talking about residents and trainees. We're not necessarily talking about experienced attending level surgeons. But what is the minimum competence that you need to achieve on these dry lab robotic surgery drills in order to assist at the console? And so we now have these recommendations, which is that in order to operate on the console, you would want your trainees to practice using the skill drills that I showed or other VR simulators for practice, but then attend a proctored testing session where you go through these drills. Each one has a time limit and is scored. And the participant has to score greater than 13, so at least a 14 out of 20, for each drill during that testing session. And that would allow for essentially the trainee to understand that now they are ready to assist at the console. And for some programs, this kind of concept of the proctored testing session is a challenge, just because you have to set aside proctors and have a robot available. And so one of the other things that we've been doing recently, and I'm going to highlight Michael Pollan, who is our recently graduated fellow, is working with the CSATS group, which is a group that looks at crowdsourcing. And essentially we have been looking at whether or not crowdsourcing, so having laypeople who basically access videos online through a secure portal, and if they are able to grade the videos, you know, is that a reasonable grading framework? And we were able to see that indeed crowdsourcing scores do correlate very well with expert graders and that that may be a valid alternative to allowing or facilitating for grading or scoring of some of these skill drill tests. So I kind of went through an approach to initial training. There are other training programs out there. I know that, for example, at UT Southwestern there was a very rigorous training program that was developed that does require, I think, a full day set aside or that it was designed to be done as a hands-on session. And that is, you know, another option for people who have that ability to have their residents and faculty come out on one day. That may be a more attractive solution. But, you know, I kind of demonstrated one initial training program that is available and out there for other programs who are looking for something that's already ready for them to adopt. Now, you know, a number of you may also be training fellows or at the point where residents have gotten some initial training and then need some ongoing training. And that's where I really see that, you know, currently where VR simulators do have a role and a good place in that scheme. And part of that is because we do see a degradation of skills if there's been, you know, some time off the robot. So skills degrade significantly within four weeks of inactivity in newly trained surgeons. And when you think about a trainee population who may rotate on and off different rotations, it can be very easy for them to be away from the robot for four weeks where, even though they might have passed a console test, it's hard to understand if they're still at that same level of competency. Even for our fellow trainees, you know, with the new guidelines, they have to be away on dedicated research blocks, for example, which is a four-week block. There are instances where even, you know, people with more experience are going to be taken away for some period of time. So this is where some of the virtual reality simulators, I think, can be very helpful if these are available in your institution to maintain a level of skill once it's there. And you may know about the intuitive surgical, quote, backpack, you know, the simulator that you place onto the console. There's also the Mimic DV trainer and the robotics or what used to be called Symbionics Robotics Mentor. The Symbionics was bought out by 3D Systems. These are just some examples. There are other simulators out there, but these are the ones that seem to be more highly utilized from what I see right now. And these provide, you know, opportunities for ongoing drills and dry lab practice. Now, unfortunately, I'm not sure why this has not come across well. I apologize. But this is an example of some simulation training where some thought has been put into different kinds of exercises and how they pertain to sort of levels of skill where, in terms of the simulation training on the left, what you would see are some recommendations of how to approach different exercises if you're at the very beginning. You know, if you're just practicing before you've done a console test, you might start at Level 1 or then going up to Level 2 and 3. And then for the GYN Advanced on the right side of the slide, there are some skills that were thought to be a little bit more relevant to different kinds of procedures. And this is information that is, again, available through the RTN framework. And, again, I apologize that it didn't come across well. But I think, generally, if you look close enough, you could probably figure out what all these skills are. So in terms of VR simulation, you know, one of the big questions is could you use that exclusively? Could you, if you had a VR simulator, could you skip completely over that dry lab test and get into and allow your trainees to just do this all in VR? And that's a great question. I mentioned that suturing has been one of the areas or one of the hangups that has prevented that from happening to some degree. And we do have some recent advances in suturing skills that have come around that may facilitate that. And I want to highlight Megan Bradley, who's one of our current fellows, and Laura Nuko, one of our residents, who are currently working on a project. We have a grant through Intuitive, their simulator loaner program, to look a little bit more closely at a couple of simulation exercises and do some research to see if we can find some correlative scores to the dry lab arena. And they are working on that project and hopefully will publish that next year. But prior to that, I have not really been in a position to state whether or not I would be comfortable with using exclusively VR simulation for initial trainees. And I say that partially because to some degree, before you have somebody sit there with a live patient, you really want to understand if they're comfortable with the technology. And I think as a faculty member who supervises residents, I tend to feel more comfortable knowing that they can actually work with the live robot. But again, I'll look for these data to see if the simulator will work as a good proxy. We can queue up the second video. This shows you, for those of you who haven't seen some of the VR simulation activities, some of the areas where the simulator actually surpasses what we can do in dry lab. And so this is an example of one exercise that I think is excellent that we would like to use as a supplement even to dry lab testing, which really kind of allows for the participant to use different types of energy, make sure they're using the right type of energy. And the nice thing is that it does kind of seem a little bit more lifelike. Things can bleed, you can have vessels that can rip, and then if you haven't cauterized vessels well, they can actually start bleeding again. I think it happens, yeah, right there down below. You might have maybe seen it or missed it. This is another example of an exercise in the simulation, or in the simulator, where similar to that ring rollercoaster drill that we talked about before, showed you before, where you would move a ring around a vessel. And this really forces the participant to use both hands and to think about strategies sometimes. There's also one version of this drill where there's a flap of tissue that you are forced to use the third arm to lift. And so these are ways where I think the simulator can certainly surpass dry lab and have a great role in training, especially in ongoing training to maintain skills. So Pat Culligan, many of you may be familiar with him, one of the experts in our field and a great educator. He had thought about this quite a bit also and had published the, quote, Morristown Protocol. So this is what he worked on, which was a series of skills in the VR simulator that would allow novice surgeons to train towards expertise. So when I was talking before about the RTN framework, we were talking about novice trainees getting to a minimal level of competence. This program was one that was developed for new faculty or perhaps trainees who really wanna train towards expertise. This protocol involves a series of VR simulation exercises that people would have to work through. And I think from what I recall, you have to reach a certain benchmark of greater than 90% twice in a row in order to pass each particular skill. And in his study for the participants, they required an average of 20 hours of simulation lab time in order to, quote, pass or progress through that Morristown Protocol. You can see the range there. There was one person, the quickest, who did it in 9.7 hours and the person who did the longest took 38.2 hours. So it certainly is a time investment to train towards expertise. And this is where certainly fellows may be much more motivated to use something like this because they do want to train towards expertise, whereas maybe not every resident may need to do that. The other interesting and really cool thing that Dr. Colligan did was that he established predictive validity. So this was one of the few studies where simulation was used and then these were faculty surgeons who went out and did their first robotic hysterectomy and were able to demonstrate that with significant simulation practice that robotic hysterectomy times were comparable to those of experts. And he actually had a control group of people doing there who were newly training robotic surgeons who didn't go through this protocol, but also went through a different, kind of their usual care or usual standards training and then did their first hysterectomy. And the group who went through this Morristown protocol did significantly better. So I view this as something that definitely has a role for your motivated residents or fellows. If you're really trying to get people to train towards a level of more expertise, this is a great protocol that's available. And it is published, so it's in our gold journal and available for people to look and can see what all the exercises that are incorporated into that protocol. So I'm just gonna spend a little bit of time now talking about procedure-specific training because until now, the things that I've mentioned are really very general, which is to say there's different kinds of curricula and drills that are used for many different kinds of procedures. But one of the things that's very attractive is can you develop any sort of really specific training for a procedure so that when you're doing the live procedure, you can accomplish that procedure quicker with more expertise. And when it comes to hysterectomy, that certainly has come along a little further than other specialized procedures. So that's where you'll see a little bit more in terms of procedure-specific training. There are a couple of ways to approach this in terms of a procedure-specific. You could either perform a bunch of drills that simulate the activities that would be needed for a hysterectomy. And so that's sort of akin to the list of drills that I showed you earlier. And those drills that you could do either on the dry lab or on a virtual reality system. And then another sort of approach that is on the horizon is to perform a simulated procedure, a simulated hysterectomy on a VR trainer. And that is certainly available now and hopefully going to be more available in the future. But the 3D Systems company that I mentioned, used to be Symbionics, has worked on this and has a nice module available. And if you're at a conference where you can go try it out, they tend to be at different conferences that have robotic systems as vendors. It's kind of cool to be able to go down there and try out this VR hysterectomy. I know that the intuitive platform, the XI platform, will be able to use this software. And so this is something that you can look to that's on the horizon. But I don't have any video of this, unfortunately, but you can see in the top picture here, you know, what looks like a uterus and ovaries and tubes. And, you know, it really does look like the environment of a hysterectomy. And on the bottom is the cuff closure where you'd be suturing the cuff. Because this is an on event, I had assumed that many of you on the call would be interested in sacroculpopexy as a procedure. And again, we have the same sort of conundrum about how to do procedure-specific training for probably more likely a fellow population, maybe residents, but, you know, again, you could either think about drills that simulate activities needed for sacroculpopexy, refer back to that list that I showed earlier, or try to perform a simulated sacroculpopexy on a model. And that's a little bit trickier because in the virtual reality world, we don't really have a simulation procedure like we do for hysterectomy. In terms of the simulation activities, though, Intuitive does have a worksheet available on sacroculpopexy, again, Pat Kellegan has been very involved in this, as he's very involved as an educator in the robotic sphere. But this kind of steps through some of the recommended skills on the simulator that may be helpful in developing necessary skills for the surgical steps of sacroculpopexy. On the left-hand side, you see a surgical step, thinking about the procedural considerations, and then what are the recommended drills that would allow you to practice those kinds of skills to achieve some level of competency. Now, one other thing that I don't know who of you on this call may or may not remember, but many years ago, we actually presented a pretty cheap and easy sacroculpopexy model that can be created and just kept at your program. So for those of you who are on this call who are training fellows repeatedly or want to have something that's a little bit more, allows more simulation, particularly of the angles needed at the sacrum and for suturing the vagina, this is a model that was created some years ago using some pretty cheap and easy materials to find in this, let's see if I can get the pointer up, on this picture, what we're showing here is this is the old, I say old because it's no longer available, AMS LPPY polypropylene mesh, and this is a piece of tulle, the stuff that's in underneath wedding dresses you can buy from a fabric store, but essentially you can even, you don't even have to have real surgical mesh, but even just using something like this really does seem to simulate how you would need to manipulate mesh and use it in a live procedure. This model is nice because you can actually use it on a bed in Trendelenburg with a robot, and so again, facilitating suturing at angles and getting to the sacrum, it's helpful. This model has essentially a sock that is used as a vagina, you can put a manipulator in there or if you don't have an assistant when you're practicing, you can put an orange or something that's circular in there to distend the vagina, and it has a simulated anterior longitudinal ligament that you can suture to. So this model, I have to also give some credit to a couple of people, Jason Yeh is now a reproductive endocrinologist and fertility specialist, but was one of our prior residents here at Duke, and so some years ago he helped work on this model, and Casey Jenkins, who you may be wondering why is there an orthopedic surgeon involved in the mix, he happens to be my husband, and so he helped us out as well, but this site at the bottom that you can see, if I can point to it again, but this URL at the bottom is a YouTube video that shows how to assemble that model, and you'll hear Jason's voice, but he really steps through almost like a recipe, all the materials you need, how do you put everything together if you wanted to assemble this at your site. I can show a brief video of that, if you can queue up the next video. Let me get that pointer out of there, and I may just fast forward through different parts, but this is just parts of that model creation video, where Jason and Casey are just showing, literally step-by-step how to create everything, and I'm just gonna zoom on through, but you can pretty much create this if you have some household tools. We can go on to the next video. So this is the cool part that I wanted to show you, and I believe this is Jason, or one of the other trainees suturing, I cannot actually recall who's suturing here, but this actually, or actually it might be one of our fellows, this shows somebody actually using the model with the robot, and so essentially that's that piece of tulle that I mentioned before, as you can see it looks kind of like mesh, you could use whatever suture you wanna use, back at that time we were using more Gore-Tex on the vagina, and so you could use whatever you want to practice with, and have trainees practice essentially all of the suturing, all of the mesh manipulation, and that's a really attractive thing to be able to do outside of the OR, since it's time-consuming if this isn't practiced ahead of time, we can go to the next video, and what I think is kind of neat about this model is actually the ability to practice some of the suturing at the sacrum, and so this is just showing, again I think the mesh has been sutured onto the simulated vagina, and now we're sort of pulling it up to the sacrum, this is a technique where you sort of drop the needle through the mesh, and then if you were in a live patient, you'd have to mobilize some tissue, and really expose the sacrum, so you don't have to do that here, but how would you wanna place that needle, and curve it through, doing all of those components, you can have somebody practice here on a model, realizing that you don't have tissue, and you don't have blood, so there are a few downsides to that, but this kind of elastic that stimulates the anterior longitudinal ligament is quote weak enough, that you actually do have to turn, kind of curve the needle through, if you try to push it, you'll see that the tissue moves a lot, or the simulated tissue moves a lot, or it doesn't necessarily allow the needle to go through, unless you're using the arc of the needle, so that's another nice thing about this training modality. Now this is Leslie, can I ask you a question real quick? Sure. So if you were to back out from this picture, the robot's not docked, right? So it's just sort of above it, with the arms kind of doing the procedure, and it also looks like there's a ring down there distally. So correct, the robot is not quote docked onto anything, these are just the arms doing the procedure, and when we do this, we do like to try to get the arms in what we would think would be the best, you know sort of configuration, that would simulate a live abdomen, but that is a downside of this, is that you can't put this into a simulated, this doesn't really fit into that simulated abdomen, that I showed you before, so it's not easy to sort of dock, in the same standard fashion. The ring that you see at the bottom, is highlighted in that video, where the whole model was created, so that's an embroidery hoop, and it's in that recipe on the YouTube site, and it kind of shows how that's attached, and holds the stock in place. Okay thanks, no I think it's a great model, I was just trying to picture like, if I was standing like somewhere outside the room, what this would look like, from a little bit further away, so I think that's helpful, thank you. Yeah, and that's a good question, and so you're right, it's just sort of arms over it, but it is in the operating room, so this is placed on an OR table, that was put into Trendelenburg, and so it is actually kind of robotic arms, hovering over the model on an OR table, and I can't recall, there was another thought I had, but maybe it'll come back to me later, oh but part of the reason for the embroidery hoop, and some of the screws with this elastic, is that it allows for the stock for example, to be interchangeable, so you can unhook it and put in a new one, if it's getting really dinged up, just as much as you could unscrew, there's wall anchors under these screws, so you can unscrew this piece of elastic, and swap it out, if it's getting kind of dinged up, and we've used this model in the past, not only with an assistant, using an EEA sizer, or something like that in the vagina, but as I mentioned before, sometimes people wanna just be able to practice, on their own, and I know my first year faculty, I was actually getting less robotic time, than when I was a third year fellow, and periodically wanted to come in, and do some practice, and would just stick literally a piece of fruit, in the sock, or just something, some circular object, a small ball, something like that, and you can actually use this on your own, without an assistant. Great, thank you. Sure. So we can go back to the next slide, which is essentially the summary, so I hope that I have shown you a few examples, of how a robotic training program, can be used in your program, and I do think it's really helpful, to have a program, because it does help to set expectations, for how to safely incorporate trainees at the console, here at Duke in the OBGYN department, our residents pretty much know, that if they haven't done their console test, they do not expect to sit at the console in those cases, so if they're coming in earlier on, and they're still training, and they haven't passed their test, they pretty much know, that they're gonna be a bedside assistant that day, and that's okay, but at least they have that expectation, so they don't kind of have that secret, sort of harboring that desire, and then having their dashed hopes, at the end of the case. We also do make sure, that all of our trainees, do their bedside training, before the beginning of their second year, and that's because during their second year, is when they are expected, to at the very least be bedside assistants, in robotic cases on multiple rotations, and so we do ensure, that they all go through that phase one, dry lab at the very beginning, or just before their second year starts. Again, in this summary, I've kind of shown you, that this RTN curriculum is available, and if you go to the website, you can consider joining, if you would like, there is a fee, but it includes the website, the learning portal, and the training kit. There are VR curricula available, including the Morristown protocol, which is a nice protocol, that's been set out and published, and has really established, some predictive validity, so these are things that you could use, particularly in a fellow population, and then although procedure specific simulation, is more difficult, there are options available, for hysterectomy and sacrococopexy. So with that, I'm gonna conclude my presentation, and hopefully allow some time for questions, and particularly if there are questions, about implementation, I am certainly happy to talk more about that too. Perfect, yeah. As a reminder, the Q and A is located, on the right hand side of the screen, to ask any questions, just type your question, into the small text box at the bottom, and when finished, click the send button. Please note that due to time constraints, our panel may not be able to respond, to all of the questions submitted. Leslie? This is Leslie, yes while we're waiting, to see if any questions come through, one of my questions is for Dr. Siddiqui, so as you stated, when fellows come in, more and more with some robotic experience, but still a pretty, I would say, varied experience, so do you have all of them, go through sort of, from the beginning, you know at least the base, modules to establish, or at least check off, that they understand that level, do you kind of treat everybody, coming in the same? Yes we do, so we require, essentially the same thing of our fellows, that we do of our residents, the difference is that the fellows, tend to get through it much faster, and they're very motivated to, you know do their console training, pretty much right away, and this applies to not only, the Euroguide fellows, the guide on fellows here, you know pretty much, all of the trainees in our environment, go through this, but you know like I said, for our fellows I will say, that they will typically come in, they get their orientation, they hear about the program, they go out and do it, and if they've had some experience, as residents they tend to be able, to do their console test pretty quickly, I think the last few years, all of our fellows were able, to just come and sit down, and practice a little bit, and then do their test on the same day, so they didn't necessarily need, the same amount of time practicing, as perhaps some of the residents do, on average our residents, will come to three practice sessions, before they're ready to test, that's an average, some are quicker than that, and some take longer. And is there a written test, they have to pass also? So there's not, but the curriculum incorporates, questions that are based on the modules, so there is a pre-test and a post-test, built into that web-based curriculum, and we do utilize that RCN curriculum, so we just have them go through that. You know one thing I wanted to add is, since I'm in Connecticut, I've helped out with a sim lab, that Elena Tenitsky at Hartford Hospital runs, and so she's also made, or developed a sacrocopalpexy, I guess model that can hook up, to those SLS trainers, the general surgery folks need to use, to pass a lot of the sim labs, have these SLS trainers, and it bolts to it, it doesn't have the pelvis that you have, and the actual sacral promontory anchoring, but I sort of wonder just sort of offline, if there'd be some ability to integrate the two, because it does allow you to sort of, change the angles of the vagina up and down, because I think as you pointed out, that suturing to the vagina, you can practice some suturing, and sort of space management, and zooming and camera and clutching, but that suturing I think, especially the angle of the vagina, during sacrocopalpexy is the hardest thing to practice, before you get into an actual procedure. Yes and yeah, I think it'll be interesting to see, yeah how much those programs can be melded, or you know how complimentary they could be, I am unfortunately not familiar with that program, I now will have a certainly a question for Elena, when I next see her. No it's just it's not even like a software thing, it's just a pure it's a model that she created, it's pretty nice, so she's happy to share it I'm sure, to see if you could integrate with your pelvis model, that you have it also has a sickle promontory feature to it, so but I love the idea of the RTN curriculum, I think a lot of sites, are trying to figure out how to implement, a robotic training program, and like you said not to have to recreate the wheel, and spend time and resources, you know I know at our site gynecology, and neurology are working together, so I actually was not aware this curriculum was available, so I'm definitely going to bring this, you know everybody's attention. Yeah and I would say that the one thing, that we struggle with a little bit, is that this curriculum was definitely, created originally by a bunch of gynecologists, though we had urology, and some colorectal surgeons in mind, and so there are components of it, that certainly do touch on general surgery and urology, in trying to make it more applicable, but it's definitely a curriculum for you know, intra-abdominal pelvic surgery, at least the drills are not necessarily, but certainly the docking and all of that, and so you know one of the things, that we struggle with here at Duke, is that we actually need to have, something a little bit broader for thoracic, and you know pediatrics, and other areas and that's a little bit different, but certainly for GYN and urology, this can be very helpful, and I will say that we developed this originally, and kind of rolled it out in the GYN group, but our urology trainees, use the same program as well here at Duke. Yeah, the pelvic surgery techniques, I think are sort of similar probably. Yeah. So, do we have any comments from the audience? I'm not seeing any, Jacob am I missing any? No, I'm not seeing any either, there's also nothing on the phone as of now, so. Good, all right, well we've had a lot of participants listening in, so I just want to give a big thank you, to Dr. Siddiqui for her presentation, we learned so much today I think, and I also want to thank you to the participants, for carving out time in your day also, to participate in this virtual forum with our speaker, upon completion of this program, you will be prompted to provide feedback, please do share your thoughts and impressions with us, I want to thank Dr. Siddiqui again, I think this is something that is a struggle for everybody, as you said, how does practice translate into your actual competency, and I think this is a big move forward, I think standardization is the key, so I think having programs like this, and sharing them as you did tonight, so that everybody's aware of them and can adopt them, is really, really helpful, so I really want to thank you for sharing your experience, and also the training curriculum. So, looking forward to our next program, we will be having Dr. Peter Rosenblatt, speaking about biological materials, and reconstructive surgery, that will be held actually just next week, on September 7th at 7 p.m. Eastern Standard Time, so until then, everybody have a great holiday weekend, and we will see you in September, thank you. Perfect, thank you. On behalf of VOGS, I would like to thank you, for your participation in today's event, a post-event survey will appear requesting your feedback, please take a moment to complete this survey, as it will help VOGS plan future web events, this does conclude today's program, thank you, and have a great day.

robotic surgical training

residents

fellows

standardized training programs

Robotic Training Network

milestone-based approach

virtual reality simulators

procedure-specific training

minimum competence