HPB O06 Strategy, evolution and outcomes of a ‘unit-wide’ approach to robotic surgical training – evaluation of the experience in a high-volume tertiary hepatopancreaticobiliary unit

Abstract Background Robotic surgery has been a 'slow-burning' technology in HPB Surgery in the UK, partly due to availability of robotic systems due to more rapid adoption in other subspecialties. It has also been seen as the preserve of one or two early adopters, both within units and more widely. In this study we evaluate an alternative approach to starting a robotic programme, with an a priori intent to train multiple members of the same unit following a structured process and continuous real-time outcome evaluation. Methods The training programme was structured in line with the Intuitive console surgeon training pathway consisting of online modules, simulation training and laboratory courses. Case acquisition was in line with the suggested escalation of difficulty laid out in the paper by Farrugia et al (J Robotic Surg 2022). Surgeons trained in pairs, with the order determined by robotic availability and previous minimally-invasive HPB experience. Regular robotic access was secured by agreement with other robotic specialties. A prospective database of cases was maintained and regularly interrogated to evaluate outcomes at a unit and surgeon level. Results 245 cases were performed in 18 months. Case acquisition rate was similar for all surgeons. Unit volume slowed from a peak of 21 cases/month until acquisition of a 3rd Xi system, facilitating 3 regular HPB robotic lists/week. Following this both number and complexity of cases increased. All surgeons experienced a decrease in total numbers of complex cases in the first month, which had returned to baseline at 6 months (mean 9.25 v 3.5, p<0.05). Overall length of stay, HDU stay and conversion rates were lower than surgeon- and case-matched historical data, with no significant increase in complication rates. Conclusions The introduction of a unit-wide robotic programme is feasible and results in better robotic utilisation. Case acquisition can be maintained for all surgeons. A possible further benefit is a greater acceptance of the need to share the caseload for open and laparoscopic cases during the learning curve. Robotic access is key to successful implementation and must be assessed before the programme begins. Outcomes at a unit- and surgeon- level can be maintained or improved regardless of the career stage of the surgeon prior to beginning robotics.