Multimedia Article (Streaming Videos)
Title: Robotic Roux-en-Y Gastric Bypass surgical simulation curriculum.
G. Fantola, C. Perrenot, R. Frisoni, A. Germain, A. Ayav, L. Bresler, L. Brunaud.
Department of Digestive, Hepato-Biliary and Endocrine Surgery, Hopital Brabois Adultes, pole UND, Université de Lorraine-CHU Nancy, Vandoeuvre les Nancy, 54511, France.
Corresponding author:
Giovanni Fantola, MD
Background
Roux-en-Y gastric bypass (RYGB) is one of the most common procedure performed robotically in general surgery (1). Specific skills are mandatory before safely starting in O.R. Simulation Training was proved as efficient for teaching robotic skills (1-2) in addition to traditional training but no procedure-specific simulator is available for robotic RYGB. After three hundred robotic RYGB, we developed a dedicated curriculum using basic skills exercises on simulator.
Methods
We divided robotic RYGB procedure in five steps (4) and we selected 8/35 exercises available on dV-Trainer © to reproduce each specific skills. Residents and surgeons starting robotic bariatric surgery were mandatory to complete this curriculum before their first cases. Trainees were considered proficient for an exercise after completion of 90% of expert score.
Results
First step: After pneumoperitoneum and docking, the gastric pouch was fashioned using monopolar hook and bipolar forceps. Stapling was performed laparoscopically by the first assistant.
- “Camera targeting” mimics the robotic camera which has to be focused on blue targets.
- “Energy switching” mimics monopolar hook section and bipolar forceps coagulation. A fluent use of the 4 pedals is needed in order to perform this challenging step.
Second step: The backing suture attached the gastric pouch and the jejunal loop with a sero-serosal continuous suturing.
- “Tube anastomosis horizontal” was chosen for precise needle placement on intestinal tube (enter in yellow target, exit in black target, pull the suture bimanually).
Third step: The gastrojejunostomy is a fullthickness hand-sewn anastomosis performed with two continuous suturing. This is the most difficult step.
- “Tube closure horizontal” simulated this anastomosis made with one needle driver and one grasper.
- “Knot the ring 2” was dedicated to learn robotic square knots.
Fourth step: Biliopancreatic limb and alimentary limb were run respectively 60 cm and 100 cm. In robotic surgery, motion scaling exposed to measurement errors, a reproducible measure is needed. Moreover, the lack of force feedback expose to bowel injuries.
- “Rope walk” simulated a regular bimanual bowel manipulation avoiding bowel injuries.
Fifth step: This last step is a jejunojejunostomy performed by the first assistant with a side-to-side stapling. The robotic surgeon only closed the intestinal opening by hand-sewn continuous suture.
- “Tube closure vertical” reproduced this step. A regular needle placement insures a well-tensioned closure.
- “Interrupted suture” was focused on clamping your knot without force feedback.
Conclusion
This model could be useful to teach specific robotic skills needed for RYGB. Each task is repeated until proficiency on the dV-Trainer before the first cases in O.R. This procedure specific simulation curriculum is now implemented in our multimodal institutional bariatric robotic training.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
REFERENCES
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