Controversies for Credentialing in Robotic Surgery
Ricardo Estape, MD
Director
Robotics Program, Baptist Health Florida and South Miami Hospital
South Miami Gynecologic Oncology Group
Disclosure
Intuitive Surgical
Consultant/Research Grant/Proctor
Omniguide
Consultant
Ethicon
Consultant
Precision Therapeutics
Research Grant
Credentialing Dilemmas
Who Should be
Credentialed?
All surgeons?
Only LSC surgeons?
Only Urologists?
Only fast surgeons?
How should they be
Credentialed?
Training?
Fellowship trained?
Proctoring?
Case Observation?
Maintenance?
Complications
Wentworth‐Douglas Hospital in Dover, NH. Complication after robotic prostatectomy
Complications
Obstet Gynecol. 2011 May;117(5):1142‐9.
Increasing minimally invasive hysterectomy: effect on cost and
complications.
Jonsdottir GM,
et alBrigham and Women's Hospital, Boston, MA
Int J Gynecol Cancer. 2010 Oct;20(7):1284‐9.
A case‐control study of robotic radical hysterectomy and pelvic
lymphadenectomy using 3 robotic arms compared with abdominal radical hysterectomy in cervical cancer.
Nam
EJ,
et al
Yonsei University, Seoul Korea
Gynecol Oncol. 2011 Mar;120(3):413‐8. Epub 2010 Dec 30.
A comparative detail analysis of the learning curve and surgical
outcome for robotic hysterectomy with lymphadenectomy versus laparoscopic hysterectomy with lymphadenectomy
in treatment of endometrial cancer: a case‐matched controlled study of the first one hundred twenty two patients.
Lim
PC,
et al
Renown
Regional Medical Center, Reno, NV, USA.
pclimmd@centeroSopereno.com
Obstet Gynecol. 2010 Mar;115(3):535‐42.
Robotically assisted hysterectomy in patients with large uteri: outcomes in five
community practices.
Payne
TN,
et al
Ochsner Health Center, Baton Rouge, Louisiana
Gynecol Oncol. 2009 Dec;115(3):447‐52. Epub 2009 Sep 17.
Robotic‐assisted laparoscopic hysterectomy and
lymphadenectomy for endometrial cancer: Analysis of surgical performance.
Holloway
RW,
et al
, Florida Hospital Cancer
Institute and Global Robotics Institute
Gynecol Oncol. 2009 Jun;113(3):357‐61. Epub 2009 Apr 5.
A case matched analysis of robotic radical hysterectomy with
lymphadenectomy compared with laparoscopy and laparotomy.
Estape
R,
et al Baptist Health South Florida, South
Miami Hospital
50 others
As of June 10
th
, 2011, 3814 Robotic articles. None show higher complication rate
Complications
Robot related
Lost arm
Improper entry of instruments
Bumping of arms
Others
Laparoscopic injuries
Trocar entry injuries
Hernias
Procedure Injuries
GI/GU injury
Wrong Vessel
What is Robotics
Robotics is Laparoscopy
With a wrist
With 3D view
With Comfort seating
With typical suturing
technique
With happy feet
Isn’t this better?
Why the dilemma???
What are we Credentialing?
The Procedure
OR
The use of the Robot
Current Practices
Surgeon A
TAH 45 min
Acceptable complication
rate
Meets all surgical
outcomes measures
Surgeon B
TAH 4 hrs
Acceptable complication
rate
Meets all surgical
outcomes measures
Does Surgeon B get retrained, restricted,
Loss of privileges, sanctioned?
Surgery Evaluation
Are there complications in
open surgery?
Are there complications in
Laparoscopic surgery?
Does your hospital have a
review committee?
Why is the robot
different?
Forget Robotics
How do you currently
handle:
New instruments
Energy sources
Equipment
New physicians
Long cases
Complication review
Who are you?
Surgeon trying to start
Surgeon trying to do
more
Trying to start program
Director of program
Administrator
Program Director – My Shoes
Goals
Improve patient care
Train Surgeons
Train Teams
Choose appropriate
surgeons first
Grow program
Control costs
Make program profitable
Do not be exclusive
Best Approach
Center of excellence
Referral center
Marketing
Inclusive program
More cases
More referrals
More teaching
Credentialing: Prerequisites
Must have privileges to do
procedure
Ergo: Must have advanced
laparoscopic skills
Case Observation?
On‐Line course for
familiarization with system
Hands/Feet on course
Minimum 8 hours within 2
weeks of starting
Considerations
Surgeon does not have
laparoscopic privileges
MD transferring from
another institution
New MD coming out of
training
Dealing with
emergency
situation
Rapid undocking
Bleeding control
Surgeon Consideration
Advanced Laparoscopic
privileges
Train on use of robot
Short proctoring cycle
Surgeon with no
advanced laparoscopic
skills
Laparoscopic training
LSC courses
Mentoring
Set # of cases for each
procedure
Robotic Training
Mentoring for each
procedure
Set # of cases for each
procedure
Proctoring
Who should proctor
Expert robotic surgeons
>200 Cases
Surgeon in same field
If available
What are you proctoring
Use of robot
Procedure itself?
How many cases?
Minimum of 2 cases
Evaluation must have
structured evaluation
Navigating camera
Keepings moving arms in
field
Finding lost arms
Centering of hands
Coordination of feet
Exchange of instruments
Understanding of icons
Energy source evaluation
Emergency procedures
Proctoring
Procedure Evaluation
Is this necessary?
Timing of procedure
Technique
Differences in technique
Dealing with emergency
Is this a residency
program or a proctoring
of new equipment
Credentialing
Easy Answer
Surgeon that was trained
in robotics in residency or
fellowship
Primary or Co‐surgeon
>50 cases
Surgeon with advanced
laparoscopic privileges
Complex
Surgeon with no
advanced laparoscopic
privileges
Why no adoption of LSC
Rare cases
Centers of excellence
Maintenance of Credentials
Maintain advanced LSC
privileges
Number of cases
Recommendations
Min 1 case per week?
Other Solutions
Simulator training
Set number of hours per
week on simulator
Completion of specific
tasks on simulator
Completion of surgery
specific training on
simulator
Hands on labs
Conclusions
For credentialing
Advanced LSC privileges
Case observation
Online training
Proctored cases
Min of 2 with evaluation
Maintenance
1 case per week – average
Simulation training
No advanced LSC privileges
Simulate residency program
Conclusions
Credentialing
What is your goal
Build program?
Lower cost
Profit increase
Center of excellence
Be an elitist?
Have robot all to yourself
Program death
Training
Use of robot
LSC surgeon
Specific procedures
New procedures
No LSC privileges
Thank You
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