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Forward[DRAFT] Thoracic Resident Robotic Curriculum
About the Curriculum
Welcome to the Thoracic Resident Robotic Curriculum, provided by the Society of Thoracic Surgeons.
The curriculum is based on the recently published The Society of Thoracic Surgeons Expert Consensus Statements on a Framework for a Standardized National Robotic Curriculum for Thoracic Surgery Trainees. Specifically, we have chosen to address the core competency of technical skills in anatomic pulmonary resection by allowing graduated responsibility to the resident in the operating with demonstration of specific milestones. The curriculum is separated into three components:
- Preclincal (Online Modules, Hands-on Inservice)
- Simulation (Virtual and Wet Lab, Emergency Conversion Simulation)
- Clinical (Bedside Assisting, Console Surgeon)
The curriculum also includes a Formal Feedback process with video analysis of the resident's operative case(s). The resident will progress through the components of curriculum based on resident’s clinical experience and demonstrated competency.
Program administrators: Visit the Faculty tab for a more detailed overview.
How to Measure the Progress of Learners
Learners completing the STS robotic curriculum may progress at different rates. The following guidelines can be used as a reference for learners to monitor their progress.
Progression Through Curriculum Based on PGY Level
The tables below outline how we expect learners to progress through the curriculum based on their PGY level for integrated cardiothoracic surgery programs, two year cardiothoracic surgery fellowships, and three year cardiothoracic surgery fellowships.
I-6/7 Pathway
| PGY 1-3 | PGY 4/5/6 |
|---|---|
|
|
T2/3 Program
| T1 | T2/3 |
|---|---|
|
|
Progression Through Curriculum Based on Skill Acquisition Level
The figure below outlines how we expect learners to progress through the curriculum based on their own skill acquisition, irrespective of their PGY level.
[Figure placeholder]
(Taken from Mitzman et al PMID 36372530)
References
Samuel S Kim, Lana Schumacher, David T Cooke, Elliot Servais, David Rice, Inderpal Sarkaria, Stephen Yang, Abbas Abbas, Manu Sanchetti, Jason Long, Svetlana Kotova, Bernard J Park, Desmond D'Souza, Mansi Shah-Jadeja, Hana Ajouz, Luis Godoy, Nataliya Bahatyrevich, Jeremiah Hayanga, John Lazar. The Society of Thoracic Surgeons Expert Consensus Statements on a Framework for a Standardized National Robotic Curriculum for Thoracic Surgery Trainees. Practice Guideline. Ann Thorac Surg. 2025 Apr;119(4):719-732. doi: 10.1016/j.athoracsur.2024.12.003. Epub 2024 Dec 18.
Brian et al. Consensus Guidelines on the Bedside Assistant Skills Required in Robotic Surgery. Surgical Endoscopy (2024) 38:6406-6412. September 2024.
Turner et al. Development and Pilot Testing of an Assessment Tool for Performance of Anatomic Lung Resection. Ann Thorac Surg. 2020 Jun;109(6):1922-1930. doi: 10.1016/j.athoracsur.2019.09.052. Epub 2019 Nov 9.
Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997 Feb;84(2):273-8.
Mitzman et al. The Accelerating Robotic-Assisted Thoracic Surgery (ARATS) Curriculum: Establishing Proficiency-Based Training for Robotic-Assisted Lobectomy. Ann Thorac Surg. 2023 Mar;115(3):706-713.
1. Preclinical Component - Overview
Online Modules
Learners should start by completing the introductory online modules for the robotic system that they will be using for the curriculum.
A. Intuitive Da Vinci System
www.intuitive.com
- Click My Intuitive in top left corner
- Log in to My Intuitive (create an account if you do not have one)
- Click 'Learn' on the left hand side
- Complete:
- Da Vinci Xi System Basics – v11 (Surgeons, Residents, and Fellows)
- Multiport System Fundamentals and Technical Skills
Quiz – Included on the Intuitive website
B. Other robotic system
Each robotic system will have different instructions and introductory modules that need to be completed.
Hands-On In Service
Learners should complete a hands on in service with their local robotic surgical system sales representative.
Video overview of hands on in service with Da Vinci System:
2. Simulation Component - Overview
Virtual Reality Simulation
Learners should perform virtual reality simulation modules in the following four categories: camera control, energy use, tissue & object manipulation, and needle driving. These simulations should be complete with a score of over 90%.
Wet Lab Simulation
Learners should perform a robotic wet lab once per year in their fellowship, or once in each of the last three years of an integrated residency program.
Available Courses
- STS Workshop on Robotic Thoracic Surgery (USA) - 2-day course with 6+ hours of hands-on and explicit wet-lab time (Foundations & Advanced tracks: lobectomy, thymectomy, segmentectomy; complex segmentectomy, sleeves, esophagectomy).
- AATS Foundation – Thoracic Surgical Robotics Fellowship (USA) - Society-run program that includes a lab day on KindHeart tissue and a surgeon/faculty-led lab; followed by required clinical cases and a Clinical Procedure Skills Training day. Competitive but open to public applicants.
- IRCAD Strasbourg – Advanced Course in Robotic-Assisted Thoracic Surgery (France) - Curriculum includes hands-on training on live tissue (pig) and simulators for RATS (e.g., lobectomy/lymphadenectomy on porcine model).
- ESTS Robotic School @ ORSI Academy (Belgium) - ESTS-led 2-day bootcamp specifically notes virtual, dry-lab and wet-lab training hosted at ORSI.
- ORSI Academy
- EACTS / Intuitive – Thoracic Robotic Surgery (Europe) - EACTS runs thoracic robotics courses; while agendas vary by date/location, the Academy advertises in-person training and small-group practical sessions.
- UPMC – Center for Advanced Robotic Training (USA) - Institutional program offering performance of robotic thoracic procedures within a structured lab/simulation pathway.
- TSDA / STS Resident Bootcamp
Resources for Local Wet Labs:
We also have resources to help institutions set up their own wet labs locally. See this peer-reviewed journal article with description of simulation exercises that could be set up at home institution: 2023 review paper on current state of VATS surgery simulation and training for ideas on how to set up simulation at home institution, "Video-Assisted Thoracoscopic Surgery Simulation and Training: A Comprehensive Literature Review" (PMID 37501111)
Emergency Conversion Simulation
Each year the learner should perform an emergency conversion simulation in the OR with their team.
Checklist for Surgeon Assessment During Emergency Robotic Undocking
(Bold = critical misses)
Scenario 1: Massive hemorrhage via PA bleed
- Loupes/headlight in room if desired
- Outline thoracotomy incision after patient positioning
- Identify bleeding source/suction to see bleed
- Apply manual pressure with robotic instruments
- Call for hemostatic agents
- Call for surgical support
- Discuss possible need for transfusion
- Determine need for conversion
Scenario 2: Decision to Convert to Open
- Discuss undocking plan
- Continue applying manual pressure to the bleeding vessel while bedside assistant begins thoracotomy if instructed
- Ask for lights on
- Attending surgeon scrubbed in + at bedside
- Uninterrupted visualization of bleed during conversion
- Removal of all robotic instruments without removing manual pressure
- Thoracotomy incision
- Apply manual pressure to bleeding vessel after thoracotomy
- Primarily repair PA injury
Scenario 3: Hemodynamic Instability
- Ensure bleeding has been controlled/there are no other areas of bleeding
- Discuss EBL and reasons for hemodynamic instability
- Discuss additional need for blood products and/or vasopressors
- Use closed loop communication
- Request internal paddles be set up on sterile field
Scenario 4: PEA/Asystole
- Communicate initiation of intra-thoracic cardiac massage
- Begin adequate intra-thoracic cardiac massage at a rate of 100 BPM
- Continue cardiac massage
Scenario 5: Unstable Ventricular Tachycardia/Fibrillation
- Discuss situation with Anesthesia about possible types of shock
- Continue cardiac massage
- Defibrillate at max joules with internal paddles (10J and then go up by 5)
Here is a link to the STS-created curriculum: STS Emergency Conversion Curriculum
3. Clinical Component - Overview
Bedside Assistant
Learners should act as a bedside assistant for ten cases. They should be evaluated by the attending surgeon who was on the console for these cases. Learners must pass all of the bedside assisting checklist items before it can be considered that they have completed this aspect of the curriculum.
Bedside Assisting Checklist
(Adopted from Brian et al. PMID 39227438)
| Category | Task | Pass (Yes or No) |
|---|---|---|
| Set up robot for the console surgeon | Drive robot to patient and dock robotic arms to each trocar | ☐ |
| Optimize clearance of arms and joints | ☐ | |
| Manipulate robotic arms using the port and instrument clutches | ☐ | |
| Load and insert robotic instruments and sponge rolls | ☐ | |
| Assist during case, using robotic arm | Burp, pull out, or push in trocar to facilitate ease of operation | ☐ |
| Exchange robotic instruments and camera safely | ☐ | |
| Insert new, or upsize trocar | ☐ | |
| Assist during case, using non robotic instruments | Suction in the surgical field without causing injury, or causing the lung to reinflate | ☐ |
| Provide effective retraction | ☐ | |
| Remove specimens with a grasper (lymph nodes) and bag (lung) | ☐ |
Console Surgeon
Learners will need to complete thirty thoracic surgical cases as the console surgeon. There are specific preparations the learner should complete, and specific feedback that should be completed by the attending surgeon who is the staff of record during each of the thirty cases that are completed for the curriculum.
Video Review
Before acting as the console surgeon each of the thirty console cases that going to be done and evaluated, the learner should watch a video from the STS On Demand Playlist:
Right upper lobectomy:
Right middle lobectomy: Video
Right lower lobectomy: Video
Left upper lobectomy:
Left lower lobectomy: Video
Right lower lobe superior segmentectomy: Video
Right lower basilar segmentectomy: Video
Left upper trisegmentectomy: Video
Left upper lingulectomy: Video
Case-Specific Milestones
After each case is performed by the learner, they should request and have completed the following assessment form. This assessment must be completed thirty times with a satisfactory score for the trainee to be considered to have completed the robotic thoracic surgery curriculum.
(Adapted from Turner et al. PMID 31706874)
| Competency | 1 | 2 | 3 | 4 | 5 | N/A |
|---|---|---|---|---|---|---|
| Adequately mobilizes lung, including division of adhesions and the inferior pulmonary ligament | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely divides lung parenchyma within the fissure | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Properly identifies bronchial and vascular anatomy | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely dissects and controls arterial structures using staplers and/or sutures/ligatures | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely dissects and controls venous structures | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely dissects and divides the bronchus | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely removes the specimen | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Properly identifies nodal anatomy | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Safely harvests appropriate lymph node stations | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| The above steps are performed in a safe, efficient order and in keeping with oncologic principles | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Video Analysis
Learners should have an attending view one of their videos, grade them on this scale, and give narrative feedback once yearly.
(Modified from Objective Structured Assessment of Technical Skill (OSATS) for Surgical Residents PMID 9052454)
| Criteria | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Respect for tissue | Frequently used unnecessary force or caused damage by inappropriate use of instruments | Careful handling of tissue but occasionally caused inadvertent damage | Consistently handled tissue appropriately with minimal damage | ||
| Time and Motion | Many unnecessary moves | Efficient time/motion but some unnecessary moves | Economy of movement and maximum efficiency | ||
| Instrument handling | Repeatedly makes tentative or awkward moves with instruments | Competent use of instruments although occasionally appeared stiff and awkward | Fluid moves with instruments and no awkwardness | ||
| Use of Assistants | Consistently placed assistants poorly or failed to use assistants | Good use of assistants most of the time | Strategically used assistant to the best advantage at all times | ||
| Flow of operation and forward planning | Frequently stopped operating or needed to discuss next move | Demonstrated ability for forward planning with steady progression of operative procedure | Obviously planned course of operation with effortless flow from one move to the next | ||
| Knowledge of specific procedure | Deficient knowledge. Needed specific instruction at most operative steps | Knew all important aspects of the operation | Demonstrated familiarity with all aspects of the operation |
Overall, on this task should the candidate: ☐ Pass ☐ Fail