Exposure and perception of general surgery residents' toward robotic-assisted surgeries in Riyadh, Saudi Arabia
Zeyad Yousef, Sarah Marie, Sultanah Bin Gheshayan
Department of General Surgery, Ministry of National Guard-Health Affairs; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Date of Submission 12-Dec-2021
Date of Acceptance 20-Feb-2022
Sarah Marie
Department of General Surgery, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia. King Abdullah International Medical Research Center, Riyadh
DOI: 10.4103/ssj.ssj_96_21
Introduction: Robotic surgery is one of the rapidly expanding technologies in the field of medicine. It has been implemented since 2000; and its use has expanded over the past years. Da Vinci system was first introduced to the Middle East in 2003 by Saudi Arabia; then over the following 15 years it was utilized by other gulf countries. With the expanding knowledge of this technology and the effectiveness of its utilization; formal training programs were introduced by many hospitals. However; there are no established credentialing standards or well-structured curriculum to provide this training in the gulf region.
Method: This we aim to understand the perception of general surgery residents toward robotic surgery training in tertiary care centers in Riyadh; Saudi Arabia. An anonymous web based survey was conducted on general surgery residents enrolled in Saudi Commission for health specialties approved residency training hospitals in Riyadh.
Results: 50% of GS residents were involved in robotic assisted surgery which was significantly associated with the presence of robotic machines in their training centers (P0.025). Sixty Percent of residents who were involved in RAS did not receive a formal training prior to their participation, barely even a brief introduction.
Conclusion: exposure and education about RAS at early training years showed that residents have better technical performance during their fellowship training. However, it should not the main focus of the training.
Keywords: General surgery residents, robotic surgery, training in robotic surgery
Yousef Z, Marie S, Gheshayan SB. Exposure and perception of general surgery residents' toward robotic-assisted surgeries in Riyadh, Saudi Arabia. Saudi Surg J 2021;9:40-4
Yousef Z, Marie S, Gheshayan SB. Exposure and perception of general surgery residents' toward robotic-assisted surgeries in Riyadh, Saudi Arabia. Saudi Surg J [serial online] 2021 [cited 2023 Jan 29];9:40-4. Available from: https://www.saudisurgj.org/text.asp?2021/9/2/40/345198
Robotic surgery is one of the rapidly expanding technologies in the field of medicine. It has been implemented since 2000, and its use has expanded over the past years. The number of robotic-assisted surgical (RAS) procedures done between the years 2000 and 2010 has increased from 80,000–200,000.[1] The first robot machine to be introduced was in 1994, and it was used to assess intra-abdominal surgeries. Then in 2000, the da Vinci machine was approved by the Federal Drug Association.[2] Its introduction had taken the surgical field to a new era in technology and artificial intelligence. In 2017, more than 3600 units were using the system in the United States only.[2] Da Vinci system was first introduced to the Middle East in 2003 by Saudi Arabia; then, over the following 15 years, it was utilized by other gulf countries.[3]
With the expanding knowledge of this technology and the effectiveness of its utilization, formal training programs were introduced by many hospitals. For example, Roswell Park Cancer Institute established a training curriculum in 2008.[4] Another center in Marburg, Germany, created a simulation laboratory for their surgeons and residents. Outcomes of these projects were analyzed and they show a major improvement in the skills and operative times of performing surgeons.[5]
General surgery (GS) is one of the fields where robotic surgery is being utilized significantly. It has been used to assess in colorectal procedures, upper gastrointestinal (GI) procedures, and many others.[3] In Riyadh, Saudi Arabia, more than six residency training centers have robotic machines where robotic-assisted surgeries are performed on weekly basis. It was observed that these centers are trying to train their employees and residents to utilize this technology. Fellowships and attending targeted courses were provided worldwide.[6] However, there are no established credentialing standards or well-structured curriculum to provide this training in the gulf region.
In this study, we aim to understand the perception of GS residents toward robotic surgery training in tertiary care centers in Riyadh, Saudi Arabia.
An anonymous web-based survey was conducted on GS residents enrolled in Saudi Commission for Health Specialties approved residency training hospitals in Riyadh. The survey consisted of multiple-choice questions that studied three parts: Demographics, exposure, and perception. A link was forwarded to the chief residents for further distribution. The responses were collected over 1 month from November 2021 to December 2021.
Data analysis was performed using Statistical Package for the Social Sciences, SPSS 23rd version. (IBM SPSS Statistics for Widnows, version 23rd, IBM Corp, Armonk, N.Y., USA). Frequency and percentages were used to display categorical variables. Minimum, maximum, mean, and standard deviation were used to present continuous variables. Chi-square test was used to test for the presence of an association between categorical variables. Independent t-test and analysis of variance tests were also used to test for association. Level of significance was set at 0.05.
A scoring system consisting of five items was constructed to assess the participants' positive perceptions toward robotic-assisted surgeries. Those who gave a strongly positive answer were given 2 points, those who gave a positive answer were given 1 point, and those who had a neutral or negative answer were given 0 points. Positive perception score was then summed, and a total perception score was generated (the lowest possible score was 0, and the highest score was 10).
Levels of positive perception were then constructed for the participants based on the perception score, those who had a total score of <70% (6 and less) were considered to have a low-to-moderate level of positive perception, while those who had a total score of 70% (7 and more) were considered to have a high level of positive perception.
A total of 56 participants were included in the study. [Table 1] displays the participants' gender and academic profile. Twenty-nine (51.8%) of the participants were males and 27 (48.2%) were females. As for the residency level, 33 (58.9%) were juniors and 23 (41.1%) were seniors. As for the center, the center of 4 (7.1%) was university hospital, the center of 14 (25%) was community hospital, and the center of 38 (67.9%) was military hospital.
Table 1: Participants gender and academic profile (n=56)
[Figure 1] shows the participants' hospitals that perform robotic-assisted surgeries. Thirty (53.6%) reported that their center performs robotic-assisted surgeries, 19 (33.9%) reported that their centers do not perform robotic-assisted surgeries, and 7 (12.5%) reported that they do not know whether their center performs robotic surgeries or not.
Figure 1: Participants' hospitals that perform robotic-assisted surgeries
[Figure 2] present the participants' previous involvement in robotic-assisted surgeries. Twenty-eight (50%) reported being previously involved in robotic-assisted surgeries and 28 (50%) reported not being involved previously.
Figure 2: Where you involved in robotic-assisted cases
[Table 2] demonstrates the participants' personal experience with robotic-assisted surgeries among those who had a previous involvement. Twenty-three (41.1%) were involved in 5 cases or less of robotic-assisted surgeries, four (7.1%) were involved in 6–10 cases, and one (1.8%) was involved in more than 10 cases. As for their role in these robotic-assisted surgeries, 17 (60.7%) were observers and 11 (39.3%) were assisting on the operating table. As for the rotations, the participants were involved in 22 (78.6%) were involved during colorectal surgery rotation, 3 (10.7%) were involved during upper GI surgery rotation, and 3 (10.7%) were involved during thoracic surgery rotation. As for the level, the participants were in during their involvement in robotic-assisted surgeries, 15 (53.6%) were during their junior years and 13 (46.4%) were during their senior year. Among those who previously assisted in a robotic-assisted surgery, only four (36.4%) were given a proper introduction before assisting in the procedure.
Table 2: Participants personal experience with robotic surgeries (n=56)
[Table 3] illustrates the assessment of participants' perception toward robotic-assisted surgeries. The mean positive perception score was 3.5 ± 2.15, the minimum was 0, and the maximum was 8.
Table 3: Assessment of participants' perception toward robotic-assisted surgeries (n=56)
[Figure 3] present the participants' level of perception toward robotic-assisted surgeries. Fifty-three (94.6%) had a low-to-moderate positive perception (<70% of total score, score of 6, and less), whereas only three (5.4%) had high positive perception (70% and higher of total, score of 7, and higher).
Figure 3: Participants level of positive perception toward robotic-assisted surgeries
[Table 4] shows the factors associated with participants' perception toward robotic-assisted surgeries. None of the following was significantly associated with participants' perception toward robotic-assisted surgeries: Gender, residency level, center, being in a hospital that performs robotic-assisted surgeries, nor being previously involved in robotic-assisted surgeries.
Table 4: Factors associated with participants' perception toward robotic-assisted surgeries
[Table 5] displays the factors associated with participants' previous involvement in robotic-assisted surgeries. Being in a hospital that performs robotic-assisted surgeries were significantly associated with being previously involved in robotic-assisted surgeries (P = 0.025), whereas those who had a hospital that performs robotic-assisted surgeries had a significantly higher rate of involvement compared who were not in a hospital that performs robotic-assisted surgeries (53.3% versus 21.1%). Gender and center were both not significantly associated with previous involvement in robotic-assisted surgeries.
Table 5: Factors associated with participants' previous involvement in robotic-assisted surgeries
In 2000, an article that studied the perception of GS residents toward robotic-assisted surgeries reported that merely 14% of GS residents were exposed to robotic-assisted surgeries in their training.[1] A decade later, in 2013, Farivar et al., reported that around 96% of residents have access to robotic surgery.[1] In this article, 50% of GS residents were involved in robotic-assisted surgery which was significantly associated with the presence of robotic machines in their training centers (P = 0.025). Lower exposure results in our study could be attributed to the lower implementation of robotic surgeries in Saudi Arabia compared to international data.
With the increase in exposure, residency programs worldwide have established a formal robotic surgery curriculum, some developed simulation training programs. In 2017, a study by George et al., reported that 73% of program directors in the United States stated that a formal RAS curriculum is established in their institution.[7] However, no data were found to support receiving a similar training in the Middle East. In this study, 60% of residents who were involved in RAS did not receive a formal training before their participation, barely even a brief introduction.
Given the lack of training and low exposure in the study population, 94.6% of study participants had a low-to-moderate positive perception toward RAS and only 25% believed in its importance during the residency period. This influenced their interest toward its application in their future practice. On the other hand, a growing interest in RAS was observed among surgery residents in the United States. In 2003, 57% of residents were interested in learning about RAS, and in 2017, a study reported that 81% of residents were willing to receive a formal training as part of their residency program.[1],[7]
RAS is a growing field of technology. Its significance in the surgical practice has been established in the literature. Surgeons prefer this practice for faster patient recovery and lower complication rates.[3] Exposure and education about RAS at early training years showed that residents have a better technical performance during their fellowship training. However, it should not be the main focus of the training.[8]
More significant results could be obtained with a larger sample size.
Farivar BS, Flannagan M, Leitman IM. General surgery residents' perception of robot-assisted procedures during surgical training. J Surg Educ 2015;72:235-42.
Davila DG, Helm MC, Frelich MJ, Gould JC, Goldblatt MI. Robotic skills can be aided by laparoscopic training. Surg Endosc 2018;32:2683-8.
Aldousari S, Buabbas A, Yaiesh S, Alyousef R, Al-Enezi A, Abul F.[32] perceptions of robot-assisted surgery: Results of a survey of surgeons in Kuwait. Arab J Urol 2018;16 Suppl 1:S16.
Attalla K, Raza SJ, Rehman S, Din R, Stegemann A, Field E, et al. Effectiveness of a dedicated robot-assisted surgery training program. Can J Urol 2013;20:7084-90.
Walliczek-Dworschak U, Mandapathil M, Förtsch A, Teymoortash A, Dworschak P, Werner JA, et al. Structured training on the da Vinci Skills Simulator leads to improvement in technical performance of robotic novices. Clin Otolaryngol 2017;42:71-80.
Chen R, Rodrigues Armijo P, Krause C, SAGES Robotic Task Force; Siu KC, Oleynikov D. A comprehensive review of robotic surgery curriculum and training for residents, fellows, and postgraduate surgical education. Surg Endosc 2020;34:361-7.
George LC, O'Neill R, Merchant AM. Residency training in robotic general surgery: A survey of program directors. Minim Invasive Surg 2018;2018:8464298.
Kapadia S, Shellito A, Tom CM, Ozao-Choy J, Simms E, Neville A, et al. Should robotic surgery training be prioritized in general surgery residency? A survey of fellowship program director perspectives. J Surg Educ 2020;77:e245-50.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
Yousef Z
Marie S
Gheshayan SB
General surgery residents
training in robotic surgery