Surgeon Inadequately Trained on Da Vinci Robot

This case involves a patient who underwent a robotic myomectomy in the form of a da Vinci-assisted laparoscopic hysterectomy and right salpingo-oophorectomy in a major university hospital setting. A physician who did not receive extensive training with the new technology performed the surgery. In the operative report, the surgeon did not record any difficulty making the incision or introducing the surgical needle into the abdominal cavity. Likewise, there was no mention of difficulty introducing the laparoscope or placing the port. When the needle was being removed from the abdominal cavity, however, it was dislodged and lost in the abdominal cavity. The device was eventually located in the right upper quadrant and removed through the trocar sleeve intact. Several weeks later, the patient was taken for emergency surgery due to a small bowel perforation and generalized acute feculent peritonitis. An abscess was discovered in the abdominal cavity just below the robotic incision site. The patient had extensive complications following the exploratory surgery as she was found to have an enterocutaneous fistula from the colon to the incision. The patient remained hospitalized for two months before being transferred to long-term care for wound care and physical rehabilitation.

Question(s) For Expert Witness

1. What are your thoughts on the training required for robotic surgical techniques?

Expert Witness Response E-000493

Robotic surgery requires immense training. Many studies have demonstrated improvement in laparoscopic skills with simulation and laboratory drills. This improvement has also been shown in robotics. Laboratory drills improve accuracy, decrease errors, result in a shorter learning curve, and increase the speed of intracorporeal suturing and knot tying. Because of these improvements, issues exist regarding how to appropriately train and credential robotic surgeons. In general, the credentialing can be granted only by the institution where the surgeon is employed and is based on the concepts of technical training, capability, and documented robotic surgery cases. In addition, training should incorporate how to respond to technical malfunctions and how to rapidly remove the device in case of an emergency.