Draft to Date: June 26, 2018

Courtney Green, MD Courtney.Green@ucsf.edu

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UCSF General Surgery

Resident Robotics Curriculum—DRAFT

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CONTENTS:

Curriculum Content Overview Pg 3

Detailed Curriculum:

STAGE I Pg 6

STAGE II Pg 8

STAGE III Pg 10

Session Outlines:

Dry Lab Pg 12

Proficiency Assessment Pg 13

Wet Lab _______________ _____________Pg 16

Simulator Access Set-Up Pg 17

Simulation Completion Form Pg 18

Case Logs

Bedside Surgeon Pg 19

Console Surgeon Pg 20

Attending Evaluation Pg 21

Letter for QEC Pg 22

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UCSF General Surgery Resident Robotics Curriculum UCRC (University of California Robotics Collaborative) Training Curriculum:

UCSF Proposed Curriculum:

Stage I: (Online modules) (Dry Lab) à Docking Proficiency Stage II: (Simulation)à Documentation + (Monthly Refreshers) Stage III: (Bedside Procedures)à Documentation + (Wet Labs) + (Console)à Documentation

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Goals:

1. Appreciate the potential advantages and disadvantages unique to robotic surgery and identify operations appropriate for robotic approach.

2. Understand the basic components of a robotic operating system and how they interact with each other

3. Recognize patient safety issues unique to robotic surgery 4. Learn how to dock the robot on to the patient, assist in the procedure and insert and

exchange robotic instruments. 5. Become comfortable with basic manipulation of robotic instruments, to include

camera control and clutching 6. Become comfortable assisting the primary surgeon using the dual robotic console

Documentation: All documentation should be uploaded to the Robotic Smartsheet. Contact Alexi Callen if you cannot find the email sent with the link to access @ Alexi.Callen@ucsf.edu The following list reflects all of the documentation components associated with UCSF’s Robotic Curriculum that are collected for the Department of Surgery.

1. Online module completion form (.pdf) 2. Dry docking proficiency form (.pdf) 3. Simulation completion sheet (with photographs of scores) 4. Bedside case log form(s)(10 cases total) 5. Console case log form(s) (20 cases total) 6. In depth console assessments (2 faculty) (2 separate docs) 7. Complete case list (to attached to chairman’s letter) 8. Letter from chairman

Qualification Equivalency Certification:

FDA regulated certification issued by Intuitive Surgical (With the proposed curriculum design, UCSF could become one of the few residency programs in the country with enough robotic exposure to realistically provide this opportunity to any and all general surgery residents) Letter from Department Chair (FDA requirement): documenting resident experience and competency at the time of graduation. To obtain QEC, UCSF residents need to meet the following requirements:

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1. Successfully complete Stages I and II 2. Document completion of bedside surgeon for minimum of 10 cases 3. Document docking proficiency 4. Completion of wet lab (SF or Sunnyvale) 5. Console surgeon for minimum of 20 cases with evaluation 6. Complete 2 detailed console reviews

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Detailed General Surgery Curriculum: STAGE I

Online E-Modules / Training Videos Goals: be able to describe current robotic systems, list standard equipment, demonstrate ability to troubleshoot, describe benefits of robotics, demonstrate maneuvers to manage complications and errors that may occur. 1. Sign up for the daVinci Online Community:

o Navigate to www.davincisurgerycommunity.com o Click “Join the Community” on the front page o Fill out the information requested including your name, account, and email address o Hospital: UCSF Medical Center

2. Click Training on the toolbar at the top and select Xi System. The following screen should appear:

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3. Click on the grey bar that reads P _ at the bottom of the screen and select P7. If this is not an available option, click P6.

4. Click on Select Product and choose the Overview for Surgeons option.

5. Watch all videos within the module, then click on the document icon on the upper right hand corner to activate the Take the Assessment option.

6. Click on “Go Enroll and Pass da Vinci Xi (or Si) System assessment”

7. The Online Training and Assessments screen will appear, (confirm Xi and Residents/Fellows is selected). The required module will appear on the right-hand side of the screen:

Click the Enroll button, then click on the My Training button on the upper right corner, which will display the modules you are enrolled in:

8. Click on the Take Assessment option to launch the assessment:

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Once you complete the training, please upload your assessment certificate to the Robotic Smart sheet. If you need assistance with access, please email Alexi Callen in the Surgery Education Office: Alexi.Callen@ucsf.edu

If you have questions or need assistance with online training please contact one UCSF’s Intuitive Surgical Representatives: Jennie.Taylor@intusurg.com or Heather.Weiss@intusurg.com

OR Dry/Tool Lab • Fall PGY2s (and new transplants) • WED 9-12 session with surgical attendings +/- Da Vinci rep in OR8 (Parnassus campus) • Fall of R2 year –during skills lab • 2016: catch up: NOVEMBER 30th, 2016 • Yearly there after (2018: August 15) • 1.5 hour overview of robot tool functions: docking/instrument exchange/collisions • Didactics on collisions • Trouble shooting collisions

Documentation of Docking Proficiency • During dry lab pending attending availability • Or different time –monthly • Completion of docking proficiency form (Qualtrics assessment) • Goal: R2s complete early fall

STAGE II

Da Vinci Skill Simulator Exercises: There are multiple simulators available for access at the surgical campuses where UCSF residents rotate. Simulators have several exercises to help users become more familiar with the robotic functions. We have identified some specific exercises to illustrate appropriate readiness for the operative environment.

All exercises can be accessed on any simulator. Locations and availability of the simulators vary by campus. Please see below for details:

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Campus # of Sims

Simulator Location Availability Access

Contact prior to use:

Questions?

PARNASSUS 2 In OR 8

S0550

OR8: When OR not in use (+ evenings and weekends)

S0550: 24 hours

OR- Badge

S0550: Badge **use sign in sheet**

No For badge access issues contact Surgery Education Office

MISSION BAY 2 In OR x2 OR: When OR not in use (+ evenings and weekends)

Badge No Lissette Chao lissette.chao@ucsf.edu

CPMC 2 In OR OR: When OR not in use (+ evenings and weekends)

Badge No

KAISER 1 In OR OR: When OR not in use (+ evenings and weekends)

Badge ?

VAMC 1 In OR OR: When OR not in use (+ evenings and weekends)

Badge No

Please see attached form (Pg 17) for step-by-by step instructions for accessing the simulators.

Residents are required to achieve a score of 85% on each of the exercises. Some will be easy, but others will take multiple attempts to improve skills and reach 85%. We ask that residents take a screen shot (photo of monitor) with >85% completion of each exercise and document on the attached sheet (Pg 18) the date, time and location of completion. Once all the required modules have been completed with a score of 85% or greater, upload the form (Pg 18) to the Robotic Smartsheet. If you need assistance with Smartsheet access, please email Alexi Callen in the Surgery Education Office: Alexi.Callen@ucsf.edu

Additionally, when you complete a task with a score >85% take a photograph of the robotic

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screen (illustrating the task name and your score). There is a place on the Smartsheet to upload each of the 6 photographs.

1. Camera targeting 1 2. Peg Board 2 3. Energy switching 1 4. Ring walk 2 5. Thread the rings 6. Suture sponge 2

If you have questions or need assistance with simulator training please contact your local Intuitive Rep: Jennie.Taylor@intusurg.com or Heather.Weiss@intusurg.com Intuitive Rep Hands-on Refresher

• Monthly (usually during 1st week) • 1-6 residents per group – (residents on service) • Recurring at rotation sites for resident review • Organized with Da Vinci rep

STAGE III

Bedside procedures: • Scrubbed, bedside assistant • ROLE: Participate in port placement, inserting trocars, docking the robot, inserting and

exchanging instruments, operate assistant port, trouble shoot collisions • 5 Cases required for UCSF (10 for QEC) • Document via Case Log (pg 19) and upload to smartsheet

Wet Lab: (specific lab outline on pg 16) **Of note, wet labs will initially be optional for UCSF residents. However, to obtain QEC residents will be expected to complete 1 of each lab prior to graduation. Sunnyvale Lab: When: Early June (yearly) – 4 hours Who: 16 spots (4 groups of 4). Upcoming R4s/R5s have first priority then open to others (fellows, residents, etc) Staffed: 4+ UCSF affiliated robotic general surgery attendings Chicken Lab: (Mission Bay) (Details pending) When: Q3 mo or Q4 mo (second Saturday) 10am-noon Who: 4-8 students (priority)

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Staffed: Chern? Rogers? Kratz? Console Procedures:

• Should have completed simulation exercises • Track cases and type/degree of console participation • Identify degree of involvement and types of skills utilized • Document via Case Log (pg 20) and upload to smartsheet

Final Console Evaluation • After 20 cases have been completed • In depth performance review by two different attending surgeons for 2 separate robotic

cases (pg 21)

Additional Robotic Resources:

Rotation Folders: UCSF Box Folders with case-specific pre-operative review materials. These are maintained by attending surgeons from each rotation and can be accessed using the following link:

https://ucsf.box.com/s/7lbjconqbu0brka3o08rvcon5648hz23

Online Webinars: Weekly live webinars on robotic operative topics (peer-to-peer discussions hosted by Intuitive Surgical) with focus on the following specialties: Thoracic, MIS and Colorectal. For more information or to be included on the mailing list, please email: Jennie Taylor @ jennie.taylor@intusurg.com

QEC Certification: To obtain a QEC certification you must compile the following documents and request a letter of recommendation from the Chair of the department of surgery. (pg 22)

1. Online module certificate 2. Docking proficiency sheet 3. Documentation of simulation completion 4. Bedside assistant cases (10) 5. Console cases (20) 6. Comprehensive attending review (2x)

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DRY LAB SESSION:

Goals: • To improve resident knowledge and procedural competency with the robotic instrument • Participants will be able to recognize unique components of the robotic tool including:

o Port placement o Docking robot o Instrument Insertion and Exchange o Camera functions o Trouble shooting collisions

• Participants will be able to SAFELY and efficiently dock the robot and exchange instruments.

Objectives: • Describe the steps for docking the robot • List 3 key components of port placement • Demonstrate ability to dock robot and exchange instruments • Compare features of internal and external collisions • Recognize different types of collisions and explain how to manage

Activities: 1. Instructors will walk through the key steps, highlighting important features 2. Participants will complete an assessment to demonstrate competency in docking

robot and instrument exchange 3. Instructors will describe features of external and internal collisions 4. Participants will practice managing collisions from console and bedside.

~*~*~*~*~*~*~*~**~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~* 1) Walk through

PORT PLACEMENT • Size of ports: 8mm for camera, vessel sealer; 12mm for stapler, • Working distance for Xi robot: ~8cm apart • Measurements: to be performed after insufflation and creation of pneumoperitoneum • Port insertion: to second black line imprinted on trocar

BRINGING ROBOT TO BEDSIDE • Lighted green crosshatch marker (+) for guidance to center robot • Grab and move • Clutch to bring arm • Release tab = BEEP

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ARM STAGES • Insert camera into port & adjust angle • “Target” anatomy • Dock remaining arms

EXTERNAL ADJUSTMENTS ***Avoid Collisions*** • Clearance • Arm spacing and alignment • Burp / Assess for collisions

INSTRUMENTATION ***Avoid Instrument Injuries*** • Guided (visualize) tool exchange • Camera exchange • Clean camera / flip scope • Connect cables • LED lights

2) Proficiency Assessment Dock robot, camera and instruments to target anatomy.

Instrument Exchange Clean camera Theme Skill ATTEMPT 1 2 Bringing Robot to Bedside

Green + 5cm from camera port Grab and move feature Clutch to bring arm to port

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Use release tab to dock. Hear beep Arm stages Camera angle correct

Camera target anatomy Dock remaining arms

External Adjustments Avoid Collisions

Adjust patient clearance Adjust proper spacing and alignment (fist width of elbows)

Burp ports Instrument Exchange Avoid Injuries

Guide tool exchange Guided camera exchange Use clutch at top of arm to move and advance instrument

Scope flip and cleaning Connect cables to energized instruments Identify colored LED light indications.

3) Collisions Info:

3) Collisions Troubleshooting:

Collisions:Restrictedmovementduetoinstrumentcollision

BASEDONLOCATIONOFCOLLISION

INTERNALEXTERNAL

MASTER

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CONSOLE: internal • Cholecystectomy exercise • Arms: 1) Tip up; 2) Prograsp 3) Camera; 4) scissors • Balloon retraction

CONSOLE: external

• Cholecystectomy set up • Arms(BAD): 1) Tip up; 2) Prograsp 3) Camera; 4) scissors • Dropped clip in pelvis • CG set up—participant reach for clip • BEDSIDE TROUBLE SHOOT – patient clearance

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WET LAB OUTLINE

The goal of this lab is to provide residents with an opportunity to work with live tissue using robotic technology. The focus will be on applying surgical techniques and concepts in this unique environment. Instructors will be present and provide individual feedback for console surgeons. However, instructors will not be allowed to sit at the console and thus must rely on verbalization of instruction using language, gestures or a combination of both.

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Simulator Access Instructions:

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SIMULATION COMPLETION FORM

You are encouraged to explore all the exercises, but the following are required. To meet the requirement you need to achieve a score of 85%. Some will be easy, but others will take multiple attempts to improve your skills and reach 85%. Please record your score, the date you achieved it and the location of the simulator used in the table below. Once all the required modules have been completed with a score of 85% or greater, upload this form to the Robotic Smartsheet. If you need assistance with Smartsheet access, please email Alexi Callen in the Surgery Education Office: Alexi.Callen@ucsf.edu

Module Date Completed Location Score (%) Camera targeting 1

Peg Board 2

Energy switching 1

Ring walk 2

Thread the rings

Suture sponge 2

***Don’t forget to upload a photograph of the robotic screen illustrating the task name and your score for each module listed above.

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ROBOTIC CASE LOG: Bedside Assistant Please place stickers from cases in which you were the bedside assistant and participated in inserting trocars, docking the robot, and inserting and exchanging instruments. You need a minimum of five cases. Once complete, please upload to the Robotic Smartsheet.

Patient Sticker Date Attending Operation

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ROBOTIC CASE LOG: Console Surgeon Please place stickers from a minimum of 5 cases in which you were the console surgeon and performed a significant portion of the case. You may copy this page as many times as necessary. Once complete, please upload to the Robotic Smartsheet.

Min/Mod/Max: Refers to the amount of time at the console you were acting as surgeon. (Min = 0-24% of the case as primary surgeon, Mod = 25-50% of the case as primary surgeon, Max = > 50% as primary surgeon)

Skills 1-6: Mark all that apply: 1) Retraction, 2) Tissue Manipulation, 3) Dissection, 4) Suture, 5) Electrocautery/Staple, 6) other

Patient Sticker Date/ Attending

Operation/ Min/Mod/Max

Skills (1-6)

Jane Doe, MRN 1234567 1/1/17 Sigmoid

colectomy 1 X

2 X

3

Chern Min X

Mod Max 4 5 6

1

2 3

Min

Mod Max 4 5 6

1

2 3

Min

Mod Max 4 5 6

1

2 3

Min

Mod Max 4 5 6

1

2 3

Min

Mod Max 4 5 6

1

2 3

Min

Mod Max 4 5 6

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Attending Evaluation: Console Surgeon This form is for residents in their final year who have already performed 20 cases as console surgeon. The evaluation is to be completed by the attending physician and reviewed with the resident at the completion of the case. Once complete, please upload to the Robotic Smartsheet.

Patient Sticker Resident Date

Operation

Skill Adequate More Practice Recommended

Demonstrates understanding of trocar placement and spacing

Understands principles of docking and is able to dock in a timely fashion

Uses camera appropriately and is able to focus the camera

Demonstrates appropriate clutching and maintains hands in a comfortable workspace

Demonstrates ability to use third arm and switch between instruments

SAFETY: Does not move instruments that are not in view

SAFETY: Recognizes tissue response to assess grip strength and handles tissue appropriately

Demonstrates ability to troubleshoot system and manage collisions

Please comment on areas of strength: Please comment on opportunities for improvement: The resident demonstrates competency on the robotic system. YES NO ____________________________ ______________________________ Attending Name Attending Signature

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Example QEC letter from Department Chair

Date:

Regarding: Robotic Surgical Qualification Equivalency Certificate

To Whom It May Concern:

As the chairman of the Department of Surgery at the University of California, San Francisco (UCSF), it is my honor and pleasure to voluntarily recommend an exceptional candidate, (Candidate Name), for your Robotic Surgeon Qualification Equivalent Certification. I have worked directly with (Candidate Name) for 7 years as a surgical resident in our general surgery program. He/She has excelled in all 6 core competencies, patient care, medical knowledge, professionalism, systems-based practice, practice-based learning, and interpersonal and communication skills.

At UCSF we are exceptionally proud of our residents and their ability to independently operate safely and efficiently within the full scope of general surgery procedures during their final years of training. This has afforded our graduates the opportunity to seamlessly transition to independent practice immediately following residency without additional training.

Brief background into UCSF Robotics Curriculum: As you are aware, practicing surgeons who wish to begin performing robotic procedures are required to complete a training protocol through industry, and document a minimum number of proctored cases. While this has been successful at many institutions, we believe that we have the unique opportunity during the 5-7 year training program of our residency to far surpass these minimums and better prepare surgical residents to be successful in robotic general surgery procedures.

In 2016 our department implemented the UCSF General Surgery Robotic Resident Curriculum. This was developed with assistance from a group of multidisciplinary academic surgeon-educators whose focus was to improve the quality and consistency of resident and fellow education in robotic surgery. Our goals are to further standardize and streamline robotic surgery curricula, to support advances in educational resources, and collaborate effectively in regional to national dissemination. Surgical residents who have completed the full extent of this curriculum progress through didactics and on-line robotic training modules, demonstrate robotic docking proficiency and successful robotic simulation competence, have completed a robotic live tissue lab and have performed a minimum of 10 bedside robotic cases and 20 cases as console surgeon.

We have included the robotic cases that (Candidate Name) participated in below. (Candidate Name) has clearly proven to be a dedicated, talented, safe and efficient robotic surgeon at UCSF. I give my highest recommendation to (Candidate Name) for the Robotic Surgery Qualification Equivalent Certificate.

Sincerely,

(Program Chair)

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Robotic Surgical Log for (Candidate Name) for (time period)

Procedure Number as console surgeon

Number as bedside assistant

Abdominoperineal Resection

Abdominal Colectomy

Adrenalectomy

Cholecystectomy

Esophagectomy

Gastrectomy

Gastric Bypass (Revision)

Heller Myotomy

Hepatectomy

Inguinal Hernia Repair

Left colectomy

Low anterior resection

Other (not listed)

Pancreatectomy (+/- Splenectomy)

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Parastomal Hernia Repair

Proctectomy

Rectopexy

Right colectomy

Sigmoid colectomy

Thoracic Wedge Resection

Thoracic Lobectomy

Total Colectomy with J-pouch and DLI

Ventral Hernia Repair

_____________________ ______________________________

Resident Name Signature

_____________________ ______________________________

Program Director Date

_____________________ ______________________________

Department Chair Date