Table 2.

Portsmouth Training Protocol: steps, modules, and objectives

Step	Module	Objective
1	ROBO-CERT course	Virtual and hands-on basic robotic surgical skills course to train participants on the components of the robotic platform, instruments, basic of navigation, and basic task delivery (EndoWrist [Intuitive Surgical Inc] manipulation, force control, use of the 3rd arm, use of the scissors, suturing, and dissection on a synthetic model for clip applicator and robotic stapler use)
2	Case observation	Case observation of high-quality robotic colorectal operations performed by expert surgeons. Training on patient positioning and setup, port placement, docking, robotic procedure, undocking, and closure
3	Bedside assistance	Assisting at the bedside, practicing patient positioning, port placement strategy, docking, exchange of robotic instruments, intraoperative assistance, and surgeon-bedside team communication
4	Robotic hands-on fellowship	Robotic total mesorectal excision modular training program for safe and efficient training (6 mo)
5	Case selection and progression	Three-tier program:
		(1) Low risk/complexity (groin hernia repair, small umbilical/ventral hernia repair, and cholecystectomy; ≤1 hr)
		(2) Intermediate risk/complexity (sigmoid resection for cancer/uncomplicated diverticular disease in patients with low BMI, and right hemicolectomy for early colon cancer [not CME]; avoid male pelvises, high BMI [>30 kg/m2], and patients with previous abdominal surgery)
		(3) Advanced risk/complexity (most complex cases such as procedures involving pelvic dissection (low anterior resection, abdominoperineal resection, and lateral pelvic lymphadenectomy), and CME for colon cancer)
6	Robotic immersion courses	Short 1-wk “scrub-in” robotic experiences with a 1-on-1 relationship with the trainer to gain confidence

BMI, body mass index; CME, complete mesocolic excision.