ACPGBI position statement on robotic‐assisted colorectal surgical training

Abstract

The uptake of robotic‐assisted colorectal surgery (RACS) across the UK and Ireland has increased exponentially over the last 5 years. It is anticipated that most ‘conventional’ laparoscopic procedures will eventually move to a robotic approach within a National Health Service that is committed to embracing robotic‐assisted surgery. Working in collaboration with the surgical Royal Colleges, a more structured framework is necessary for robotic training. Inequality in robotic access and the impact that RACS is having on current colorectal surgical trainees need to be addressed, The Association of Coloproctology of Great Britain and Ireland (ACPGBI) has set out a framework to help support training in RACS at basic, advanced and trainer levels. Safer, better‐trained robotic surgeons will ensure improved patient outcomes, which is the overriding goal of the ACPGBI.

The uptake of robotic‐assisted colorectal surgery (RACS) across the UK and Ireland (UKI) has increased exponentially over the last 5 years. This has primarily been due to collaborative efforts between surgeons and industry partners. The perceived advantages of enhanced views, articulating instruments and improved surgeon ergonomics have accelerated adoption [1]. Proponents of RACS have cited robotic surgery as the natural evolution of laparoscopic surgery, enabling the clinical benefits of a minimally invasive surgical approach while facilitating the technical ability to perform complex surgical procedures [2]. It is anticipated that most ‘conventional’ laparoscopic procedures will eventually move to a robotic approach, with the National Health Service (NHS) committed to embracing robotic‐assisted surgery (RAS) and producing, in collaboration with the surgical Royal Colleges, a more structured framework for its adoption and implementation [3].

RACS within the UKI has been largely dominated by one robotic surgical system. However, there are a growing number of alternative robotic platforms entering the market. This, combined with future innovations and the continuous advancement of technologies, will only fuel the increased utilization of robotics within colorectal surgery, especially amongst current trainees and surgeons of the future. Standardized training with the benefit of accreditation will be necessary to ensure patient safety, surgeon competence and to effectively navigate the medicolegal aspects of robotic surgery [4].

To date RACS training in the UKI has been driven by industry‐supported pathways, and while several surgical organizations have advocated a structured robotic curriculum, at present there is no regulation or governance from the surgical training bodies within the UKI [5]. The Future of Surgery Technology Enhanced Surgical Training commission formed by the Association of Surgeons in Training and the Royal College of Surgeons of England Robotics and Digital Surgery Group recommended the need for a core, preprocedural robotics curriculum [6]. The NHS Long Term Work Force Plan described the need for regulated RAS training [7] with the recent Getting it Right First Time/NHS England document providing an overview of training recommendations for consultants, residents and the extended surgical team including the first assistant. It provides guidance on proctorship, standardizing consultant training pathways and the encouragement for residents to acquire a basic knowledge of RAS [3].

The drive to RACS has been supported through significant investment in acquisition of robotic platforms from healthcare authorities either locally or at a national level, and while there has been a centralized approach in Scotland and Wales this has not been the case across the rest of the UKI. This has led to inequalities in access to RACS [8] and raises challenges when proposing a structured robotic training curriculum at a national level.

Akin to the transition from open to laparoscopic surgery 20 years ago, RACS training has been focused on the upskilling of consultant surgeons combined with specific robotic fellowships for post/peri‐Certificate of Completion of Training senior trainees. The current RACS training models have left many junior surgical trainees disheartened [9]; feeling that training opportunities are being lost to more senior surgeons undergoing their own robotic training, they have not had exposure to the robotic platforms to enable hands‐on involvement in cases, plus they are struggling to meet the laparoscopic and open case numbers required to meet accreditation for completion of training. This has been reflected within England's surgical deaneries, with anecdotal reports of increasing requests from trainees to be placed in hospitals with reduced or no RACS activity. The ACPGBI has acknowledged these trainee concerns, and while it is beyond the Association's scope of practice to change surgical curricula it is working with the Royal Surgical Colleges, surgical education bodies and industry to help shape and accredit improved robotic training pathways and learning modules for trainees.

Current RACS training models incorporate a combination of theoretical, anatomical and/or robotic system knowledge in online, webinar and/or lecture format, access to RACS case observations from expert centres, simulation training (including virtual reality simulators delivering a combination of nonanatomical tasks and simple surgical tasks), dry and wet labs, and proctored robotic training using a component‐based approach to individual colorectal operations—all in conjunction with objective assessments of robotic skills and procedural competence [10]. When engaged surgeons have access to all components of these models there is a successful uptake of RACS. However, at present, colorectal trainees within the UKI struggle to access many of the components of these training modules, including robotic system knowledge modules, access to robotic simulators and trainers experienced enough to teach RACS. To facilitate RACS training for trainees in line with national recommendations [3], the ACPGBI proposes the following interventions:

1. Enhanced junior trainee exposure and training to basic components of robotic surgery including improved simulator access—basic robotic training/course.

2. Increasing trainee exposure to component based, robotic colorectal surgical procedure training: advanced robotic training/course.

3. Increasing consultant skills/proficiency in training RACS—training the trainer's course.

BASIC ROBOTIC TRAINING/COURSE RACS

Trainees should be encouraged to engage with RACS training from as early as the core training level. A basic core robotic surgical knowledge and the skill sets to utilize the robotic systems are vital for trainees to begin any hands‐on training during live surgery. Trainees should be able to access theoretical robotic learning and simulators and explore regional units if lack of access remains an issue. Several basic robotic skills courses have already been delivered for surgical trainees across the UKI. The ACPGBI has now accredited a standardized basic robotic surgical course that will be delivered at selected centres across the UKI and will utilize the Dukes' Club to provide a coordinated process for registering onto these courses. The ACPGBI also believes that creating a network of sites across UKI with access to robotic simulators will give trainees improved opportunities to build up their core robotic skills. Trainees are also encouraged to attend RACS cases early in their surgical training as exposure to bedside assistance, robotic cart docking and observing live surgery will provide the solid foundations for the next steps in their RACS training.

ADVANCED ROBOTIC TRAINING/COURSE RACS

RACS involves complex, multistep operations. To facilitate learning while ensuring patient safety, a competency‐based approach has been adopted [11]. This involves breaking down RACS into key component parts and facilitating progression through each step of the operation with increasing difficulty, thus enabling mastery of each step prior to overall completion of the procedure. Enabling access of UKI surgical trainees to advanced courses offering training in common RACS procedures, including anterior resection and right hemicolectomy, is seen by the ACPGBI as an opportunity to facilitate hands‐on training while also providing objective measures of progress. The ACPGBI has now accredited an advanced robotic surgical course that will be delivered at selected centres across the UKI. The ACPGBI also proposes creating a portal of educational curricula and videos of key RACS procedures for access by ACPGBI members and Dukes' Club trainees. With industry support, ACPGBI robotic fellowships have been created at two experienced robotic colorectal centres. A robust selection policy for these fellowships has been implemented, with previous robotic experience not deemed relevant to application, encouraging trainees from regions that currently have limited robotic colorectal access. Six‐month fellowships were felt to be sufficiently long for trainees to gain the necessary expertise if utilizing the proposed basic and advanced RACS training methods. The ACPGBI will also be looking to support the delivery of advanced standardized RACS course for senior trainees not yet applying for fellowships.

TRAINING THE TRAINERS RACS

Successful surgical training is dependent on the quality of trainers. It has been demonstrated that a structured train the trainer course has a significant impact, improving the quality of training delivered by a surgical faculty [12]. The training of robotic surgery adds additional levels of complexity to the process. Ergonomics, specific skills and user–machine interfaces differ from those of traditional laparoscopic surgery [13]. A combination of both technical robotic and procedure‐specific actions require simultaneous evaluation and training. At the same time there is a loss of the direct surgeon‐to‐trainee contact found in traditional surgery, with a robotic platform placing a mechanical barrier between the two. The opportunities to participate in a case simultaneously as surgeon and trainer are reduced, with one or other solely in charge of the platform while the other observes as opposed to actively assisting. Most consultants practising RACS within the UKI are still transitioning through their own robotic learning curve, and while the majority will be entering the mastery phase, there is generally still a hesitancy to begin training without some form of accreditation of the appropriate technical skills to do so. The ACPGBI believes that the provision of standardized RACS train the trainer courses will build trainer confidence and encourage increased training opportunities for trainees.

Robotic surgical innovation will increasingly be part of colorectal surgery. There is a need for standardized platform‐agnostic training and accreditation. The training must have the capacity to evolve as the technologies advance and the number of robotic platforms expands. However, this must be balanced with a need to ensure equity of access and equal training opportunities. At this current point of inflection of colorectal practice we want to reassure trainees that they will receive the appropriate skills to progress with their careers in the future digital surgical era. RACS is primarily an alternative platform for performing minimally invasive surgery; the key principles and techniques of colorectal surgery remain the same as when performed in open and laparoscopic approaches.

The ACPGBI acknowledges the current frustrations of trainees with RACS and the perceived impact upon their training. It is taking measures to help support training in RACS at basic, advanced and trainer levels. Robotic surgical training offers many opportunities for trainees, including increasingly advanced simulators and a standardized surgical curriculum plus objective measures of improvement. The association will support active participation in robotic surgical training from early in a trainee's career so they can transition through the levels of training as smoothly as possible. Safer, better‐trained robotic surgeons will ensure improved patient outcomes, which is the overriding goal of the ACPGBI.

AUTHOR CONTRIBUTIONS

Charles Evans: Writing – original draft; writing – review and editing; conceptualization. Taner Shakir: Writing – original draft; writing – review and editing. Charlotte El‐Sayed: Writing – review and editing. Danilo Miskovic: Conceptualization; writing – review and editing. Jim Khan: Conceptualization; writing – review and editing. James Kinross: Conceptualization; writing – review and editing. Richard Justin Davies: Writing – review and editing; conceptualization. Deena P. Harji: Conceptualization; writing – review and editing. Irshad Shaikh: Conceptualization; writing – review and editing.

FUNDING INFORMATION

No funding was received for this work.

CONFLICT OF INTEREST STATEMENT

Charles Evans: Intuitive Proctor. Taner Shakir: None. Charlotte El‐Sayed: Advisor for Medtronic Touch Surgery. Deena Harji: Honorarium J&J MedTech, CMR, Intuitive, Medtronic. Safety Board: Medtronic. Danilo Miskovic: Intuitive Proctor. Shareholder Proximie. Irshad Shaikh: Intuitive Proctor. Jim Khan: Intuitive Proctor. James Kinross: Scientific advisory boards: JnJ, Safeheal, Ysopia therapeutics, UDX. Safety board: Medtronic, Shareholdings: Surgease Ltd., Concentric Health, Wype, IntusBio, Flowmark, Medical iSight. Richard Justin Davies: Member of CMR Global Advisory Board.

ETHICS STATEMENT

Ethical approval was not required for this work.

Evans C, Shakir T, El‐Sayed C, Harji DP, Miskovic D, Shaikh I, et al. ACPGBI position statement on robotic‐assisted colorectal surgical training. Colorectal Dis. 2025;27:e70161. 10.1111/codi.70161

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.