Equivalent Certificate Training Program for Gynecologic Robotic Surgery: A Multicenter Feasibility Study

ABSTRACT

Objective

To evaluate the feasibility, safety, and short‐term effectiveness of a society‐led, proctor‐guided Equivalent Certificate program designed to support the supervised initiation of robot‐assisted gynecologic surgery in Japan.

Methods

A multicenter pilot program was conducted across four academic institutions. Fourteen surgeons without prior da Vinci console experience were enrolled. The training pathway included: (1) manufacturer‐provided e‐learning, on‐site system training, and written assessment; (2) institution‐based, proctor‐supervised training with mandatory simulator proficiency (≥ 80 points across 10 tasks) and at least five bedside assistant cases; (3) standardized proctor evaluation of technical readiness using a 5‐point Likert scale; and (4) post‐case assessment following each surgeon's first console case. Upon completion of all requirements, participants received an equivalency‐based Certificate of da Vinci System Training issued by Intuitive Surgical.

Results

Eleven surgeons completed the full program and performed at least one robotic procedure. No intraoperative complications or proctor takeovers occurred. Proctor evaluations demonstrated satisfactory performance across all assessed skill domains, with mean scores ranging from 3.09 to 4.55 out of 5. Instrument insertion and exchange received the highest ratings (mean 4.55), while third‐arm control showed relatively lower scores (mean 3.09), consistent with known early learning challenges. The overall composite score was 3.79, indicating performance approaching a “well done” level under supervised conditions.

Conclusion

This feasibility study suggests that a structured, society‐led Equivalent Certificate program is a feasible and safe approach for the supervised introduction of robot‐assisted gynecologic surgery. By integrating manufacturer‐aligned education with institution‐based proctor supervision and objective performance benchmarks, this framework may serve as a complementary training pathway as robotic surgery education continues to evolve in Japan.

1. Introduction

Robot‐assisted surgery using the da Vinci Surgical System has been increasingly adopted in gynecology for procedures such as hysterectomy because of its enhanced precision and minimally invasive advantages. In Japan, surgeons have traditionally been required to complete training programs provided by Intuitive Surgical before performing robotic procedures, as stipulated in national guidelines stating that surgeons must “participate in training programs provided by the company and obtain certification” to operate the da Vinci system [1]. Unlike many countries where surgeons gradually gain experience through supervised cases and are credentialed by mentors after achieving sufficient proficiency, Japan has historically maintained a framework in which surgeons are not permitted to serve as the primary console operator before completing formal company‐provided training. This approach was influenced, in part, by concerns regarding patient safety during pre‐training console use.

In contrast to laparoscopic surgery—where structured certification systems have been established by academic societies, such as the technical certification introduced by the Japanese Society of Gynecologic and Obstetric Endoscopy (JSGOE) in 2002 and the facility accreditation system launched in 2014 [2]—robotic surgery has not been governed by an equivalent society‐led credentialing framework. For the da Vinci system, Intuitive Surgical has provided standardized technology training programs, and surgeons who complete all required educational components are issued a “Certificate of da Vinci System Training,” which serves as documentation of training completion rather than a formal credential independently certifying surgical competency.

As robotic surgery rapidly expanded across Japan, the number of surgeons seeking access to training increased substantially. Intuitive Surgical has recognized the importance of this issue and, in response, expanded its training infrastructure by establishing two additional training centers in 2024 and 2025, thereby increasing national training capacity. Nevertheless, alongside these efforts, broader discussions emerged within the surgical community regarding how best to provide appropriate training opportunities in an environment where robotic surgery had already become widely adopted and where experienced instructors were available across many institutions.

Within this context, discussions at the Japan Society for Endoscopic Surgery (JSES) initially included concerns related to training availability and scheduling; however, as deliberations progressed, the focus shifted toward a broader perspective. Rather than positioning new initiatives primarily as solutions to training wait times, the official academic framing emphasized the maturation of robotic surgery in Japan and the need to offer additional structured training options for surgeons practicing in environments where adequate mentorship and institutional resources were already in place.

Against this background, a pilot training pathway—the Equivalent Certificate program—was developed to provide an alternative, institution‐based option that aligns with the established manufacturer training framework while leveraging local proctor supervision. In the gynecologic area, proctors were defined as surgeons formally certified as da Vinci proctors by the Japanese Society of Gynecologic Robotic Surgery (JSGRS), the Japanese Society of Gynecologic and Obstetric Endoscopy (JSGOE), and the Japan Society of Gynecologic Oncology (JSGO), with extensive experience in robotic gynecologic surgery and authorized roles in surgical supervision and trainee evaluation. Under this pathway, surgeons complete the same foundational educational components required by Intuitive Surgical, followed by structured simulator training, bedside assistance, and standardized proctor evaluation within their home institutions. Upon confirmation that all requirements have been met, Intuitive Surgical issues a “Certificate of da Vinci System Training (Equivalency),” recognizing completion of an equivalent training process.

The Equivalent Certificate pathway incorporates key elements of contemporary robotic training, including simulation‐based skill acquisition, supervised clinical exposure, and objective proficiency assessment, consistent with international trends in robotic surgical education. For example, the European Society for Gynecological Endoscopy has recently introduced a structured robotic certification program emphasizing simulator‐based benchmarks [3].

In this pilot study, we describe the concept, implementation, and early outcomes of the Equivalent Certificate program in gynecologic surgery. We evaluate its feasibility, safety, and effectiveness using simulation performance, proctor assessments, and initial clinical experience, and discuss its potential role as an additional training option within Japan's evolving robotic surgery landscape.

2. Materials and Methods

2.1. Training Curriculum and Certification Process

The pilot program was designed to incorporate all essential elements of Intuitive's traditional training pathway while introducing structured, proctor‐led mentoring within each institution (Figure 1). The workflow—identical to the process shown in the training diagram—consisted of the following steps:

FIGURE 1.

Training pathway of the Equivalent Certificate program. This diagram outlines the structured steps of the Equivalent Certificate training program, which parallels the essential components of the traditional Intuitive Surgical pathway. The process includes manufacturer‐provided e‐learning and on‐site system training, followed by proctor‐guided simulator practice, bedside assistant experience, and a standardized institutional skills assessment. After completing all required elements, trainees receive the Certificate of da Vinci System Training.

2.1.1. Manufacturer‐Provided Training (Traditional Training Components)

Before beginning institutional training, all trainees completed the standard educational components provided by Intuitive Surgical:

1. Online Training (e‐learning): Completion of Intuitive's official online modules to learn basic system knowledge, safety, and console operation.

2. On‐site Training (Hands‐on/System Demonstration): An Intuitive representative conducted an in‐person session covering actual system operation and safety checks.

3. Online Assessment (Web‐based Test): Trainees were required to pass Intuitive's online written assessment evaluating foundational system knowledge.

These steps ensured that all participants received the same fundamental instruction as in the conventional certification pathway.

2.1.2. Institutional Training Under Proctor Supervision

After completing manufacturer‐provided training, each trainee underwent structured institutional training conducted by an experienced robotic surgeon (Proctor).

2.1.2.1. Required Simulator Training

Trainees were required to perform the following 10 simulator exercises (da Vinci Skills Simulator, software version 1.9) and achieve a score of ≥ 80 on each:

• Ring Roller Coaster 1

• Ring Roller Coaster 2

• Clutch

• Camera 0

• Energy Pedals 1

• Three Arm Relay 1

• Three Arm Relay 2

• Running Suture

• Around the World Needle Driving

• Vessel Energy Dissection.

Scores were verified through the My Intuitive platform.

2.1.2.2. Bedside Assistant Experience

Each trainee was required to have at least 5 bedside assistant cases within the past 6 months.

If the requirement was not met, the proctor supervised additional assistant experience at the institution.

2.1.3. Proctor Evaluation (Institutional Skills Assessment)

Once the simulator and bedside requirements were achieved, the proctor evaluated the trainee's readiness using a standardized checklist.

Skill domains included.

• Port placement

• Patient cart setup

• Docking/Undocking

• Instrument insertion and exchange.

• Camera control

• Clutch operation

• Third arm control

• Retraction and exposure

• Range‐of‐motion and collision avoidance

• Suturing

• Tissue dissection

• Use of energy devices

• Troubleshooting and emergency undocking

• Communication with the assistant

A trainee could advance only if the proctor confirmed adequate proficiency in all categories.

2.1.4. Certification Application and Issuance

After the evaluation, the proctor submitted a simple application form to Intuitive Surgical confirming that the trainee had met all certification requirements.

Following review, Intuitive Surgical issued the:

Certificate of da Vinci System Training (Equivalency).

This certification allowed the trainee to perform robot‐assisted surgery as the primary console surgeon.

2.1.5. Clinical Case Initiation and Post‐Case Evaluation

Each newly certified surgeon performed at least one real clinical robotic surgery.

Following this case, the proctor completed a post‐case evaluation survey assessing:

• Technical performance

• Safety

• Communication

• Overall readiness

Initially, the program planned to evaluate after 5 cases, but during the pilot, the first case evaluation was used to collect early feasibility data.

2.1.6. Comparative Safety Assessment

In addition to simulator training and the standardized proctor‐led skills assessment, each trainee underwent a secondary evaluation after completing the first clinical robotic surgery. In this post‐case assessment, the proctor reviewed whether the trainee was able to appropriately apply the required skill domains—defined in the institutional checklist—within an actual operative environment. This evaluation served as a direct confirmation of intraoperative performance and overall safety.

The findings from these assessments were collected and analyzed to determine whether trainees certified through the Equivalent Certificate pathway could perform robot‐assisted gynecologic surgery with a safety profile comparable to surgeons who obtained conventional manufacturer‐based certification. This comparison constituted a key component of validating that the Equivalent Certificate meets the same safety standards as the traditional certification process.

2.2. Ethical Considerations

Ethical review was delegated to each participating institution. At Tottori University, the study was reviewed and overseen by the Center for Minimally Invasive Surgery, and written informed consent for participation was obtained from all patients at the time of surgery. Robot‐assisted procedures in this study were performed as part of routine clinical practice by surgeons who had completed an Intuitive Surgical–recognized training pathway. Written informed consent for surgery was obtained from all patients at each participating institution in accordance with local institutional policies. No investigational interventions or protocol‐driven treatment modifications were introduced.

3. Results

3.1. Background of Registered Surgeons and Pre‐Existing Robotic Qualifications

A total of 14 surgeons from four academic institutions (Kyoto University, Tottori University, Hirosaki University, and Kobe University) were registered for the Equivalent Certificate program. Of the 14 enrolled surgeons, 3 had not performed their first console case within the study period due to scheduling and case availability constraints and were therefore excluded from the analysis focused on initial clinical outcomes. None of the surgeons held prior da Vinci console certification, although several had experience with alternative robotic platforms such as hinotori or Hugo RAS. Importantly, this framework does not exclude surgeons with no prior robotic experience but is designed to accommodate a heterogeneous trainee population reflective of contemporary practice.

Their pre‐existing robotic certifications or experience are summarized in Table 1.

TABLE 1.

Pre‐existing robotic certifications and experience of surgeons enrolled in the Equivalent Certificate program.

Institution	Surgeon ID	Existing robotic certification/Experience
Kyoto University	A	None
	B	None
	C	None
Tottori University	A	None
	B	None
	C	None
	D	None
	E	Hugo RAS experience
	F	Hugo RAS experience
Hirosaki University	A	hinotori experience
Kobe University	A	None
	B	None
	C	None
	D	None

3.2. Board Certification Status of Participating Surgeons

Most surgeons were JSOG specialists (Table 2); however, the levels of board certification varied across participants.

TABLE 2.

Board certifications included.

Institution	Surgeon ID	JSOG specialist	JSGOE certified endoscopist
Kyoto University	A	Yes	No
Kyoto University	B	Yes	Yes
Kyoto University	C	No	No
Tottori University	A	Yes	No
Tottori University	B	Yes	Yes
Tottori University	C	Yes	No
Tottori University	D	No	No
Tottori University	E	Yes	No
Tottori University	F	Yes	No
Hirosaki University	A	Yes	Yes
Kobe University	A	Yes	No
Kobe University	B	No	No
Kobe University	C	Yes	No
Kobe University	D	Yes	Yes

4. Post‐Implementation Proctor Evaluation Scores

Among the surgeons who performed at least one console case under the Equivalent Certificate pathway (n = 11), proctors completed structured post‐case evaluations using a 5‐point Likert scale (1 = Not adequate, 5 = Excellent).

Assessed domains included:

• Technical performance

• Safety behaviors

• Communication

• Overall readiness

Mean scores across all domains demonstrated satisfactory competency for initial console surgery.

Detailed evaluation results are presented in Table 3.

TABLE 3.

Proctor‐based competency evaluation scores across robotic skill domains.

Skill domain	Min	Max	Mean
Port placement and setup	3	5	4.18
Patient cart positioning & configuration	4	5	4.09
Docking and undocking the robot	3	5	3.91
Instrument insertion and exchange	4	5	4.55
Camera control (visualization)	2	5	3.73
Clutch use (instrument reorientation)	3	5	3.82
Third‐arm control (accessory arm usage)	2	4	3.09
Tissue traction and retraction	2	5	3.64
Range‐of‐motion & collision awareness	3	5	3.82
Needle handling & suturing technique	3	5	3.91
Tissue dissection technique	2	4	3.55
Energy device usage & safety	3	4	3.73
Troubleshooting & emergency procedures	2	5	3.45
Communication with surgical team	3	5	3.57
Overall (all items)	2	5	3.79

As shown in Table 3, all trainees were rated favorably across the evaluated skill domains, with mean scores ranging from 3.09 to 4.55 out of 5. Most items averaged ≥ 3.5, indicating solid competency. Instrument insertion and exchange was the highest‐rated skill (mean 4.55), followed by patient cart setup and suturing. The lowest score was for third‐arm control (mean 3.09), reflecting a common challenge for novice robotic surgeons, yet even this domain remained above the “moderately good” threshold, and no trainee received a score of 1 in any category.

The overall composite score was 3.79, suggesting that trainees performed closer to “well done” than merely adequate. Proctors reported that all surgeons completed their initial cases without major issues, demonstrated safe technique, and adhered to operative protocols. Written feedback highlighted strengths such as stable camera handling and precise needle control, with suggestions to improve docking efficiency or third‐arm use.

Importantly, no safety‐compromising events occurred, and proctors unanimously agreed that each trainee was ready to continue operating independently with limited oversight. These findings indicate that all surgeons successfully met the competency benchmarks of the Equivalent Certificate program and safely performed their initial robotic procedures.

5. Discussion

This pilot study demonstrates that a structured, proctor‐guided Equivalent Certificate program can effectively prepare gynecologic surgeons for the safe initiation of robot‐assisted surgery within an institutional setting. All surgeons who completed the curriculum met predefined simulator benchmarks, achieved satisfactory performance across all evaluated skill domains, and successfully performed their initial clinical cases without intraoperative complications. These findings suggest that the program provides a viable pathway for establishing baseline robotic competency under supervised conditions.

The results highlight the importance of core elements of competency‐based training, including mandatory simulator proficiency, bedside assistant experience, and standardized proctor assessment. High scores in fundamental domains such as instrument insertion, patient cart setup, and suturing indicate adequate acquisition of essential console skills. In contrast, lower scores for third‐arm control—while still above acceptable thresholds—reflect a known challenge among novice robotic surgeons and identify a specific area for curricular reinforcement. This domain‐specific pattern is consistent with early learning curves reported in robotic surgery and supports the role of objective performance metrics in guiding structured progression.

Conceptually, the Equivalent Certificate program aligns with the established manufacturer‐led training framework while offering a more accessible, institutionally embedded model. Previous work has described the standardized multi‐phase Intuitive training pathway, including TR100 and TR200 for preclinical skill development followed by staged clinical integration [4]. Our program incorporates these foundational principles while leveraging local proctor supervision, potentially mitigating limitations associated with centralized training capacity. The requirement for objective simulator thresholds is also consistent with international trends toward proficiency‐based robotic training, such as those advocated by the European Society for Gynecological Endoscopy [3].

Although direct comparative outcome data with conventionally certified surgeons were not available, the uniformly favorable proctor evaluations and absence of adverse intraoperative events provide preliminary evidence that the competency achieved through this equivalency pathway is appropriate for supervised console initiation. Recent international survey data have further indicated that completion of mandatory technology training alone may not ensure operative readiness, emphasizing the need for structured mentorship and hands‐on proficiency assessment [5]. These findings support the educational rationale underlying institution‐based, proctor‐supervised training models. The first console case was selected as the primary evaluation point because it represents the most critical safety threshold in the transition from training to clinical robotic surgery for novice surgeons.

This study has several limitations and should be interpreted as a proof‐of‐concept pilot investigation designed to establish initial feasibility and safety, rather than to provide definitive conclusions regarding long‐term effectiveness or generalizability. Additionally, broader implementation may be constrained by simulator availability and access to experienced proctors. Future multicenter studies with larger cohorts and longitudinal outcome assessment will be necessary to validate the durability, scalability, and safety of this framework. In the absence of a direct comparison group, the requirement to achieve ≥ 80 points across 10 validated simulator tasks served as a stringent, objective benchmark to ensure technical readiness before clinical entry.

Despite these limitations, the present findings support the feasibility and short‐term safety of a society‐led equivalency certification model. With appropriate oversight and objective performance standards, this approach may serve as a complementary pathway for robotic training as surgical practice continues to evolve.

6. Conclusion

The Equivalent Certificate program, piloted under the guidance of JSGRS‐certified proctors in Japan, demonstrated feasibility and short‐term safety as a structured pathway for introducing gynecologic surgeons to robot‐assisted surgery. All participating surgeons met predefined training benchmarks, completed the equivalency‐based training requirements, and successfully performed their initial robotic procedures without intraoperative complications. Proctor evaluations confirmed that trainees achieved competency across core robotic skill domains, with consistently satisfactory performance levels.

These findings suggest that the program can support the safe and supervised initiation of da Vinci surgery in the gynecologic field while maintaining alignment with established training standards. As a complementary, competency‐based training pathway embedded within institutional settings, the Equivalent Certificate framework may help expand access to robotic surgery education without compromising patient safety. Although further validation with larger cohorts and longer follow‐up is required, the results of this pilot support the potential role of society‐led equivalency programs in meeting evolving educational needs as robotic surgery continues to mature in Japan and beyond.

Conflicts of Interest

Dr. Tsukasa Baba, Dr. Yoshito Terai, and Dr. Masaki Mandai are Editorial Board members of ASES and are co‐authors of this article. To ensure transparency and minimize potential bias, they were excluded from all editorial decision‐making and peer review processes related to the acceptance of this manuscript.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.