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Body et al. Art Int Surg 2022;2:186-94 https://dx.doi.org/10.20517/ais.2022.28 Page 188

platforms and future technological innovation, a reduction in cost is hopeful and would enable further
[29]
implementation and access to minimal access surgery .
In the majority of centres worldwide, robotic pancreatic operations are usually low-volume procedures.
Therefore, without deliberate training outside the operating room, it is challenging to develop adequate
robotic skills to become familiar with complex resections and this will limit the growth in robotic pancreatic
resections. Researchers have shown that a comprehensive procedure-specific robotic training protocol for
pancreatic surgery can improve the initial learning curve from training and simulation to the live operating
[31]
phase . Note that, inevitably, the learning curve also depends on a surgeon’s experience with open and
laparoscopic surgery . Robotic training should enhance the acquisition of these robotic technical skills,
[32]
potentially shortening the learning curve. Training programmes should aim for the participant to develop
mastery of the procedure within a standardised environment, which must be introduced to ensure the safe
introduction and expansion of this technology.

METHODS
A non-systematic search of the MEDLINE and Embase databases was performed on 5 July 2022 to identify
relevant studies in which current training pathways in HPB robotic surgery were assessed. Search terms
included the following, individually or in combination: “hepatobiliary”, “pancreas”, “robotic” or “minimally
invasive” and “training”; in addition to “machine learning”, “video analysis”, “computer vision”, “neural
networks” and “surgery”. Articles were included if they were in English or translated into English and
included robotic pancreatic training. After titles and abstracts were screened, full-text articles and references
were reviewed. Conference abstracts were excluded.

DISCUSSION
How should surgeons train?
The Miami Consensus guidelines on minimally invasive pancreas resections strongly recommend that all
surgeons interested in performing MIS HPB procedures participate in a structured training programme .
[33]
[34]
This is supported by the Society of American Gastrointestinal and Endoscopic Surgeons . A training
programme should include virtual reality simulation, inanimate bio-tissue model work to practice
dissection and anastomotic techniques, surgical video review, on-site proctoring and remote tele-
mentorship. Following formal training programmes, a steep increase in the use of MIS has been seen, with
[35]
reduced blood loss and conversion rates .

Specific to RPD, a five-step proficiency-based robotic curriculum has been described by the University of
Pittsburgh Medical Center [36,37] . The five steps are (1) a proficiency-based virtual reality simulation
curriculum; (2) an inanimate bio-tissue curriculum; (3) video library training; (4) an intra-operative
evaluation; and (5) skill maintenance with ongoing assessment. The European-African HPB Association
(E-AHPBA) has now also developed a European training programme for RPD based on the Pittsburgh
technique.

The simulation curriculum is delivered using the inbuilt Da Vinci robotic system (Intuitive Surgical Inc.
Mountain View, CA) simulation exercises. Simulation should be the first stage of console training for all
robotic procedures. An understanding of the system, instrument manipulation and fourth arm integration,
camera skills, energy device and needle control needs to be established. After each module, an automated
score is calculated from performance metrics, including time to completion, the economy of motion,
instrument collisions, instrument force, instruments out of view and master workspace range. Progression
through the curriculum is based on the achievement of target scores for individual tasks. The median time