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Ruff et al. Mini-invasive Surg 2024;8:12 https://dx.doi.org/10.20517/2574-1225.2024.39 Page 3 of 7

biotissue, video library review of cases, intraoperative feedback with experienced mentors, and ongoing
quality assessments [24-28] . The biotissue sessions focused on complex anastomoses required for a PD and
were shown to complement the virtual experience by improving metrics and decreasing errors on skill
assessments. Implementation of a formal mentorship program and robotic curriculum among surgical
fellows was associated with decreased learning curves and improved patient morbidity .
[29]
While this data is primarily in the setting of PD, the methodology of this curriculum holds true for complex
operations such as a hepatectomy. Surgeons need to complete both a formal robotics curriculum and one
designed specifically for liver surgery. There are clearly defined steps of a formal hepatectomy that must be
demonstrated to establish competency: dissection of the hepatic hilum, hepatocaval dissection, and
transection of the liver. Practice sessions with biotissue and live animal or cadaver labs should revolve
around maneuvers required to complete a hepatectomy, such as obtaining proximal and distal vascular
control, vessel ligation, performing a biliary-enteric anastomosis (e.g., for cases of hilar
cholangiocarcinoma), parenchymal division techniques (e.g., electrocautery, vessel sealer), performing a
pringle maneuver, and hilar dissection. Even for partial or parenchymal-sparing hepatectomies, this skillset
will be useful and help prepare surgeons to deal with emergencies. Additionally, surgeons need the
opportunity to work with different instruments in each of these scenarios so that when in the operating
room they can adapt to the patient’s anatomy. Animal and cadaver labs should also be used to practice
trocar placement, obtain intra-abdominal exposure, and respond to emergencies (e.g., bleeding).
Throughout the curriculum, surgeons must meet specific milestones prior to advancing in the program and
operating on a patient.

Upfront education is critical to reducing the learning curve. Part of this curriculum requires bringing
experienced robotic surgeons to the institution to lend their expertise through proctored live animal labs,
cadaver labs, and live case demonstrations. As mastery is achieved, these experienced surgeons can return
for additional visits to observe cases, critique technique, and offer suggestions for improved efficiency.

TEAM DYNAMICS
Equally important as the technical considerations of establishing a program is assembling a team that can
overcome early obstacles and foster growth. At least two surgeons with extensive experience in open liver
surgery should be committed to adopting this technology. As these surgeons become proficient, they can
alternate between the robotic console and the patient’s bedside to gain additional exposure. Additionally,
surgeons graduating from fellowship with extensive robotic training and/or who are already established at
other programs should be recruited to join the team and lend their expertise.

A dedicated team must also include the commitment and investment of the operating room staff. The same
learning curve will exist for the anesthesia team, circulating nurses, scrub nurses and technologists,
residents, and bedside first assistants. It is advantageous to hire and/or recruit clinical staff with robotic
experience who can be an extra source of support as the program is launched. It will take time and
experience to learn the instruments, robotic technology, and how to best assist the surgeon at the console. A
curriculum with in-service training for all team members can shorten this learning curve. Additionally, the
same team should regularly work together during early cases to provide consistency, build rapport, and
eventually disseminate their expertise as mentors to the rest of the clinical staff. Most importantly, an adept
clinical team acts as a safety measure to quickly resolve issues and convert to an open operation in an
emergency.