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Table 3. Educational Program in Shizuoka Cancer Center
Step Target item Purpose
1 Has taken the training courses led by Intuitive Surgical Inc. and acquired Learn the basic operation of the da Vinci Surgical System and
surgeon certification perform repetitive training of surgical techniques and surgical
procedures
Perform at least 10 h of offsite training using the da Vinci Surgical System Learn the smooth operation of the da Vinci Surgical System
2 Under the guidance of the proctor, perform over 10 robotic gastrectomies Gain experience in robotic gastrectomy
(including total gastrectomies, cardia side gastrectomies)* 1-4
Do not cause other organ damage requiring repair, arterial injuries
requiring reconstruction, or other intraoperative complications requiring
an open conversion
Perform one or more robotic total gastrectomies Gain experience as a surgeon for robotic total gastrectomies
to acquire esophagus jejunal anastomosis
3 Achieve a rating of B or higher from the proctor in all items of the surgical The proctor evaluates whether or not the target surgeon
evaluation on robotic distal gastrectomy is appropriate as a robotic surgeon, according to unified
standards

*1: The proctor performs surgery mainly for the first case and the operator learns beside or performs part of the surgery; *2: at least the
second case should be a case of distal gastrectomy, D1 + dissection, with BMI < 25, PS = 0, and ASA - PS 2 or less; *3: teaching by dual
console is desirable until the third case; *4: in the case of a longer than 6 months absence during participation, 2 cases of experience will
be added after receiving a retraining program provided by Intuitive Surgical Inc., regardless of the number of experienced cases

[43]
cases of RG including one or more cases of total or proximal gastrectomy . A proctor scores the surgeon
in accordance to the evaluation list, and when a high score is achieved, the surgeon will be allowed to
perform RG independently.

Ergonomics
Robotic surgery provides surgeons with an ergonomically sound work environment because although
LG is usually performed in the standing position, RG can be performed in a sitting position at an
ergonomically designed surgeon console, which is expected to reduce operator fatigue. A survey study
comprising 26 questions was performed to document the discomfort of robotic surgery compared with
open and laparoscopic surgery, and to investigate the factors that affect the risk of physical symptoms,
involving surgeons with various specialties and 1,215 who practiced all three approaches. This survey
demonstrated that robot-assisted surgery was associated with the least physical discomfort and symptoms
[44]
compared with open and laparoscopic surgery . The breakdown of symptoms indicated that robotic
surgery was less likely to lead to neck, back, hip, knee, ankle, foot, shoulder, elbow, and wrist pain than
open or laparoscopic surgery, although the frequency of eye and finger pain was higher in robotic surgery.
In another survey of 432 surgeons using robotic surgery in various fields, 56.1% complained of physical
symptoms or discomfort, with the most frequent complaints being neck stiffness, finger pain, and eye
[45]
fatigue . Thus, although robotic surgery reduces the physical symptoms and discomfort of surgeons in
comparison to open and laparoscopic surgery, more than 50% of surgeons have complained of a certain
degree of physical stress, typically finger pain and eye strain.

Disadvantages of robotic compared to laparoscopic gastrectomy
The most critical disadvantage of RG is a lack of tactile perception, which can lead to incomplete ligature
and tissue damage due to excessive stress. Visual information can compensate the lack of tactile perception;
however, serious injury could still happen outside the field of view. Surgical robotics can potentially apply an
unexpectedly strong force that never occurs in conventional surgery. Thus, even slight mishandling of the
DVSS may lead to a fatal accident, even with a built-in system to prevent excessive compression to organs.

Requiring a long operation time is another disadvantage in RG. A retrospective study investigating factors
[46]
contributing to prolongation of the operation time identified “junk time” as a cause of the prolongation .
In this study, the authors classified the overall operation time into two groups: the effective time (time
required for actual surgical techniques such as port replacement, lymphadenectomy, and reconstruction)
and the junk time (setup docking, and adjustment of surgical instruments). They found that junk time