Simulator Practice Is Not Enough to Become a Robotic Surgeon: The Driving Lessons Model

Dear Editor:

We have read with interest the study by Cho et al. ¹ entitled “Virtual reality training improves da Vinci performance: A prospective trial.”

We agree that the learning curve of robotic surgery skills can be associated with a virtual reality (VR) simulator.^1–5 Cho et al. ¹ affirmed that simulator training can improve da Vinci^® Surgical System (Intuitive Surgical, Sunnyvale, CA) performance and that VR practice can result in an early plateau in the learning curve for robotic practice under controlled circumstances. Simulation could be used to predict the proficiency with the robot, but the authors' data ¹ focused only on the use of the da Vinci trainer without any predictive validity in the operating room with actual patients.

We believe that robotic simulation should not be the only safety checkpoint in a surgeon's training. In our opinion, robotic simulation is necessary during basic training, but it remains unsatisfactory to achieve a safe clinical practice.

After the first 1000 patients operated on robotically and 12 years of robotic general surgery, we have developed a robotic surgical learning system based on a safety step-by-step model. The new robotic da Vinci SI platform is very useful in surgical learning with its dual console. A surgeon taught on this platform could directly and safely control all learning surgical steps similar to driving lessons. The learning surgeon could perform a part of the procedure as one scheduled step of his or her own training program. In our learning model, the teaching surgeon identified two main different robotic steps: dissection and reconstruction. There are also three robotic surgical levels for each step: first, basic level; second, intermediate level; and third, advanced level. For driving lessons, it is widely recommended to learn driving on the same road using a standardized car. Robotic Roux-en-Y gastric bypass is a procedure with well-defined steps, with different levels of dissection and reconstruction and with a high volume of cases. In our opinion, it is dangerous to affirm that a surgeon is proficient with the robot after four to five attempts in simulation-based training (SBT). The step-by-step additional clinical training is mandatory for all surgeons to become proficient with the robot.