Survey on Robot-Assisted Surgical Techniques Utilization in US Pediatric Surgery Fellowships

Introduction

Robotic surgery in children was initially described in the late 1990s, first by Partin et al. ¹ and then by Okada et al. ² Robotic technology has since undergone rapid growth and evolution, with some claiming it to be one of the most important recent innovations in the field of pediatric surgery.^3,4 However, while the increasing complexity of endoscopic surgery in various adult specialties, such as general, thoracic, urologic, and gynecologic surgery, resulted in the adoption of robotic procedures, ⁵ pediatric surgeons' views on this technology and their willingness to adopt it in clinical practice have varied extensively. ⁶

Although the future of robot-assisted surgery continues to be debated, its presence and current influence cannot be ignored. ⁷ As the technology has become more prevalent in the pediatric environment, questions regarding training and credentialing standards for this new technology platform are becoming more imperative. ⁸ Furthermore, while the field of postgraduate minimally invasive surgery training has undergone substantial growth and change, ⁹ there are currently no established requirements for robot-assisted training in these fellowships.

Recently published cross-sectional surveys have examined the effects of this new technology platform on general surgical, ⁸ urological, ¹⁰ and gynecological residencies. ¹¹ However, no study has examined the effect of this technology on the pediatric surgery fellowships. Since the patterns of innovation diffusion are effectively measured by cross-sectional analyses, ¹² the purpose of our study was to utilize a cross-sectional survey to assess the prevalence of robotic procedures and the extent of robotic surgery education in ACGME accredited US pediatric surgical fellowship programs. Our hypothesis is that robotic surgical systems are widely available to pediatric surgeons and trainees, but are underutilized in practice and lack significant emphasis in pediatric surgery training curricula.

Materials and Methods

Results

Of the 47 ACGME-approved pediatric surgery fellowships in the United States, 41 fellowship programs (87%) responded to the survey. Sixty-seven percent of respondents indicated the presence of a robotic surgical system in their facility, with an additional 5% indicating that plans were being made to introduce the system in the near future. However, only 26% reported utilizing the robot in their surgical practice, with only 5% utilizing the robot routinely. Those pediatric surgeons utilizing the robot most often used it for hepatobiliary (79%) and foregut (64%) procedures. Table 1 demonstrates further breakdown of robot implementation according to types of procedure.

Those programs not using the robotic surgical system were then further queried as to the reasons of lack of utilization. The results are summarized in Table 2. The most common reasons provided were lack of clear supportive evidence (81% Agree or Strongly Agree), increased intraoperative time (80%), and incompatibility of instrument size to pediatric patients (79%). Surprisingly, most program directors either disagreed or strongly disagreed with concerns regarding lack of access to robotic training (65%) or lack of robot availability (58%) as a possible reason against the use of the robot system. The system's overall size, cost, range, and docking time do not seem to be important factors, as their response aggregate did not demonstrate significant deviation from the central tendency on the scale.

Fifty-eight percent of all program directors believe that there is a future role for robot-assisted minimally invasive surgery in children (Table 3). However, most of them do not believe that robotic surgery would replace any of the other existing minimally invasive techniques, including conventional laparoscopy (74%), single incision laparoscopy (48%), or natural orifice transluminal endoscopic surgery (34%). The views on the necessity of robot procedures as a marketing tool for a pediatric surgery practice did not deviate from the median toward agreement or disagreement.

While almost 60% of program directors believe in the future of pediatric robotic surgery, only 18% indicated that robotic training should play an important part in pediatric surgery education. Consequently, while over 66% of survey respondents received training in robot-assisted surgical technique, only 29% of fellows receive robot-assisted training during their fellowship. Moreover, only 27% of fellows participate in live robot-assisted procedures and only 24% operate the console. When comparing the modality of training between fellowship directors and trainees (Table 4), the most common modalities among directors were one-on-one hands-on training (36.8%) and formal didactic education (34.2%), while trainees were most likely to engage in self-directed reading (24.4%) or study on a robotic simulator (17.1%).

Very few of the programs have expressed interest in research into robotics. Only 14% of fellowships have ever engaged in such research and only 9% are currently researching the use of robot-assisted surgical techniques in the pediatric population.

Discussion

With the continued expansion of robot-assisted procedures, trainees in pediatric surgery fellowships continue to receive more exposure to this new technology throughout their residency and fellowship training. However, despite the increasing rates of robot-assisted pediatric cases over the last two decades, the role of this technology in both pediatric surgery training and clinical practice remains unclear. This fact further underlines the importance of the current cross-sectional study, as the first published report on the current pattern of robotic surgery utilization and training within US pediatric surgery fellowships. The survey gains further significance, considering its high response rate (87%) among pediatric surgery fellowship directors queried, compared to prior surveys among International Pediatric Endosurgery Group members (48%) ³ or members of Pacific Association of Pediatric Surgery (38.2%). ¹⁵

Our survey demonstrated the availability (67% of fellowships) of the robotic surgical system in pediatric settings, with further expansion expected in the future. The rates of the robot's availability are consistent with those previously published by Jones and Cohen ¹⁵ in the pediatric surgery community, as well as those noted by Farivar et al. ⁸ among the general surgery residencies. However, despite this availability, less than a third of the fellowships actually utilize the available technology. Furthermore, less than 20% of those using the robot do so on a routine basis. According to the social science theory of diffusion of innovation, ¹² this places current pediatric robotic surgery in the United States at a state between early adopters and early majority implementation, that is, remaining in the early stages of adoption.

While robot-assisted surgery has been extensively utilized in a variety of pediatric gastrointestinal, genitourinary, and thoracic surgical procedures, ⁶ the distribution of cases in our study demonstrates predominance toward hepatobiliary, thoracic, and pelvic procedures. A similar distribution of cases was noted among the adult general surgery training programs. ⁸ Both instances properly demonstrate the platform's advantages of miniature structures' magnification and manipulation within spatially constrained operative spaces. ¹⁶

Considering the ubiquitous presence of the robot, it is of little surprise that availability was not considered a major perceived barrier toward utilization among our responders. Similarly, availability of training did not appear to be a preventative factor. Rather, it was the size of the instruments, the increase in operative time, and the lack of convincing supportive evidence that serve as perceived barriers to utilization. The incompatibility of instrument size to the pediatric patient has been extensively documented,^3,15,16 with scaling of the tools considered unprofitable in light of the unappealingly small gross market capacity. ⁴ A recent meta-analysis of all robotic pediatric surgery publications ⁶ indicated that the majority of publications to date have been in the form of case reports and series, with not a single randomized controlled trial yet to be published on the topic. Considering the “gold-standard” status of randomized controlled trials, such studies should be encouraged in pediatric robotic surgery to determine the risks, benefits, and appropriate procedures for utilization of this technology.

While over half of the program directors believe that the robot will play an important part in the future of pediatric surgery, the vast majority does not believe that it will eliminate any of the currently utilized minimally invasive techniques. In this, the pediatric surgeons join the views of urologists ¹⁷ and gynecologists ¹¹ who have expressed similar views. However, despite the directors' positive views on the future of pediatric robotic surgery, less than a fifth of them believe in the need to incorporate robotic surgery into fellowship training at this time. As a result, less than a third of the trainees currently receive robotic training, which is significantly less than the rate of training among the directors. Furthermore, the type of training among the fellows is usually much less comprehensive than that among their mentors. Beyond formal training, only a narrow minority of the fellows get to practice their robotic skills by actually participating in live robotic procedures, with even fewer of them actually getting to operate the console.

Finally, we must consider the extent of pediatric robotic surgery research, as both progression of the technology and its adoption rely on research data. However, despite the fact that almost 80% of all pediatric robotic publications originate in the United States, ⁶ less than 14% of fellowships have ever actively engaged in such research, with less than 10% still engaged in it. This serves to further explain why the majority of publications on the subject in the pediatric surgery literature consist of case reports and series, ⁶ rather than proper randomized controlled or cohort studies.

Several limitations of the current study are those inherent to cross-sectional surveys. The major limitation is, of course, the data from the missing responders. While lower than in other similar cross-sectional studies, the rate of nonresponders is still concerning in its statistical ability to sway some of the results. However, considering the multiple parallels between some of our findings and those established in other specialties, it appears safe to assume that the results in our report can be similarly generalized. Second, cross-sectional study by its very nature allows us only to determine the situation as it exists at a specific instance in time. Considering the multistaged and time-sensitive nature of diffusion of innovation, the results of future studies will change as experience with the robot grows and more advances are made in this arena.

Conclusions

In conclusion, we believe this report offers an important insight into the current state of robotic surgery utilization and training among the US pediatric surgery fellowships. While a majority of training programs have access to a robotic surgical system within their hospital, only few utilize the technology in their current practice. Current barriers to utilization include lack of convincing supportive evidence, increased operative time, and lack of appropriate scaling of instruments. Furthermore, while most fellowship directors see a future role for the robot in the practice of pediatric surgery, only a few of the fellows receive robotic training and even fewer participate in actual robotic cases. As such, further investigation is required into both the technology's potential benefits in the pediatric population and its role in pediatric surgery training.