Alexander Beulens

11 Introduction and Outline of the Thesis Introduction Healthcare is constantly moving towards the improvement of quality of care and safety for patients. Increasing attention is being paid to the relocation of complex treatments, such as robot assisted surgery, to high-volume centres as it is expected to improve the quality of care and increases patient safety due to the increased exposure of surgeon and staff.1–3 In the Netherlands, a move to large high-volume centres is seen in some specialties including Urology.4 This change is influenced by recent studies linking hospital volumes to surgical outcome.1–3 With the increasing call for the formation of high-volume centres in order to improve quality of care the question remains whether the higher number of surgeries per hospital or the quality of the surgeon influences outcome. There are large variations in postoperative complication rates amongst surgeons with similar surgical volumes per centre or even in the same centre.5,6 The qualification and certification of surgical skills are still in a preliminary phase within all surgical specialties, also in urology. The skills of a surgeon assessed by surgical video analysis has been correlated to the prevalence of major complications (i.e. readmissions) in the past.7 This initial study has sparked a new field of research into surgical skills and the use of surgical videos analysis.8–10 In more recent studies, surgical skills have been associated with functional outcome.2,6,11 Systematic evaluation of surgical skills, both technical and non-technical, is thought possible through video analysis methods. A description of the surgical steps in the procedure is needed in order to use the surgical videos for the assessment of surgical skills, and detect possible errors for the association with adverse outcomes. Problem statement With the increasing number of procedures and the increasing technical difficulty of procedures, the current challenge for both novice and expert surgeons is to learn how to analyse past performances and subsequently use this as a lesson for the future. We therefore describe surgical skills needed for robot assisted surgery and its shortcomings, next the educational and training status of novice and experienced robotic surgeons, and resume with a list of research questions related to the overall problem of how to test robotic skills and the impact of those tests. The methodology of testing and evaluation are shortly introduced at the end of the introduction.