Alexander Beulens

12 Chapter 1 Surgical Skills in Robot Assisted Surgery Although laparoscopic surgery has it benefits, it also has its technical challenges. Examples of these challenges are such as a limited range of motion of the instruments and related loss of dexterity, fixed instrument tips, and an inadequate visual field associated with an unstable camera view.12,13 In order to improve these limitations, new methods of minimal invasive surgery were investigated. This resulted in the development of so-called robot assisted surgery. The introduction of this technique could potentially overcome some of the drawbacks of laparoscopic surgery through the improvement of ergonomics and enhanced dexterity with tremor filtration. Even for those surgeons transferring from laparoscopy, slow learning curves were described based on operating time, complication rates and surgical margins.14,15 The effect of a surgeons’ skills during these robots assisted surgeries on the outcome of the surgery has sparsely been investigated. In many clinics in the United States and Europe, the Robot Assisted Radical Prostatectomy (RARP) has replaced the open radical prostatectomy and laparoscopic radical prostatectomy. The RARP is a complex and highly specialized operation in which the surgical robot is used to remove the prostate. Multiple ports are placed in the abdomen to facilitate robotic access to the prostate. Since the removal of the prostate leads to the separation of the bladder neck and the urethra a new bladder neck/urethra anastomosis is created. The combination of the removal of the prostate with the new anastomosis can lead to severe post-operative incontinence. Due to the relative position of the neurovascular bundle to the prostate, erectile dysfunction is another common post-operative complication.16–18 Since the RARP is a video recorded procedure and one of the most performed procedures in urology, the RARP seems an optimal procedure to develop and validate competency assessment. This process could be used as an example for other operations within and outside the field of urology. Even though the RARP surgery could be used for competency assessment it remains unclear how this surgical skills analysis using surgical videos should be performed. It remains unclear if video analysis is a valid measuring tool to assess the competency of expert surgeons. The additional questions are “who should assess the video’s?” since it is a time-consuming method of analysis and “how do you define the competency of a surgeon?” since multiple assessment methods have been developed using different levels of detail.