Robotic Colorectal Fellowships

There has been a huge surge in the popularity of robotic colorectal surgery fellowships in recent times. Robotic colorectal fellowships come in all shapes, sizes and locations. They provide an excellent opportunity to consolidate your minimally invasive skills, develop new robotic skills and gain insights into leading and developing your own robotic practice. However, the delivery of robotic fellowship training is not straightforward and you need to consider a number of key criteria before embarking on a robotic colorectal fellowship.

Are you ‘fellowship ready’?

The first thing to consider before embarking on an application for a robotic colorectal fellowship is whether you are ‘fellowship ready’? Have you got all the basic robotic skills to hit the ground running on day 1 of your fellowship? Being ‘fellowship ready’ means you have completed all pre-requisite online and simulator training modules, you can dock and undock the robot and are an effective bedside assistant. Demonstrating these skills will make you competitive at time of interview, but will also ensure that you can hit the ground running as a console surgeon. If you do not have access to a robotic platform during your training, you must factor this into your fellowship, and dedicate the early part of your fellowship on completing your simulation assessments and acquiring key robotic bedside skills.

Expert Centre and Trainer

The second key consideration is your centre and trainer. I would highly recommend selecting a robotic centre and trainer with expert recognition in robotics. Robotic colorectal surgery is a team sport; working for an expert robotic trainer, with a dedicated robotic team, including trained robotic assistants, in a centre with an established track recording of robotic training will accelerate your robotic learning curve. There are many important non-technical skills you will pick up in such an environment which will be important when you achieve independence and lead your own robotic programme. Of course, completing an robotic fellowship with an internationally renowned robotic expert as a trainer at a prestigious unit comes with many additional benefits including the opportunity to participate in high-quality and cutting edge research and innovation, networking within the robotic community and lifelong mentoring following completion.

The true measure of a successful trainer is the ability to pass their expertise onto their trainees and fellows. Speak to previous fellows to find out about their experiences, including, whether they went onto become independent robotic surgeons and were able to develop their own robotic program. It’s also important to speak to trainees in the unit, irrespective of their robotic experience, about their views and experiences of training; this is invaluable in identifying the training ethos of the unit and whether the environment is truly set up to deliver high quality surgical training.

Robotic Access

It’s important to understand the makeup of the proposed robotic fellowship you are applying for. Are you going into a dedicated robotic fellowship or is this a ‘hybrid’ minimally invasive fellowship consisting of laparoscopic and robotic surgery? The rate limiting factor to skills acquisition in robotic colorectal surgery is access to the robotic platform. Understanding how robotic surgery is delivered in your proposed centre is essential. Asking key questions such as the presence of a dedicated colorectal robot, the number of robotic colorectal trainers within the unit, the weekly colorectal robotic access and the number of dedicated robotic lists, how many robotic cases are done per list, the presence of a dual console and out of hours access to the robotic simulator will give you an insight into your anticipated access to the platform. I have experience of both shared access and dedicated colorectal robotic access, and have been successfully trained in both scenarios. The key to my success in robotic training has always been regular access with expert trainers and a dedicated robotic team who have invested in me and my training.

Case Volume

As in many walks of surgery, the volume-outcome relationship is highly relevant to robotic training, the more robotic cases you do, the more rapidly you will gain confidence in your robotic skills. The ‘golden bracket’ for the learning curve in robotic colorectal surgery is considered to be between 20-40 cases, however, from my own personal experience, this is just when you start to become comfortable with the robotic platform, becoming an expert is a much longer process. It’s, therefore, essential that you factor in case volume when selecting your robotic colorectal fellowship. My advice is to look at published datasets on robotic procedures and overall procedures to gain insight into the robotic volume at each centre. In the UK, the National Bowel Cancer Audit and NHS England Individual Surgeon Outcome Dataset will give you some insight into how many colorectal cancers the individual trainer and the individual hospital operate on per year. Similar datasets exist in Europe, for example, Le Point in France publishes the annual operative volume for all cancers. My fellowship centre, CHU de Bordeaux – Hôpital Haut-Lévêque, is reported to be the highest volume unit for colorectal cancer in France, having performed 216 rectal cancer resections and 164 colonic cancer resections in 2020. The Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and the Royal College of Surgeons of England take this one step further by advertising all training centres and the volume of training operations.

Specialist skills

The acquisition of specialist robotic colorectal skills during a fellowship, such as pelvic sidewall dissection, robotic pelvic exenteration, CME, ventral mesh rectopexy or robotic pouch surgery will add to your overall repertoire and enable you to offer additional expert skills during your own consultant practice. Increasing the complexity of robotic procedures you are trained on will develop your confidence and will help refine your operative skills. Acquiring additional skills beyond robotic colorectal resections is important, especially, as robotic colorectal surgery becomes more ‘mainstream’ and is offered by a greater proportion of surgeons and hospitals. My advice to you is to find a robotic centre and trainer that aligns with your subspecialist area with a robotic practice in this arena and go and work with them. I certainly combined my subspecialist interest of advanced pelvic maligancy and pelvic exenteration with my robotic interest and my experience has been the richer for it. Training in robotic pelvic exenteration has challenged my robotic skills, operative decision-making and understanding of complex multidisciplinary working.

Leaving your robotic colorectal fellowship as an accredited and independent robotic surgeon should be the goal. Leaving with the skills and ability to train others, including consultant colleagues, trainees and theatre staff is an additional bonus. This is a key skill, especially, if you are going to start and lead your own robotic program as a Consultant Surgeon. Garnering the skills to be able to develop your own robotic team during your fellowship will prove to be invaluable. Take the time to observe how your robotic trainer interacts with the rest of the robotic team, organises the robotic schedule and manages the team overall.

The verdict

Going on a dedicated robotic colorectal fellowship will no doubt accelerate your robotic training, however, choosing the right one is the key to ensuring appropriate and timely accrual of robotic skills under the guidance of an experienced robotic trainer. Personally, my ESCP/Intuitive Robotic Colorectal Fellowship in Bordeaux under the auspices of Professor Quentin Denost has been one of the most invaluable experiences of my life. I may be biased but my fellowship consists of all the component parts of what makes a robotic colorectal fellowship great with an expert trainer and centre, brilliant team, dedicated colorectal robotic access, high volume operating and the development of specialist skills. Alongside this, I get to live in one of the most beautiful parts of the world! But, don’t just take my word for it, here is my good friend Lena Ngu outlining the benefits of an ESCP/Intuitive fellowship in Barcelona and my brilliant trainer, Quentin Denost, outlining just how to deliver a high quality fellowship.

Robotic Colorectal Surgery Training

I started my robotic training in 2018 as a surgical trainee (ST7) at Sunderland Royal Hospital in the North East of England. Over the last few years I’ve learnt a huge amount as I’ve carved out my path in the field of robotic surgery. Here are my top ten tips for all surgical trainees wanting to pursue a career in robotics.

🤖 1. Good basic laparoscopic skills

Having good basic minimally invasive skills will serve you well when you come to transition your training from laparoscopic to robotic surgery. Good laparoscopic skills including psychomotor skills, spatial awareness and good tissue handling are easily applicable to the robotic setting. It is also widely accepted that laparoscopic proficiency can help flatten the robotic learning curve.

🤖 2. Robotic Mentors

A dedicated robotic mentor is an invaluable resource. Pick a mentor who is an established and accredited robotic surgeon, with a track record in training. Established robotic mentors can share a wealth of expertise with you beyond operative training, including, setting up and navigating a service, brokering relationships with industry and introductions to other robotic experts. The best mentors are generous with their knowledge, expertise and wisdom.

🤖 3. Industry Partners

At present robotic surgery training is largely driven by industry, although, this is beginning to change. Find out who your local robotic industry representative is and talk to them about the potential training opportunities available. There are many available online learning tools available through industry platforms to get you started and help you understand the essential fundamentals of robotic surgery.

Golam Farook and Deena Harji

🤖 4. Training Resources

There are a multitude of training resources available for robotic surgery outside of the theatre setting. The amazing Belgian robotic surgeon, Dr Ellen Van Eetvelde, once said, ‘you have to learn to operate with your eyes’ and I couldn’t agree more! There are a number of available platforms with high quality robotic training videos, these are well worth a look at. I would highly recommend the detailed, step-by-step procedural videos produced by Dr Mark Solimon.

There has also been a huge expansion in the availability of cadaveric and robotic simulation courses for surgical trainees over the last 12 months. I would recommend that you attend such a course when you are working in a robotic unit with appropriate surgical access as this will provide you with maximal benefit.

The European Society of Coloproctology launched their robotic colorectal surgery webinars earlier this year providing tips and tricks on a range of robotic scenarios from port placement to complete mesocolic excision. These are well worth a look.

🤖 5. Simulation

Robotic simulation is the first key step of your robotic training journey, providing you with an immersive introduction to the robotic platform. Do not underestimate the time it takes to complete all of the simulation exercises to the appropriate level. Complete these exercises in short, dedicated time blocks consisting of 60-90 minutes, after this fatigue sets in and affects your performance.

🤖 6. Robotic Test Drive

Understanding the fundamental principles of how the different components of the robotic platform work is essential. Book a robotic test drive with your industry representative or robotic trainer and go through the key features of how the platform works, including set-up and safety features.

🤖 7. Robotic Bedside Assistance

Robotic bedside assistance includes set-up, robotic docking, operative assistance, instrument exchange and adjustment of robotic arms as well as performing emergency undocking manoeuvres if required. Being an effective robotic bedside assistant provides you with key insights into the synergistic relationship between the surgeon console and the patient cart. Robotic bedside assistance will also help you develop key communication skills required between robotic assistant and console surgeon. These skills become invaluable as you progress from robotic bedside assistance to console surgeon and begin to direct your own assistant.

🤖 8. Component Learning

Break down each robotic operation into its component part following discussion with your trainer and aim to perfect each individual step. For example, low anterior resection is broken down into four key steps ; 1) lateral mobilisation, 2) IMA division, 3) TME and 4) splenic flexure mobilisation. Progress through each of these steps starting with the easiest and working towards the most complicated. Employing this approach will gradually build your confidence with the robotic platform and will help develop your operative skills.

🤖 9. Track your progress

Keep a record of all your robotic procedures including bedside assistant cases, robotic docking and operative procedures. Record all your operations and watch these back with your robotic trainer to identify keys areas for improvement. There are available platforms such as C-SATS on which you can upload your robotic videos for independent objective assessment from international robotic experts.

🤖 10. Robotic Fellowship and Opportunities

Robotic colorectal surgery is expanding in the UK and internationally, as a result, there are a number of well established, high volume dedicated robotic fellowships available. These are highly recommended to accelerate your robotic training as they provide trainer expertise, regular robotic access and volume. Keep a look out on relevant websites including the ASGBI, ESCP and ALSGBI. I can personally recommend the ESCP Robotic Fellowship at Hôpital Haut-Lévêque Groupe Hospitalier CHU Bordeaux under Professor Quentin Denost.

As robotic surgery and training continues to evolve so will the opportunities to get involved in robotic research, training and curriculum development. Make the most of these opportunities and get involved in initiatives such as the Royal College of Surgeons Robotic and Digital Surgery (RADAR) Initiative and its partnership initiative with the Association of Surgical Trainees Technology Enhanced Surgical Training.

Attendance at dedicated robotic conferences will keep you abreast of the latest developments in robotic surgery and will allow you to network with international robotic experts. The upcoming virtual Robotic Colorectal Surgery Symposium 2021 (ROCS2021) provides you with an ideal opportunity to do this. There are also a number of industry delivered symposia throughout the year, which are worth checking out.