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.