Keywords minimally invasive surgery - robot-assisted surgery - curriculum - Delphi process
- consensus
Introduction
The rapid progress of technological developments in minimally invasive surgery (MIS)
and robot-assisted surgery (RAS) is creating many more options for more precise and
more effective patient care [1 ]. The positive impact of these innovative procedures, especially in terms of fewer
postoperative complications and faster convalescence times, is well proven [2 ]
[3 ]. In addition, integrating AI applications (AI: artificial intelligence) into MIS
and RAS will significantly support surgical practice and develop it further [4 ]
[5 ].
Given the rapid changes in technology, the challenge for surgical teams is to keep
pace with rapidly developing new technologies and provide comprehensive training [6 ]. In Germany, standardized national structures to teach these specialized skills
are lacking. At present, there are only a few regionally limited initiatives which
are attempting to confront this problem [7 ]
[8 ]. The existing training regulations continue to rely on target figures and do not
sufficiently focus on improving competencies when they define further training, especially
with regards to integrating simulator-based and specialized training [9 ].
Given these circumstances, the necessity of a national training curriculum for MIS
and RAS is becoming increasingly urgent. Such a curriculum would not just offer the
opportunity to increase patient safety using targeted training based on the principle
of PBP (PBP: proficiency-based progression) but would also contribute to the active
shaping of technological advances in surgery. It would permit comparability in an
era of technological change and thereby ensure a better quality of care. Moreover,
such a curriculum would increase the attractivity of a surgical career for young doctors
by offering innovation and better structured advanced training, which is a basic part
of attracting and retaining new entrants to the field of surgery [10 ]
[11 ].
With the support of the Germany Society for General and Visceral Surgery (Deutsche
Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV), a Delphi process was initiated
to create the structural conditions to develop and implement such a curriculum. National
experts were included to ensure that the curriculum would be practice-oriented, comprehensive
and state-of-the-art in science and technology. The Delphi process provided an opportunity
to gather opinions, define a consensus, and draft a future-oriented curriculum by
forming a working group within the specialist medical association. The cross-location
cooperation aimed to create a structured and broadly accepted national curriculum
for Germany which would best meet the requirements for this medical specialty and
ensure high-quality patient care.
Method
Working group and approach
The Delphi process to create a national curriculum for minimally invasive and robot-assisted
surgery (GeRMIQ = German Robotic and Minimally Invasive Surgery Qualification) was
initiated by a specialist panel of experts. The working group (AG) was set up by specialists
for visceral surgery working at different universities (TH, FN, HM) who stood out
based on their professional expertise, scientific activities and many years of experience
in the field of minimally invasive and robot-assisted surgery and its training.
A deliberate choice was made not to have an ethics vote as the study did not involve
any patients and the study design did not require it.
The approach was divided into 4 steps:
1. Analysis of the status quo and literature search
An independent search of the literature was carried out to analyze the existing training
curricula for MIS/RAS in Germany and internationally. This systematic examination
used sources such as PubMed, Google Scholar and the DNB-OPAC catalog of the German
National Library. A detailed list of questions was developed in kick-off meetings
by the initiators of the project.
2. Choice of experts and online survey
The choice of national experts was based on their scientific activity and expertise
in MIS/RAS. Particular care was taken to include the broadest range of experts with
different levels of seniority to ensure a wide range of experience. The questions
were prepared in advance and sent out via the SoSci Survey platform and were available
for evaluation from 27 September 2023 to 8 October 2023. The questions/statements
were structured to elicit either a dichotomous response or be answered using a Likert
scale. This was done to create a more differentiated weighting of specific topics.
The concept of the questions allowed the experts to give their responses based on
their clinical experience and personal judgment. The Comments function of the survey
also allowed respondents to freely express their opinions. Anonymization of all participants
was maintained to ensure the necessary integrity and objective expressions of opinion.
A reminder email was sent to non-responders to
maximize participation.
3. Conference of experts to build a consensus
The results of the online survey were processed statistically and presented visually
in PowerPoint. The presentation of the results of the online survey aimed to identify
those areas where no consensus was achieved during personal discussions and to discuss
them, taking the scientific evidence into account. The conference of experts was held
in the Bonn Surgical Technology Center (BOSTER). Finally, the 3rd iteration took the
form of an online conference. Participants had the option to revise or double-down
on their positions. Ambiguous cases were discussed and second vote was carried out
where necessary.
4. Implementation of the consensus content
The development and practical implementation of the consented contents as the basis
of a nationally applicable curriculum is currently in its developmental stage. The
aim is to create high-quality standards which will be continuously optimized while
including more surgical interest groups.
Delphi process and definition of consensus
A 2-step modified Delphi process was used to achieve consensus. This approach is used
to arrive at a consistent result when numerous high-level scientific perspectives
are under consideration. The a priori definition of consensus was an agreement of
≥ 80%, based on the standards for leading scientific publications [12 ].
Results
All 12 experts invited to participate in the online round of questions responded (response
rate: 100%). The group of participants consisted of 10 senior physicians, one medical
specialist and one junior doctor. A total of 122 questions/statements were sent out
in the form of an electronic questionnaire, of which 78 questions had binary response
options and 44 questions required ranking on a Likert scale. There was a primary consensus
on 89 of the 122 questions (73%). During the meeting of experts, a secondary consensus
was achieved for 6 further questions, meaning that there was consensus regarding 77.9%
of the questions (n = 95). Four questions/statements (3.9%) were dropped because they
were redundant. No consensus was achieved for 23 questions (18.9%), even after discussion
([Fig. 1 ]). For the sake of clarity the focus here will mainly be on the statements for which
a consensus could be achieved during the
process.
Fig. 1 Percentage of questions for which a consensus was reached.
Basic concept and target group
Position
Overall, everyone agreed about the benefits of having a standardized curriculum ([Table 1 ]). All of the medical specialists agreed with the statement that such a curriculum
should be developed and evaluated quickly. There was also a clear agreement (100%)
about the need for comprehensive improvements in the quality of training and of the
need to ensure that medical staff had the requisite knowledge and skills and the option
to carry out extensive scientific studies. All of the experts unanimously agreed (100%)
that patient safety and outcomes should be improved. There was also an unanimous consensus
that the GeRMIQ curriculum would make the national surgical community more competitive
on the global stage and would encourage an independent evaluation and introduction
of innovative technologies. Finally, all of the experts agreed that continuous updates
of the GeRMIQ would provide sustainable support for further
training and lead to more innovation in the field of surgery.
Table 1 Position.
1st round:
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
A national curriculum for minimally invasive and robot-assisted surgery (BCMR) is
beneficial because …
… overall, it would offer more benefits than disadvantages, and it should be developed
and evaluated quickly.
91.7/8.3
100/0
Yes
… the quality of training can be improved nationwide.
100/0
100/0
Yes
… it will ensure that medical staff have the requisite knowledge and skills.
100/0
100/0
Yes
… it can improve patient safety and therefore patient outcomes.
100/0
100/0
Yes
… comprehensive scientific studies will be possible (e.g., didactic studies, studies
on simulation technology, etc.).
91.7/8.3
100/0
Yes
… the national surgical community can become more competitive on the global market
in some areas.
91.7/8.3
100/0
Yes
“… the increasing numbers of innovative technologies entering the market (e.g., new
robot-assisted systems) can be evaluated and introduced independently of industry.”
83.3/16.7
100/0
Yes
… it could increase the trust of patients in innovative surgical techniques.
66.7/33.3
9.1/90.9
No
“… continuous updates (e.g., annually) will sustainably support further training and
a more innovative orientation in the field of surgery.”
83.3/16.7
100/0
Yes
Basic concept
The overwhelming majority (90.9%) finally voted for the creation of a combined curriculum
for MIS and RAS and almost unanimously rejected the idea of developing a curriculum
exclusively for RAS which would not include standard laparoscopy. There was a general
consensus with regards to the possible use of the GeRMIQ as the basis for other medical
specialties (urology/gynecology), with a primary agreement in the 1st round of 83.3%
and a subsequent secondary consensus of 100%. There was full agreement that the “basic
training” of the GeRMIQ should be designed as a minimum target to allow for future
specialization ([Table 2 ]).
Table 2 Basic concept.
1st round:
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
BCMR: national curriculum for minimally invasive and robot-assisted surgery; HPB:
Hepato-pancreaticobiliary; UGI: Upper gastrointestinal tract; COLO: Colorectal
A combined BCMR should be created for MIS and RAS.
91.7/8.3
90.9/9.1
Yes
A BCMR should only be created for RAS and not include conventional laparoscopy.
0/100
0/100
No
A BCMR could also serve as the basis for other medical specialties (urology/gynecology).
83.3/16.7
100/0
Yes
In parallel to a “basic” BCMR, a “specialized” BCMR should also be devised (HPB/OGI/COLO
etc.).
50/50
0/100
No
The minimum goal should be to first design a “basic” BCMR which can serve as a basis
for a future “specialized” BCMR (HPB/UGI/COLO, etc.).
91.7/8.3
100/0
Yes
Target group
Clear tendencies were identified with regards to target groups but there were also
differences of opinion ([Table 3 ]). A consensus was achieved regarding the proposal that the curriculum should be
available to doctors in advanced training (especially before they have completed their
specialist qualification). The idea that the curriculum should only be available to
medical specialists or preferably to senior physicians with no experience of working
with medical robots (which is currently the case in many places) was rejected. The
majority of the experts (1st round: 83.3%; after the meeting of experts: 100%) supported
the integration of basic training in MIS and RAS already in the first years of surgical
training. Likewise, it was noted with an agreement of 81.8% that successful completion
of the GeRMIQ curriculum should be an obligatory part of admission to the final specialist
examination, for example in visceral
surgery.
Table 3 Target group.
1st round:
e-survey
yes/no in %
2nd round:
yes/no in %
Consensus
BCMR: national curriculum for minimally invasive and robot-assisted surgery; MC: German
Medical Council
A BCMR should be initially available for:
91.7/0
100/0
Yes
33.3/66.7
0/100
No
75/25
18.2/81.8
No
75/25
–
No consensus
58.3/41.7
–
No consensus
25/75
–
No consensus
Basic training in MIS/RAS already in the first years of surgical training is an advantage.
83.3/16.7
100/0
Yes
Successful completion of the curriculum should be obligatory for admission to specialist
examinations (e.g., for visceral surgery) of the MC.
83.3/16.7
81.8/18.2
Yes
Components and organization
There was unanimous consensus that the curriculum should consist of a number of consecutive
stages ([Table 4 ], [Table 5 ], [Table 6 ]; [Fig. 2 ]) and should include objective criteria to evaluate progression, including online
tests and benchmarks for practical exercises. The group also agreed that the curriculum
demonstrate highlight proficiency-based progression (PBP) to identify the progress
of individual learners during the different stages. Benchmarking the performance of
learners was also agreed upon, with 90.9% of the experts voting in favor.
Table 4 Components and organization (Part 1).
1st round:
e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
The BCMR should consist of different consecutive stages (e.g., e-learning, learning
to use equipment, dry lab exercises, first surgical procedures with video-based assessment
[VBA]).
91.7/0
100/0
Yes
The BCMR should include objective criteria to evaluate progression during different
stages (e.g., online tests, benchmarks for practical exercises, etc.).
83.3/8.3
100/0
Yes
The BCMR should be able to show proficiency-based progression (PBP).
83.3/8.3
100/0
Yes
As part of the BCMR, a performance level for persons doing the training should be
defined as part of benchmarking.
75/16–7
90.9/9.1
Yes
Table 5 Components and organization (Part 2).
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
The BCMR must include the following obligatory basic components (which are not part
of any surgical procedures):
0/0/0/25/75
100/0
Yes
0/8.3/16.7/25/50
100/0
Yes
0/0/0/8.3/91.7
100/0
Yes
0/8.3/8.3/16.7/66.7
81.8/18.2
Yes
0/0/8.3/8.3/83.3
100/0
Yes
8.3/8.3/8.3/25/50
90.9/9.1
Yes
25/16.7/25/0/33.3
–
No consensus
41.7/8.3/16.7/8.3/25
–
No consensus
Table 6 Components and organization (Part 3).
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
VR: virtual reality
The BCMR must include the following basic components (steps of surgical procedures
on real patients):
16.7/8.3/25/16.7/33.3
18.2/81.8
No
0/0/0/16.7/83.3
100/0
Yes
8.3/8.3/0/16.7/66.7
81.8/18.2
Yes
Fig. 2 Components of the curriculum.
The obligatory integration of e-learning contents including virtual contents and their
assessment (100% agreement) as well as learning to use equipment, e.g., through training
provided by the respective RAS companies (100% agreement), and the assessment of what
has been learned (81.8% agreement) were considered essential elements of the curriculum.
Dry lab training (100% agreement) and the assessment of dry lab skills (90.9% agreement)
were considered important components of the GeRMIQ. It was not possible to arrive
at a general agreement with regards to wet lab training and the assessment of wet
lab skills.
However, there was a consensus (81.8%) that sitting-in on live operations, whether
virtually or in person, should not be viewed as an obligatory basic component of the
curriculum. In contrast, assisting in a specified number of MIS/RAS index operations
(100% agreement) and carrying out surgical procedures or substeps of a specified number
of MIS/RAS index operations oneself (81.8% agreement) was considered an obligatory
basic component.
The consensus was unanimous (100%) with regards to implementing a system of continuous
monitoring and updating of the curriculum and the qualification requirements to ensure
that they comply with current standards and technologies ([Table 7 ]). The experts were unanimously in favor of setting up a GeRMIQ expert committee
which would be responsible for organizing the curriculum and continually adapting
it. Likewise, the value and importance of having an examination board to review applications
for accreditation and to issue certificates was unanimously accepted by the experts
(100%). A unanimous consensus was achieved with regards to the teaching format, whereby
the theoretical part would be largely carried out online and completed prior to the
practical part, which would be carried out locally in hospitals. All of the experts
voted in favor of graduates of the GerMIQ receiving a certificate. A co-operation
with
hospitals, medical facilities and other relevant organizations to promote the availability
of training options was unanimously endorsed. The professional medical organization
DGAV (Germany Society for General and Visceral Surgery) was unanimously considered
to be the most suitable organization to provide sufficient staffing, financial and
other resources to implement the curriculum and to serve as a communication platform,
especially with the German Medical Council.
Table 7 Other organizational aspects.
1st round:
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
Any system of continuous monitoring and updating the curriculum and qualification
requirements must ensure that they conform to current standards and technologies.
91.7/8.3
100/0
Yes
Such an update should be carried out annually.
33.3/66.7
–
No consensus
Such an update should be carried out every 2 years.
41.7/58.3
–
No consensus
Such an update should be carried out every 3 years.
16.7/83.3
–
No consensus
A points system can be used to facilitate the accreditation of parts of the BCMR and
would be generally sensible.
91.7/8.3
100/0
Yes
Setting up a BCMR expert committee is useful for the organization and continuous adaptation
of the curriculum in future.
100/0
100/0
Yes
It would be useful to set up an examination board which would review applications
for accreditation and decide on the issuing of certificates.
83.3/16.7
100/0
Yes
In principle, the theoretical part should be largely done online and completed prior
to starting practical training, which would be carried out locally in hospitals.
83.3/16.7
100/0
Yes
After completing the BCMR, graduates should receive a certificate (e.g., “DGAV basic
certificate for conventional minimally invasive and robot-assisted surgery”)
83.3/15.7
100/0
Yes
A collaboration with hospitals, medical facilities and other relevant organizations
will be required to promote the availability of training options in robotic surgery.
100/0
100/0
Yes
As a professional assocation, the DGAV could ensure the availability of staff, financial
and other resources, monitor certification and serve as a communication platform including
to the German Medical Council.
100/0
100/0
Yes
Theory
Theory: contents
There was an unanimous consensus (100%) with regards to integrating legal aspects
(e.g., information, responsibility) and ethical questions in the context of artificial
intelligence (AI) which should be included in e-learning. Similarly, the panel agreed
that the curriculum would also need to provide an overview of the current level of
e-learning technology. A consensus (100%) was also achieved with regards to the inclusion
of recommendations on the clinical implementation of new systems (including team training)
and that e-learning modules would also need to include information about the selection
and preparation of patients, trocar placement and docking, as well as approaches for
index operations (e.g., laparoscopic cholecystectomy [CHE] and robotic hemicolectomy).
The group of experts agreed that the basic characteristics of different systems and
the pitfalls associated with controlling them would need to be shown and taught as
part of e-learning modules ([Table 8 ]).
Table 8 Theory: contents.
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
E-learning should include:
0/33.3/41.7/8.3/16.7
–
No consensus
0/0/8.3/41.7/41.7
100/0
Yes
0/0/16.7/16.7/66.7
100/0
Yes
0/0/41.7/16.7/41.7
0/100
No
0/0/8.3/33.3/58.3
100/0
Yes
0/0/8.3/16.7/25
100/0
Yes
0/0/0/25/75
100/0
Yes
0/0/0/8.3/91.66
100/0
Yes
0/0/0/16.7/83.3
100/0
Yes
0/8.3/16.7/16.7/58.3
0/100
No
0/16.7/41.7/16.7/16.7
0/100
No
0/0/16.7/33.3/50
100/0
Yes
0/0/0/16.7/83.3
100/0
Yes
Theory: Organization, examination, accreditation
The results for certain organizational aspects of e-learning in the context of the
proposed curriculum showed that the experts were clearly in agreement ([Table 9 ]) with a unanimous consensus that e-learning should be available free of charge and
be financed by hospitals. There was also a clear preference for new e-learning modules
to be integrated into an existing learning platform (81.8% agreement). There was unanimous
consensus (100%) with regards to the (partial) accreditation of already established
courses for MIS and RAS. It was suggested that a points system to evaluate existing
courses/curricula would be useful for parts of the GeRMIQ. This approach was explicitly
supported to ensure that not all courses will have to be completely re-oriented.
Table 9 Theory: Organization, examination, accreditation.
1st round: e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
E-learning should be available free of charge (e.g., financed by hospitals).
100/0
100/0
Yes
It would make sense to affiliate e-learning to an existing learning platform.
66.7/33.3
81,8/18,2
Yes
The (partial) accreditation via already existing courses on minimally invasive and
robot-assisted surgery appears to be useful and is explicitly supported, meaning that
not all courses will have to be completely re-oriented.
91.7/8.3
100/0
Yes
Practical training without patients
Practical training without patients: contents
The experts unanimously agreed (100%) that practical elements such as tissue dissection,
tying of sutures, suturing, and the use of instruments by assisting medical staff
should be included in the practical training ([Table 10 ], [Table 11 ]). There was 100% consensus for carrying out simulations of specialty-relevant index
operations such as laparoscopic cholecystectomy, which shows the importance of practical
training as a good preparation for successful surgery. The integration of surgery-relevant
non-technical skills (NOTSS) and the need to review benchmarks (local/regional or
central, e.g., at conferences) after accreditation was unanimously approved. There
was a general consensus (100%) that a review of benchmarks should be consistent with
other national/international accreditation processes, for example with those of the
UEMS (European Union of Medical
Specialists).
Table 10 Practical training without patients: contents (Part 1).
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
Practical training without patients should include:
0/0/0/0/100
100/0
Yes
0/0/8,3/8,3/83,3
100/0
Yes
0/0/0/16,7/83,3
100/0
Yes
0/0/0/0/100
100/0
Yes
0/0/0/0/100
100/0
Yes
0/0/8,3/0/91,7
100/0
Yes
0/0/8,3/25/66,7
100/0
Yes
0/0/0/0/100
100/0
Yes
Table 11 Practical training without patients: contents (Part 2).
1st round: e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
Specialty-relevant index operations (e.g., laparoscopic cholecystectomy) should be
first performed using a simulator prior to the first real surgery.
91.7/8.3
100/0
Yes
The curriculum should include surgery-relevant non-technical skills (NOTSS).
N/A*
100/0
Yes
Local and regional benchmark reviews should be possible (after accreditation).
66.7/33.3
–
No consensus
Benchmark reviews should be done centrally (e.g., at conferences /surgical courses).
41.7/58.3
–
No consensus
Benchmark reviews should carried out locally or regionally (after accreditation) but
central reviews (e.g., at conferences /surgical courses) should also be possible.
N/A*
100/0
Yes
Benchmark reviews should be compatible with other national/international accreditation
processes (e.g., UEMS).
83,3/16,7
100/0
Yes
Practical training without patients: organization, practical examination, accreditation
Access to practical training
When the panel considered the organization of practical training and practical examinations,
the experts unanimously supported the introduction of regional structures (100%),
while the consensus about the corresponding monitoring of regional centers was more
mixed. There was a consensus (81.8%) that, in general, the persons providing practical
training in MIS/RAS should be accredited and that there should be separate accreditations
for MIS and RAS (100%) to do justice to the specific demands and features of the respective
areas. This again shows how important a differentiated evaluation of MIS and RAS will
be when developing the curriculum ([Table 12 ]).
Table 12 Practical training without patients: organization, practical examination, accreditation.
1st round: e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
If practical training in MIS/RAS with all the accessories is not available in all
hospitals, a regional structure could be created to ensure that everyone has access
to BCMR practical training and BCMR examinations.
100/0
100/0
Yes
If training for robot-assisted surgery is available in a hospital, a regional training
structure could be created to optimize access to training.
75/25
–
No consensus
Regional centers should be monitored by persons who offer training in MIS/RAS.
75/25
–
No consensus
The individual providing practical training in MIS/RAS should be accredited (e.g.,
by the DGAV).
83.3/16.7
81.8/18.2
Yes
Practical training centers and teaching hospitals should be evaluated and accredited
(e.g., by the DGAV).
75/25
–
No consensus
There should be separate accreditations for MIS and for RAS.
83.3/8.3
100/0
Yes
The opinions with regards to the ideal distance to the next regional center and the
time frame (flexible/according to a fixed schedule during working hours or during
approved educational leave; part-time, full-time, several days) varied ([Table 13 ]). There was a clear consensus (100%) that the costs of dry lab training (for example,
artificial organs) should be borne by the teaching hospital and not by the trainees.
The experts were unanimously in favor of co-operation agreements with medical professional
societies to provide easier access to dry lab training for hospitals and trainees.
Table 13 Access to practical training.
1st round: e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
What is the appropriate time frame to carry out practical training?
According to a fixed schedule during working hours
58.3/33.3
–
No consensus
During approved educational leave
91.7/8.3
–
No consensus
In the trainee’s free time
25/58.3
–
No consensus
Flexibly during working hours
58.3/33.3
–
No consensus
If regional centers existed, what would be the preferred time frame?
Full-time
58.3/25
–
No consensus
Part-time
8.3/66.7
–
No consensus
Over several days
66.7/25
–
No consensus
A reasonable distance to a regional center is:
< 20 km
25/58.3
–
No consensus
< 50 km
41.7/50
–
No consensus
< 100 km
75/8.3
–
No consensus
The teaching hospital should bear the costs of dry lab training (e.g. artificial organs).
83.3/16.7
100/0
Yes
Co-operation agreements (DGAV) should be concluded for dry lab training to provide
easier access to dry lab training for hospitals and trainees.
100/0
100/0
Yes
Practical training with patients: contents, videos, NOTSS, etc.
Evaluation of practical competence
There was a general consensus (100%) that, in the medium term, the first real surgical
procedure after successfully completing training outside of the operating room should
be evaluated by video-based assessment (VBA; [Table 14 ] and [Table 15 ]). There was also a general consensus (100%) that evaluation of a representative
operation of an index procedure should be carried out at the time of performance and
after completing the learning curve. The experts unanimously supported a points system
which would reflect the level of difficulty, an evaluation of defined surgical steps,
and mistakes which must be avoided. There was a consensus that there should be an
opportunity for experts to provide constructive feedback to the surgeons in training,
and that established scores (e.g., GEARS, OSATS, OPSA, ABS, Operative Performance
Assessment) could be used for this.
Initially used standardized evaluations by experts could be useful for future AI-based
evaluations.
Table 14 Practical training with patients: contents, videos, NOTSS, etc.
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
In the medium term, the first real surgical procedures after successful completion
of training outside the operating room should, in future, also be evaluated by video-based
assessment (VBA) in Germany in accordance with international models, to increase patient
safety.
8.3/8.3/25/16.7/41.7
100/0
Yes
Table 15 Evaluation of practical competencies.
1st round: e-survey
yes/no (in %)
2nd round:
yes/no (in %)
Consensus
GEARS: Global Evaluative Assessment of Robotic Skills; OSATS: Objective Structured
Assessment of Technical Skills etc.
Evaluation of practical competencies and skills in the operating room (also using
video analysis) should include the following:
50/50
–
No consensus
8.3/83.3
9.1/90.9
No
8.3/91.7
9.1/90.9
No
91.7/8.3
100/0
Yes
100/0
100/0
Yes
100/0
100/0
Yes
83.3/16.7
100/0
Yes
91.7/0
100/0
Yes
91.7/8.3
100/0
Yes
58.3/41.7
100/0
Yes
33.3/66.7
0/100
No
100/0
100/0
Yes
75/25
100/0
Yes
Non-technical skills for surgeons (NOTSS)
There was a clear consensus (100%) about the need to integrate emergency scenarios
in the curriculum. The consensus on training decision-making was 81.8%. There was
also general support (90.9% respectively) for training situational awareness and training
the surgical team ([Table 16 ]).
Table 16 Non-technical skills for surgeons (NOTSS).
1st round: e-survey
no/rather no/neutral/rather yes/absolutely (in %)
2nd round:
yes/no (in %)
Consensus
The following non-technical skills should be integrated in the BCMR:
8.3/0/16.7/16.7/58.3
–
No consensus
8.3/0/0/0/91.7
100/0
Yes
16.7/0/8.3/25/50
81.8/ 18.2
Yes
16.7/8.3/33.3/25/16.7
0/100
No
16.7/16.7/16.7/25/25
0/100
No
16.7/0/16.7/25/41.7
0/100
No
Non-technical skills should include:
8.3/8.3/16.7/16.7/50
90.9/9.1
Yes
0/16.7/16.7/16.7/50
90.9/9.1
Yes
Discussion
In contrast to several international initiatives [13 ]
[14 ]
[15 ], the Federal Republic of Germany currently lacks a comprehensive standardized curriculum
for the advanced training of MIS and RAS. Although these advanced technologies are
becoming increasingly important in medical practice [16 ], structured training and advanced training in these areas is not yet properly established
in Germany.
Traditionally, surgical skills were acquired in accordance with the model proposed
by Halsted: “See one, do one, teach one”, which was based on observation, followed
by the gradual acquisition of competencies by emulating role models, in accordance
with social cognitive theory [17 ]. The problems with this approach are well known, including misgivings that if the
acquired understanding is purely based on clinical experience, this will result in
trainee surgeons having heterogeneous skills. Moreover, the current expectation is
that physicians providing surgical training will both educate the new generation of
surgeons and learn to master the new technologies themselves [18 ].
To prevent heterogeneous and inadequate training, some of the different surgical subspecialties
have come up with a number of approaches to improve training by amending the curricula,
but the scope of the proposed changes has often been limited and inconsistent. The
Surgical Clinic of the UKSH Campus Lübeck developed a “Robotic Surgery Training Curriculum
– RoSTraC,” a 3-stage training program which ranges from basic and simulation training
to training in the lab using institutional robotic systems to structured training
on patients in the operating room [8 ]. The “Robotic Curriculum for young Surgeons” (RoCS), which was developed by the
Surgical Department of Magdeburg University Hospital, also includes theoretical and
simulation training but it focuses on the clinical implementation of practical robotic
training. With the RoCS concept, surgeons should gradually acquire basic competencies
in the use of
robotic systems until they sit their final medical specialist examinations [20 ].
The advanced training initiatives described above are promising. But the lack of national
training standards despite the continuous advances of MIS and RAS technologies in
Germany means there is a risk that the clinical implementation and application will
be suboptimal [19 ] which would be a barrier to technological progress in the field of surgery. There
is also the risk that the lack of advanced training programs will limit surgeons’
ability to cope with the latest technological developments and and integrate them
into clinical practice, potentially preventing them from developing these technologies
further in co-operation with the medical industry. The consequences would not just
limit technological progress but also reduce the willingness to carry out innovative
procedures. One example of this is the limited use of minimally invasive surgery to
treat colorectal carcinoma in Germany compared to other
countries internationally; in 2015, around 55% of procedures to treat colorectal cancer
in the United Kingdom were minimally invasive interventions as opposed to just 28.5%
in Germany [20 ]
[21 ]. Setting up a structured curriculum is therefore not just important for patient
safety and the quality of medical care but also for the promotion and continued development
of MIS and RAS and for integrating innovative technologies into clinical practice.
The results of the Delphi consensus presented here reveal the current challenges and
deficits of existing training programs and the need to amend them sooner rather than
later. Although the new competencies-based structure of the regulations on specialist
training has increased reference numbers, minimally invasive techniques and robotic
procedures are still not sufficiently integrated into the curriculum [22 ]. A survey of the members of the DGAV carried out by the Young Surgeons Working Group
in 2023 showed that they felt that MIS and RAS had not been adequately incorporated
into the new specialist training regulations. More than half of the persons surveyed
would have liked minimally invasive surgery to play a greater role and around 30%
demanded the integration of RAS. A majority of the respondents considered training
using simulators to be an important part of surgical training [23 ]. In addition to the lack of specifications in the specialist training regulations,
incorporating a comprehensive training program into the clinical routines of surgical
departments will be an organizational challenge [7 ]. Critics point to the still limited prevalence of robot-assisted systems (and digital
simulators) and the corresponding lack of progress in the use of minimally invasive
technologies [20 ]. The evaluation of the results of the Delphi process shows that the experts largely
agreed with this assessment. The introduction of such a curriculum would be an important
contribution to improving the quality of training and ensuring that medical staff
have the necessary knowledge and skills. The unanimously positive attitude towards
improving patient safety is an
indication of the overarching objective, which is to advance the quality of surgical
care. The clear support for creating a joint basic training program as a basis for
future specialization corresponds to the general international trend. The creation
of such a curriculum would have the advantage that its implementation would be less
dependent on industry and that it would be regularly evaluated, although such a curriculum
cannot completely replace manufacturer-specific training. Similar to international
proposals, the evaluation by various target groups showed how important it is to make
training available in different stages of a surgical career [24 ]. There should be a special focus on providing training for physicians working towards
their specialist qualification and training in MIS should start early. In the USA,
learning the fundamentals of laparoscopic surgery (FLS) is obligatory to pass the
Board
Examination of the American College of Surgeons [25 ]. The Delphi process revealed a consensus that the curriculum should be an obligatory
part of advanced specialist training. The evaluation of components of the GeRMIQ demonstrated
the multifaceted nature of surgical training. The unanimous support of a curriculum
which would consist of different stages and include objective assessment criteria
at different stages underlines the importance of a structured transparent assessment
of learners’ progress by evaluating their acquired competencies. The current global
trend towards integrating digital teaching methods into medical training focuses on
including e-learning an an obligatory basic component of training. In view of the
current discussion about flexible working times, the compatibility of family and a
career, parental leave, and the problems of combining a scientific carer with clinical
surgical training,
e-learning and non-patient-based simulations offer distinct advantages. The experts
supported continuous monitoring and updating of the curriculum, indicating an awareness
of the rapid progress of technological developments. The unanimous consensus with
regards to the introduction of a points-based system for accreditation corresponded
to international recommendations on establishing transparent assessment systems. It
was generally agreed that a panel of experts and an examination board should be set
up to ensure the continued quality and topicality of the curriculum. The assessment
of the proposed theoretical contents of the curriculum clearly showed the multidimensional
nature of MIS and RAS. The general consensus was that theoretical training should
include legal aspects, basic ethical principles, and information on current technologies.
When the experts turned their attention to the organization of e-learning, they were
agreed about the need to ensure that these programs
would be accessible and have adequate financing. The unanimous consensus that e-learning
should be available free of charge and that e-learning should be integrated in existing
teaching platforms corresponds to international attempts to facilitate access to medical
education [26 ]. This would permit the seamless integration of digital teaching methods into established
educational environments. When the experts were asked about practical aspects of training,
the central importance of hands-on training and the need for a structured assessment
of this training was evident. The consensus was that training should include two-handed
movements, guiding the camera, and other practical aspects, in line with international
recommendations on the simulation of surgical procedures [27 ].
Digital assessment methods including VBA (video-based assessment) are becoming increasingly
important in surgical training [28 ], and this was evident by the clear position and final unanimous consensus of the
experts. The issues associated with assessing practical skills and integrating non-technical
skills reflect the comprehensive nature of surgical competencies. The consensus on
video-based assessments and the focus on the need to perform representative surgical
procedures was in line with international trends for the digital assessment of surgical
skills.
The study on the development of a national curriculum for minimally invasive and robot-assisted
surgery in Germany using a Delphi process has some methodological limitations which
could limit its informative value. Firstly, the choice and limited number of participating
national experts could have limited the range of perspectives and led to bias, which
would potentially limit the transferability of the results to other countries or other
medical specialties. Secondly, despite the comprehensive list of questions, relevant
external factors such as the need to adapt to hospital reforms and the fact that the
healthcare system is running close to full capacity due to the rise in the number
of inner-European conflicts could not be taken fully into consideration. These potential
gaps indicate the necessity of regularly review and adapting the curriculum to ensure
that it remains relevant and effective. Another important limitation is that the practical
implementation of the
curriculum was not addressed, which leaves such issues as the availability of resources,
the acceptance of the changes by the larger surgical community, and the long-term
impacts on surgical training and patient care open. These limitations demonstrate
the need for continued research and regular amendments of the curriculum to ensure
that it remains relevant and effective in a dynamic medical field.
Conclusion
Given the upcoming far-reaching changes in the healthcare sector, especially those
caused by digitalization, demographic change, structural change and limited financial
resources, the results of this Delphi process highlight the need for a clearly structured
organization of advanced surgical training in MIS and RAS. The survey clearly demonstrates
the urgent need for a national curriculum which will not only facilitate further training
but also establish clear structures for such training. Consensus-based standardized
training guidelines have many advantages with regards to patient safety, technological
progress, and the comparability and quality of training. An established curriculum
based on theory, dry lab training, and clinical assessment ([Fig. 2 ]) will make the effective implementation of established procedures possible and promote
the use of modern technologies which can improve the safety and effectiveness of
surgical procedures. The Delphi process also highlighted the importance of a structured
curriculum as a highly attractive factor for surgical trainees. This will be essential
to attract qualified young talent in the field of surgery and guarantee the long-term
quality and sustainability of surgical care.
