ORIGINAL REPORTS
Can Robotic Surgery be Done Efficiently While Training Residents? Michael Drew Honaker, MD, Beverly L. Paton, MD, Dimitrios Stefanidis, PhD, and Lynnette M. Schiffern, MD Carolinas Medical Center, Charlotte, North Carolina INTRODUCTION: Robotic surgery is a rapidly growing
KEY WORDS: robotic surgery, training, general surgery,
area in surgery. In an era of emphasis on cost reduction, the question becomes how do you train residents in robotic surgery? The aim of this study was to determine if there was a difference in operative time and complications when comparing general surgery residents learning robotic cholecystectomies to those learning standard laparoscopic cholecystectomies.
outcomes
METHODS: A retrospective analysis of adult patients
undergoing robotic and laparoscopic cholecystectomy by surgical residents between March 2013 and February 2014 was conducted. Demographic data, operative factors, length of stay (LOS), and complications were examined. Univariate and multivariate analyses were performed. The significance was set at p o 0.05. RESULTS: A total of 58 patients were included in the study (18 in the robotic cholecystectomy group and 40 in the laparoscopic group). Age, diagnosis, and American Society of Anesthesiologists score were not significantly different between groups. There was only 1 complication in the standard laparoscopic group in which a patient had to be taken back to surgery because of an incarcerated port site. LOS was significantly higher in the standard laparoscopic group (mean ¼ 2.28) than in the robotic group (mean ¼ 0.56; p o 0.0001). Operating room (OR) time was not statistically different between the standard laparoscopic group (mean ¼ 90.98 minutes) and the robotic group (mean ¼ 97.00 minutes; p ¼ 0.4455). When intraoperative cholangiogram was evaluated, OR time was shorter in the robotic group. CONCLUSION: Robotic training in general surgery residency does not amount to extra OR time. LOS in our study was significantly longer in the standard laparoscopic group. C 2015 Association of Program ( J Surg 72:377-380. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.) Correspondence: Inquiries to Drew Honaker, MD, 10223 Hugue Way, Charlotte, NC 28214; e-mail: [email protected]
COMPETENCIES: Practiced-Based Learning and Improve-
ment, Medical Knowledge, Systems-Based Practice
INTRODUCTION Although robotic surgery continues to evolve and become more sophisticated, conferring the advantages of a 3-dimensional view, magnification, tremor suppression, and increased degrees of movement of instruments resulting in more precise movements, its place in the general surgery residency curriculum is controversial.1,2 Arguments of extended operative times and increased costs and charges are among the most frequently cited criticisms of this educational focus.2-4 The essential question facing teaching institutions is how to balance operating room (OR) time and cost with adequate training of general surgery residents in robotic surgery. As multiple studies have demonstrated that operative time and costs increase when using a robotic system,3,5,6 this study set out to evaluate and compare operative times, length of stay (LOS), and complications of robotic surgery and compare them with standard laparoscopic approaches. We hypothesized that operative times, complications, and LOS would be similar when comparing robotic operations with standard laparoscopic operations in general surgery residency training.
METHODS Following institutional review board approval, a search using procedural codes was conducted to identify 2 groups of patients seen at Carolinas Medical Center (CMC) between March 2013 and February 2014: those undergoing robotic cholecystectomies performed by senior-level residents and those undergoing standard laparoscopic cholecystectomies performed by junior residents. These 2 groups were chosen to establish relative parity between learning curves. Because robotic cholecystectomies are performed by
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.008
377
senior-level residents who have had prior experience with laparoscopic approaches but are new to robotic surgery, they represent a learning curve that we deem equivalent to that of to junior-level residents performing laparoscopic cholecystectomies with little or no exposure or experience in them. (Interns were excluded from the study because their exaggerated learning curve would skew operative times in the standard laparoscopic group.) Procedures conducted by attending physicians with resident assistance were excluded, as were patients who underwent endoscopic retrograde cholangiopancreatography as their LOS would not be directly related to their surgery. The use of intraoperative cholangiogram (IOC) was evaluated at the discretion of the operating attending physician. All robotic and laparoscopic cholecystectomies were performed using a multiport approach. All attending physicians involved in robotic training were certified proctors completing the necessary requirements to perform and teach robotic procedures. For robotic cases, our institution does not have a dual console; therefore, if the attending physician performed part of the case for teaching purposes, these patients were included in the study. This was also done for patients in the laparoscopic group as well. However, cases where most of the procedure was done by the attending physician were excluded from the study. Operative times were measured from the time of initial skin incision to the time that dressings were placed, as this was the most consistently recorded time. Time to dock and undock the robot was also included in the operative time calculations. The robotic and the laparoscopic groups were compared with respect to operative time, length of hospital stay, and complications, both intraoperatively and postoperatively. (Operative time was defined by time of incision to time of dressing placed.) Descriptive statistics, including means, standard deviations, counts, and percentages, were calculated. Total OR time and LOS for the 2 cholecystectomy groups (robotic and standard laparoscopic) were compared using the Student t test and the Wilcoxon rank-sum (WRS) test, respectively. (The WRS test was employed because LOS was not normally distributed.) Additional factors compared were sex, IOC, and preoperative diagnosis using the Fisher exact test, age using the Student t test, and American
Society of Anesthesiologists (ASA) score using the WRS test. SAS Enterprise Guide 5.1 was used for all analyses, and a 2-tailed p value of less than 0.05 was considered statistically significant.
RESULTS The first robotic cholecystectomy performed by general surgery residents at CMC was in March 2013. After a search was conducted using operative codes for robotic and laparoscopic cholecystectomy, 58 patients were identified who underwent cholecystectomies at CMC between March 2013 and February 2014 by senior or junior residents. Senior residents were defined as those in their final year of clinic training and junior residents were defined as those in the second and third years of clinic training. Among the 58 patients, 18 underwent robotic cholecystectomy by seniorlevel residents and 40 underwent laparoscopic cholecystectomy by junior-level residents. Patient demographics were not statistically different between both the groups (p 4 0.05; Table 1): in the robotic cholecystectomy group, there were 14 women and 4 men (77.8% vs 22.2%), and in the standard laparoscopic group, there were 29 women and 11 men (72.5% vs 27.5%). The average age of patients in the robotic group was 41 years ( ⫾16.8) and in the standard laparoscopic group was 43.6 (⫾15.1). IOC was carried out in 4 patients in the robotic group (27.5%) and 8 patients in the standard laparoscopic group (20%). Comparison of indications for cholecystectomy revealed that 15 of 18 (83.3%) patients in the robotic group and 29 of 40 (72.5%) patients in the standard laparoscopic group underwent the procedure for symptomatic cholelithiasis. Overall, 1 patient in the robotic group and 10 patients in the standard laparoscopic group underwent cholecystectomy for acute cholecystitis, and 1 patient in each group underwent cholecystectomy for gallstone pancreatitis. There was no statistically significant difference between the 2 groups (p ¼ 0.0831) with respect to indication for cholecystectomy, nor were any intraoperative complications identified in either group. Postoperatively, there were no complications in the robotic group, but one complication
TABLE 1. Patient Demographics Mean age (y) Mean ASA Sex (n) Preoperative diagnosis (n) IOC performed (n)
Robotic Group
Laparoscopic Group
p Value
41 2 M¼4 F ¼ 14 Symptomatic cholelithiasis ¼ 15 Acute cholecystitis ¼ 1 Other ¼ 2 Y¼4 N ¼ 14
43.6 2.25 M ¼ 11 F ¼ 29 Symptomatic cholelithiasis ¼ 28 Acute cholecystitis ¼ 10 Other ¼ 2 Y¼8 N ¼ 32
0.5558 0.0869 0.7559 0.0831 0.0831 1.0000
M, male; F, female; Y, yes; N, no. 378
Journal of Surgical Education Volume 72/Number 3 May/June 2015
TABLE 2. Outcomes Outcome Operative time (min) Complications (n) Length of stay (d) Operative time with IOC (min)
Robotic Group
Laparoscopic Group
p Value
97 0 0.56 110.3
91 1 2.28 112.9
0.4455 1.0000 o0.0001
was seen in the standard laparoscopic group: this patient developed an incarcerated port hernia at his umbilical incision and had to be taken back to the OR on postoperative day 3 for repair. The overall health of the 2 groups was evaluated using the ASA score. The robotic group had a mean ASA of 2, whereas the standard laparoscopic group had a mean ASA of 2.25, suggesting a trend toward a higher ASA in the standard laparoscopic group; however, this score did not achieve statistical significance (p ¼ 0.0849). The mean operative time was 97 minutes in the robotic group and 91 minutes in the standard laparoscopic group, a difference that did not achieve statistical significance (p ¼ 0.4455). The mean operative time in which an intraoperative cholangiogram was performed was shorter for the robotic group than for the laparoscopic group by 2.6 minutes (110.3 vs 112.9 minutes). LOS was significantly shorter in the robotic group (p r 0.0001), with the average LOS being less than 1 day (Table 2).
DISCUSSION In a profession that is increasingly sensitive to cost, surgical training programs have to find a balance between saving time and money and appropriately training residents. Robotic surgery is still finding its place in general surgery with an increasing number and variety of cases being performed. The aim of our study was to evaluate the operative time and complication rate in training general surgery residents in robotic surgery and to compare these statistics with those associated with training in standard laparoscopic procedures. Our hypothesis that OR time, LOS, and complications were not different between both the groups was proven by our results. LOS was significantly shorter in the robotic arm; however, this may be owing to attending physician preference of observation overnight vs discharge from post operative care unit. Another possibility is that, although the indications for cholecystectomy were not significantly different between the 2 groups (p ¼ 0.0831), there was a trend toward significance, with more patients undergoing laparoscopic cholecystectomy for acute cholecystitis. This could contribute to the significant difference in LOS observed between both the groups. The choice to use cholecystectomies was based on the fact that most general surgery residents initially learn laparoscopy doing cholecystectomies, and this holds true for learning robotic surgery as well. Some argue that robotic
cholecystectomies result in unacceptable increases in both time and cost. We argue that the same could be said about junior residents learning laparoscopic cholecystectomies, as a senior resident or attending surgeon can do a laparoscopic cholecystectomy in much less time than an intern or junior resident. If we insist on choosing the least time- and resourceintensive option, then we must ask the obvious question, “How will we train surgeons?” The limitations of this study include its retrospective nature and the nonstandardization of both the groups. Although the groups were comparable in preoperative diagnosis and ASA score, there is a selection bias inherent to the study design. Although we tried to eliminate the difference in the learning curve by comparing junior residents performing laparoscopic cholecystectomy with senior residents performing robotic cholecystectomies, there is no mathematical way to definitely characterize both the groups so as to determine if this effectively resulted in equal learning curves for them. Another limitation is the small sample size. Larger sample sizes may have resulted in a similar LOS, given the trend toward significance in the number of patients undergoing laparoscopic cholecystectomy for acute cholecystitis.
CONCLUSION Robotic training in general surgery residency is feasible and safe. It does not amount to extra OR time when compared with standard laparoscopic approaches performed by junior residents. LOS was no longer in the robotic group than in the standard laparoscopic group, and there were no complications in this group. Our study supports the notion that robotic training in general surgery residency is feasible and results in similar operative times and outcomes as with the standard laparoscopic approach. As more robotic cases are performed and the learning curve becomes less, operative times will continue to decrease.
REFERENCES 1. Breitenstein S, Nocito A, Puhan M, Held U, Weber M,
Clavien P. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a casematched control study. Ann Surg. 2008;247 (6):987-993.
Journal of Surgical Education Volume 72/Number 3 May/June 2015
379
2. Morino M, Pellegrino L, Giaccone C, Garrone C,
Rebecchi F. Randomized clinical trial of roboticassisted versus laparoscopic nissen fundoplication. Br J Surg. 2006;93(5):553-558. 3. Melvin WS, Needleman BJ, Krause KR, Schneider C,
Ellison EC. Computer-enhanced vs. standard laparoscopic antireflux surgery. J Gastrointest Surg. 2002;6(1): 11-16. 4. Muhlmann G, Klaus A, Kirchmayr W, et al. DaVinci
robotic-assisted laparoscopic bariatric surgery: is it
380
justified in a routine setting? Obes Surg. 2003;13(6): 848-854. 5. Nio D, Bemelman WA, Busch OR, Vrouenraets BC,
Gouma DJ. Robotic-assisted laparoscopic cholecystectomy vs conventional laparoscopic cholecystectomy. Surg Endosc. 2004;18(3):379-382. 6. Delaney CP, Lynch AC, Senagore AJ, Fazio VW. Compar-
ison of robotically performed and traditional laparoscopic colorectal surgery. Dis Colon Rectum. 2003;46(12): 1633-1639.
Journal of Surgical Education Volume 72/Number 3 May/June 2015
Can Robotic Surgery be Done Efficiently While Training Residents? Michael Drew Honaker, MD, Beverly L. Paton, MD, Dimitrios Stefanidis, PhD, and Lynnette M. Schiffern, MD Carolinas Medical Center, Charlotte, North Carolina INTRODUCTION: Robotic surgery is a rapidly growing
KEY WORDS: robotic surgery, training, general surgery,
area in surgery. In an era of emphasis on cost reduction, the question becomes how do you train residents in robotic surgery? The aim of this study was to determine if there was a difference in operative time and complications when comparing general surgery residents learning robotic cholecystectomies to those learning standard laparoscopic cholecystectomies.
outcomes
METHODS: A retrospective analysis of adult patients
undergoing robotic and laparoscopic cholecystectomy by surgical residents between March 2013 and February 2014 was conducted. Demographic data, operative factors, length of stay (LOS), and complications were examined. Univariate and multivariate analyses were performed. The significance was set at p o 0.05. RESULTS: A total of 58 patients were included in the study (18 in the robotic cholecystectomy group and 40 in the laparoscopic group). Age, diagnosis, and American Society of Anesthesiologists score were not significantly different between groups. There was only 1 complication in the standard laparoscopic group in which a patient had to be taken back to surgery because of an incarcerated port site. LOS was significantly higher in the standard laparoscopic group (mean ¼ 2.28) than in the robotic group (mean ¼ 0.56; p o 0.0001). Operating room (OR) time was not statistically different between the standard laparoscopic group (mean ¼ 90.98 minutes) and the robotic group (mean ¼ 97.00 minutes; p ¼ 0.4455). When intraoperative cholangiogram was evaluated, OR time was shorter in the robotic group. CONCLUSION: Robotic training in general surgery residency does not amount to extra OR time. LOS in our study was significantly longer in the standard laparoscopic group. C 2015 Association of Program ( J Surg 72:377-380. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.) Correspondence: Inquiries to Drew Honaker, MD, 10223 Hugue Way, Charlotte, NC 28214; e-mail: [email protected]
COMPETENCIES: Practiced-Based Learning and Improve-
ment, Medical Knowledge, Systems-Based Practice
INTRODUCTION Although robotic surgery continues to evolve and become more sophisticated, conferring the advantages of a 3-dimensional view, magnification, tremor suppression, and increased degrees of movement of instruments resulting in more precise movements, its place in the general surgery residency curriculum is controversial.1,2 Arguments of extended operative times and increased costs and charges are among the most frequently cited criticisms of this educational focus.2-4 The essential question facing teaching institutions is how to balance operating room (OR) time and cost with adequate training of general surgery residents in robotic surgery. As multiple studies have demonstrated that operative time and costs increase when using a robotic system,3,5,6 this study set out to evaluate and compare operative times, length of stay (LOS), and complications of robotic surgery and compare them with standard laparoscopic approaches. We hypothesized that operative times, complications, and LOS would be similar when comparing robotic operations with standard laparoscopic operations in general surgery residency training.
METHODS Following institutional review board approval, a search using procedural codes was conducted to identify 2 groups of patients seen at Carolinas Medical Center (CMC) between March 2013 and February 2014: those undergoing robotic cholecystectomies performed by senior-level residents and those undergoing standard laparoscopic cholecystectomies performed by junior residents. These 2 groups were chosen to establish relative parity between learning curves. Because robotic cholecystectomies are performed by
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.008
377
senior-level residents who have had prior experience with laparoscopic approaches but are new to robotic surgery, they represent a learning curve that we deem equivalent to that of to junior-level residents performing laparoscopic cholecystectomies with little or no exposure or experience in them. (Interns were excluded from the study because their exaggerated learning curve would skew operative times in the standard laparoscopic group.) Procedures conducted by attending physicians with resident assistance were excluded, as were patients who underwent endoscopic retrograde cholangiopancreatography as their LOS would not be directly related to their surgery. The use of intraoperative cholangiogram (IOC) was evaluated at the discretion of the operating attending physician. All robotic and laparoscopic cholecystectomies were performed using a multiport approach. All attending physicians involved in robotic training were certified proctors completing the necessary requirements to perform and teach robotic procedures. For robotic cases, our institution does not have a dual console; therefore, if the attending physician performed part of the case for teaching purposes, these patients were included in the study. This was also done for patients in the laparoscopic group as well. However, cases where most of the procedure was done by the attending physician were excluded from the study. Operative times were measured from the time of initial skin incision to the time that dressings were placed, as this was the most consistently recorded time. Time to dock and undock the robot was also included in the operative time calculations. The robotic and the laparoscopic groups were compared with respect to operative time, length of hospital stay, and complications, both intraoperatively and postoperatively. (Operative time was defined by time of incision to time of dressing placed.) Descriptive statistics, including means, standard deviations, counts, and percentages, were calculated. Total OR time and LOS for the 2 cholecystectomy groups (robotic and standard laparoscopic) were compared using the Student t test and the Wilcoxon rank-sum (WRS) test, respectively. (The WRS test was employed because LOS was not normally distributed.) Additional factors compared were sex, IOC, and preoperative diagnosis using the Fisher exact test, age using the Student t test, and American
Society of Anesthesiologists (ASA) score using the WRS test. SAS Enterprise Guide 5.1 was used for all analyses, and a 2-tailed p value of less than 0.05 was considered statistically significant.
RESULTS The first robotic cholecystectomy performed by general surgery residents at CMC was in March 2013. After a search was conducted using operative codes for robotic and laparoscopic cholecystectomy, 58 patients were identified who underwent cholecystectomies at CMC between March 2013 and February 2014 by senior or junior residents. Senior residents were defined as those in their final year of clinic training and junior residents were defined as those in the second and third years of clinic training. Among the 58 patients, 18 underwent robotic cholecystectomy by seniorlevel residents and 40 underwent laparoscopic cholecystectomy by junior-level residents. Patient demographics were not statistically different between both the groups (p 4 0.05; Table 1): in the robotic cholecystectomy group, there were 14 women and 4 men (77.8% vs 22.2%), and in the standard laparoscopic group, there were 29 women and 11 men (72.5% vs 27.5%). The average age of patients in the robotic group was 41 years ( ⫾16.8) and in the standard laparoscopic group was 43.6 (⫾15.1). IOC was carried out in 4 patients in the robotic group (27.5%) and 8 patients in the standard laparoscopic group (20%). Comparison of indications for cholecystectomy revealed that 15 of 18 (83.3%) patients in the robotic group and 29 of 40 (72.5%) patients in the standard laparoscopic group underwent the procedure for symptomatic cholelithiasis. Overall, 1 patient in the robotic group and 10 patients in the standard laparoscopic group underwent cholecystectomy for acute cholecystitis, and 1 patient in each group underwent cholecystectomy for gallstone pancreatitis. There was no statistically significant difference between the 2 groups (p ¼ 0.0831) with respect to indication for cholecystectomy, nor were any intraoperative complications identified in either group. Postoperatively, there were no complications in the robotic group, but one complication
TABLE 1. Patient Demographics Mean age (y) Mean ASA Sex (n) Preoperative diagnosis (n) IOC performed (n)
Robotic Group
Laparoscopic Group
p Value
41 2 M¼4 F ¼ 14 Symptomatic cholelithiasis ¼ 15 Acute cholecystitis ¼ 1 Other ¼ 2 Y¼4 N ¼ 14
43.6 2.25 M ¼ 11 F ¼ 29 Symptomatic cholelithiasis ¼ 28 Acute cholecystitis ¼ 10 Other ¼ 2 Y¼8 N ¼ 32
0.5558 0.0869 0.7559 0.0831 0.0831 1.0000
M, male; F, female; Y, yes; N, no. 378
Journal of Surgical Education Volume 72/Number 3 May/June 2015
TABLE 2. Outcomes Outcome Operative time (min) Complications (n) Length of stay (d) Operative time with IOC (min)
Robotic Group
Laparoscopic Group
p Value
97 0 0.56 110.3
91 1 2.28 112.9
0.4455 1.0000 o0.0001
was seen in the standard laparoscopic group: this patient developed an incarcerated port hernia at his umbilical incision and had to be taken back to the OR on postoperative day 3 for repair. The overall health of the 2 groups was evaluated using the ASA score. The robotic group had a mean ASA of 2, whereas the standard laparoscopic group had a mean ASA of 2.25, suggesting a trend toward a higher ASA in the standard laparoscopic group; however, this score did not achieve statistical significance (p ¼ 0.0849). The mean operative time was 97 minutes in the robotic group and 91 minutes in the standard laparoscopic group, a difference that did not achieve statistical significance (p ¼ 0.4455). The mean operative time in which an intraoperative cholangiogram was performed was shorter for the robotic group than for the laparoscopic group by 2.6 minutes (110.3 vs 112.9 minutes). LOS was significantly shorter in the robotic group (p r 0.0001), with the average LOS being less than 1 day (Table 2).
DISCUSSION In a profession that is increasingly sensitive to cost, surgical training programs have to find a balance between saving time and money and appropriately training residents. Robotic surgery is still finding its place in general surgery with an increasing number and variety of cases being performed. The aim of our study was to evaluate the operative time and complication rate in training general surgery residents in robotic surgery and to compare these statistics with those associated with training in standard laparoscopic procedures. Our hypothesis that OR time, LOS, and complications were not different between both the groups was proven by our results. LOS was significantly shorter in the robotic arm; however, this may be owing to attending physician preference of observation overnight vs discharge from post operative care unit. Another possibility is that, although the indications for cholecystectomy were not significantly different between the 2 groups (p ¼ 0.0831), there was a trend toward significance, with more patients undergoing laparoscopic cholecystectomy for acute cholecystitis. This could contribute to the significant difference in LOS observed between both the groups. The choice to use cholecystectomies was based on the fact that most general surgery residents initially learn laparoscopy doing cholecystectomies, and this holds true for learning robotic surgery as well. Some argue that robotic
cholecystectomies result in unacceptable increases in both time and cost. We argue that the same could be said about junior residents learning laparoscopic cholecystectomies, as a senior resident or attending surgeon can do a laparoscopic cholecystectomy in much less time than an intern or junior resident. If we insist on choosing the least time- and resourceintensive option, then we must ask the obvious question, “How will we train surgeons?” The limitations of this study include its retrospective nature and the nonstandardization of both the groups. Although the groups were comparable in preoperative diagnosis and ASA score, there is a selection bias inherent to the study design. Although we tried to eliminate the difference in the learning curve by comparing junior residents performing laparoscopic cholecystectomy with senior residents performing robotic cholecystectomies, there is no mathematical way to definitely characterize both the groups so as to determine if this effectively resulted in equal learning curves for them. Another limitation is the small sample size. Larger sample sizes may have resulted in a similar LOS, given the trend toward significance in the number of patients undergoing laparoscopic cholecystectomy for acute cholecystitis.
CONCLUSION Robotic training in general surgery residency is feasible and safe. It does not amount to extra OR time when compared with standard laparoscopic approaches performed by junior residents. LOS was no longer in the robotic group than in the standard laparoscopic group, and there were no complications in this group. Our study supports the notion that robotic training in general surgery residency is feasible and results in similar operative times and outcomes as with the standard laparoscopic approach. As more robotic cases are performed and the learning curve becomes less, operative times will continue to decrease.
REFERENCES 1. Breitenstein S, Nocito A, Puhan M, Held U, Weber M,
Clavien P. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a casematched control study. Ann Surg. 2008;247 (6):987-993.
Journal of Surgical Education Volume 72/Number 3 May/June 2015
379
2. Morino M, Pellegrino L, Giaccone C, Garrone C,
Rebecchi F. Randomized clinical trial of roboticassisted versus laparoscopic nissen fundoplication. Br J Surg. 2006;93(5):553-558. 3. Melvin WS, Needleman BJ, Krause KR, Schneider C,
Ellison EC. Computer-enhanced vs. standard laparoscopic antireflux surgery. J Gastrointest Surg. 2002;6(1): 11-16. 4. Muhlmann G, Klaus A, Kirchmayr W, et al. DaVinci
robotic-assisted laparoscopic bariatric surgery: is it
380
justified in a routine setting? Obes Surg. 2003;13(6): 848-854. 5. Nio D, Bemelman WA, Busch OR, Vrouenraets BC,
Gouma DJ. Robotic-assisted laparoscopic cholecystectomy vs conventional laparoscopic cholecystectomy. Surg Endosc. 2004;18(3):379-382. 6. Delaney CP, Lynch AC, Senagore AJ, Fazio VW. Compar-
ison of robotically performed and traditional laparoscopic colorectal surgery. Dis Colon Rectum. 2003;46(12): 1633-1639.
Journal of Surgical Education Volume 72/Number 3 May/June 2015
