Navigating the Pathway to Robotic Competency in General Thoracic Surgery Christopher W. Seder, MD, Stephen D. Cassivi, MD, and Dennis A. Wigle, MD, PhD Objective: Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Methods: Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or di- aphragmatic procedures were performed. Data on patient character- istics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. Results: The robot-assisted procedures performed included lung re- section (n = 38), mediastinal mass resection (n = 19), hiatal or para- esophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thora- coscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Conclusions: Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway. Key Words: Robotics, Education, General thoracic surgery, Minimally invasive surgery. (Innovations 2013;8:184Y189) T he era of minimally invasive surgery began with the in- troduction of laparoscopic cholecystectomy in the early 1990s. 1 Minimally invasive approaches have since been ap- plied in nearly every surgical subspecialty, including thoracic surgery. Multiple studies have demonstrated reduced postop- erative pain, shorter hospital stay, and earlier return to function with videoscopic approaches when compared with open sur- gery. 2Y5 However, limitations of conventional laparoscopic and thoracoscopic instrumentation have restricted the adoption of many complex minimally invasive thoracic procedures. Ro- botic technology has addressed some of these limitations by improving visualization, maneuverability, and range of motion. The lure of such benefits has prompted many thoracic surgeons to consider incorporating robotic surgery into their practices. However, a distinct learning curve is required to become proficient in robotic surgery. Although most studies suggest that 20 to 50 cases are necessary to gain proficiency with ad- vanced robot-assisted procedures, 6Y8 absolute case numbers do not reflect the density of cases, surgeon skill, previous lapa- roscopic experience, or practice environment. Alternatively, a competency-based approach ensures that skills are acquired in a stepwise fashion, potentially facilitating the ability to safely perform robot-assisted surgery. We report our initial robotic thoracic surgery experience while implementing a structured, competency-based protocol for skill acquisition and discuss the elements necessary to establish a successful robotic surgery program. METHODS After institutional review board approval was obtained (January 10, 2011), we retrospectively collected data on all patients who underwent robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures at our insti- tution between December 1, 2008, and February 29, 2012. The patients were identified by querying a prospectively maintained general thoracic surgery divisional database. The exclusion cri- teria included younger than 18 years or robot-assisted surgery for malignant esophageal disease. Near the end of the study period, thoracic esophageal mobilization for esophageal ma- lignancy was performed robotically at our institution. However, because most of these cases were performed in an open man- ner, it was not deemed appropriate to report as part of an ini- tial robotic experience. The patient variables examined included the procedure performed, date of surgery, operative time, es- timated blood loss, reason for conversion to open or traditional videoscopic approach, chest tube duration, hospital length of stay, perioperative complications, 30-day readmission, and 90-day mortality. Major complications were defined as those requiring intensive care unit admission or reoperation or intra- operative injury leading to massive hemorrhage or extratho- racic exploration. Patient outcomes were compared between the ‘‘early’’ (initial 39 cases) and ‘‘late’’ (next 40 cases) ORIGINAL ARTICLE 184 Innovations & Volume 8, Number 3, May/June 2013 Accepted for publication March 30, 2013. From the Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN USA. Disclosure: The authors declare no conflict of interest. Address correspondence and reprint requests to Dennis A. Wigle, MD, PhD, Mayo Clinic, 200 First St, SW, Rochester, MN 55905 USA. E-mail: wigle.dennis@mayo.edu. Copyright * 2013 by the International Society for Minimally Invasive Car- diothoracic Surgery ISSN: 1556-9845/13/0803-0184 Copyright © 2013 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.