Introduction

The importance of non-technical skills (NTS) for safe, effective surgery is being increasingly recognised. Yet surgical training remains focussed on technical proficiency. Given the unique challenges of robotic surgery with the surgeon distanced from the immediate operating field, effective NTS training is vital._x000D_ _x000D_ This study aimed to develop and validate Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS), the first NTS assessment tool specifically for robotic surgery.

Methods

An initial framework for NTS assessment was developed through observation of robotic surgery, identifying relevant behaviours and skills. A draft assessment tool comprising all identified skills and behaviours was circulated amongst an international panel of 16 expert surgeons. A delphi methodology was used to refine the assessment checklist and provide content validation until a saturation of new information was achieved. _x000D_ _x000D_ The resultant ICARS tool was validated against the performances of 75 of novice, intermediate and expert robotic surgeons who completed simulated tasks within a distributed operating room environment using the da Vinci Xi surgical robot. During the assessment, participants were taken through 3 clinical scenarios to test NTS. NTS performance was assessed post hoc by 6 expert surgeons using ICARS and the gold standard NOTSS tool.

Results

Following expert consultation, ICARS was refined from 45 to 28 key components divided into 7 categories and 4 domains . ICARS was highly rated by the expert panel with strong support of face and content validation. 86% felt ICARS was appropriate tool for robotic surgery, 77% thought ICARS was relevant to robotic surgery and 74% felt it would be very beneficial robotic training. Significant differences were seen in scores of novice, intermediate and expert subjects. Bland-Altman plot showed a strong correlation with NOTSS. ICARS also showed robust inter-rater reliability with a mean interclass correlation coefficient of 0.81. Strong internal consistency was demonstrated for all principle domains of the rating system with a mean Cronbach Alpha 0.90 (range 0.83-0.93).

Conclusions

We have developed the first NTS assessment tool for robotic surgery. Comprehensive validation of ICARS has demonstrated equivalence to the current gold standard, generic assessment tool, extensive internal structure reliability and a high degree of acceptance by expert robotic surgeons. Structured NTS training needs to be integrated within the robotic curriculum and ICARS has been demonstrated to be a valid tool with which this can be supported.

Funding

Vattikuti Foundation