European expert consensus on a structured approach to training robotic-assisted low anterior resection using performance metrics.
AIM: To develop and operationally define 'performance metrics' that characterise a reference approach to robotic-assisted low anterior resection (RA-LAR), and to obtain face and content validity through a consensus meeting. METHOD: Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers' instructions and unedited videos of RA-LAR to deconstruct the operation into defined, measurable components – performance metrics (i.e., procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified-Delphi process. RESULTS: Performance metrics for RA-LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in females, 88 errors and 118 critical errors in males. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in females, 87 errors and 116 critical errors in males. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from Phase I (patient positioning and preparation, 83%) and Phase IV (docking, 94%). CONCLUSION: A robotic rectal operation can be broken down to procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardised procedural assessment for RA-LAR. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: The present study is the first to describe a structured approach to develop performance metrics for training in robotic-assisted low anterior resection for rectal cancer.