It seems there may be some documentation missing regarding the credentialing process. What's included shows "Step I" which concludes with stating the surgeon must operate under continuous proctoring. It then skips to a description of the requirements for proctors. What appears to be omitted are the steps that would lead to a surgeon operating independently (without which no surgeon would ever qualify as a proctor). Presumably there is a missing Step II or even more.
Good eye! The second page that included Step II got lost in the shuffle when I was uploading the documents. I edited the post and it is available above. Basically adds that once the surgeon has had 4 cases proctored, they can get independent privileges. Still seems a pretty low bar.
Credentialing for robotic surgery is extremely lax and really just a formality. It is treated as a tool that the surgeon ultimately takes responsibility for. The "8 hours" are typically an online certification course with the robot manufacturer. It is assumed however that you are not using a tool unless you are trained in it, which almost all urologists heavily use the robot in training now. My current hospital credentialing requested prior robotic case numbers in addition to the 8 hour course certificate, but I don't know that they had a minimum case load.
Unclear what this urologist's robotic surgery training was back in 2016. I agree with your review about the generic statement from the expert witness saying this was a bad outcome. I have seen very talented urologists perform successful robotic surgeries on patients who have complex abdominal surgical histories, so that is not a contraindication alone.
Thanks for the comment! Interesting that most hospitals seem relatively lax on credentialing for these cases. I think the plaintiff was trying to argue that the hospital was negligent because they didn't require more. I wonder if we will slowly see the bar raised for proving competence with robotic cases.
We’ll see! Logically it wouldn’t make much sense but you never know how rules change due to legal issues. The risks to the robot are very similar to laparoscopic surgery (port placement being one of the biggest risk factors and then adhesion takedown like in this case) in general and I would argue the robot is much safer than pure laparoscopic surgery for the rest of the procedure due to the better visibility and controlled movements it provides. This case could very well have been worse with a pure lap approach (though not done anymore for prostatectomy bc this approach sucks so much). It wouldn’t make sense to me to have a more rigorous standard for robotics vs general laparoscopic surgery but lawyers may have their own reasons.
I can think of a highly respected urologist who would say this case should be done open if a patient has a complex surgical history. I can also think of several highly respected urologists that would do this robotic and have it go great. Interesting view into the tribulations with “expert witnesses”. Was the defense not able to call their own expert?
The other interesting thing is that open prostatectomies are no longer considered the standard of care and haven’t been for a while. It’s difficult to even find urologists confident in performing them nowadays because it’s so uncommon. I personally don’t do them and only assisted in 2 open prostates in training.
Hard to know without being there but adhesion takedown with small bowel injury is a fairly commonly discussed risk in abdominal surgery. Tough situation for everyone involved compounded by the fact that you need to operate on anywhere from 6-15 patients with prostate cancer to save one life…so this patient likely would not have benefitted from the surgery to begin with. Another reason why stakes are so high on prostate cancer surgery, most patients get the operation because they are healthy with lots of life left to protect and many of these patients won’t benefit from the surgery according to the data. So any complication like this is devastating. Tough all around.
Tough case especially in light of the NNT to save a life. The defense has not disclosed an expert yet. They usually consult an expert privately but don't bother to disclose their opinion unless they're going to trial. If they're working on a settlement it usually stays confidential. I'll update if they disclose one!
It seems there may be some documentation missing regarding the credentialing process. What's included shows "Step I" which concludes with stating the surgeon must operate under continuous proctoring. It then skips to a description of the requirements for proctors. What appears to be omitted are the steps that would lead to a surgeon operating independently (without which no surgeon would ever qualify as a proctor). Presumably there is a missing Step II or even more.
Good eye! The second page that included Step II got lost in the shuffle when I was uploading the documents. I edited the post and it is available above. Basically adds that once the surgeon has had 4 cases proctored, they can get independent privileges. Still seems a pretty low bar.
Credentialing for robotic surgery is extremely lax and really just a formality. It is treated as a tool that the surgeon ultimately takes responsibility for. The "8 hours" are typically an online certification course with the robot manufacturer. It is assumed however that you are not using a tool unless you are trained in it, which almost all urologists heavily use the robot in training now. My current hospital credentialing requested prior robotic case numbers in addition to the 8 hour course certificate, but I don't know that they had a minimum case load.
Unclear what this urologist's robotic surgery training was back in 2016. I agree with your review about the generic statement from the expert witness saying this was a bad outcome. I have seen very talented urologists perform successful robotic surgeries on patients who have complex abdominal surgical histories, so that is not a contraindication alone.
Thanks for the comment! Interesting that most hospitals seem relatively lax on credentialing for these cases. I think the plaintiff was trying to argue that the hospital was negligent because they didn't require more. I wonder if we will slowly see the bar raised for proving competence with robotic cases.
We’ll see! Logically it wouldn’t make much sense but you never know how rules change due to legal issues. The risks to the robot are very similar to laparoscopic surgery (port placement being one of the biggest risk factors and then adhesion takedown like in this case) in general and I would argue the robot is much safer than pure laparoscopic surgery for the rest of the procedure due to the better visibility and controlled movements it provides. This case could very well have been worse with a pure lap approach (though not done anymore for prostatectomy bc this approach sucks so much). It wouldn’t make sense to me to have a more rigorous standard for robotics vs general laparoscopic surgery but lawyers may have their own reasons.
I can think of a highly respected urologist who would say this case should be done open if a patient has a complex surgical history. I can also think of several highly respected urologists that would do this robotic and have it go great. Interesting view into the tribulations with “expert witnesses”. Was the defense not able to call their own expert?
The other interesting thing is that open prostatectomies are no longer considered the standard of care and haven’t been for a while. It’s difficult to even find urologists confident in performing them nowadays because it’s so uncommon. I personally don’t do them and only assisted in 2 open prostates in training.
Hard to know without being there but adhesion takedown with small bowel injury is a fairly commonly discussed risk in abdominal surgery. Tough situation for everyone involved compounded by the fact that you need to operate on anywhere from 6-15 patients with prostate cancer to save one life…so this patient likely would not have benefitted from the surgery to begin with. Another reason why stakes are so high on prostate cancer surgery, most patients get the operation because they are healthy with lots of life left to protect and many of these patients won’t benefit from the surgery according to the data. So any complication like this is devastating. Tough all around.
Tough case especially in light of the NNT to save a life. The defense has not disclosed an expert yet. They usually consult an expert privately but don't bother to disclose their opinion unless they're going to trial. If they're working on a settlement it usually stays confidential. I'll update if they disclose one!