We experienced several challenges in our introduction of robot-assisted surgery for rectal cancer during the COVID-19 pandemic. From this experience, we identified three issues that should be improved upon for successful introduction of robot-assisted surgery in Japan: difficulties in obtaining certification in robot-assisted surgery, difficulties in conducting case observations at other facilities, and difficulties in inviting certified proctors from other facilities.
In Japan, surgeons receive a certificate after undergoing training courses provided by robotic equipment companies in accordance with the JSES guidelines. The training course to obtain the certificate of robot-assisted surgery requires the completion of online training, on-site training using an actual robot system, case observation of actual robot-assisted surgery at another facility, and basic training using actual robot equipment in animals. To obtain a certificate for Intuitive Surgical’s da Vinci robot system, which is the most frequently used robot system worldwide, there is a waiting period of 3 to 6 months for reservations to undergo basic training using animals in Japan. During the height of the COVID-19 pandemic, reservation slots were reduced and the number of participants per training session was limited. To efficiently obtain certificates under these circumstances, the number of training facilities in Japan should be increased and a system that would allow certificates to be obtained overseas should be established.
COVID-19 spread not only to patients but also to healthcare workers [12]. To prevent further spread of infection, medical institutions placed restrictions on pharmaceutical companies and medical device manufacturers. As a result, tours of operating rooms at other facilities were restricted, and the number of facilities accepting case observations, which are mandatory before introducing robotic surgery, decreased. However, the COVID-19 pandemic has fostered the advancement of online medical consultations and conferences for the purpose of preventing infection [13]. To improve this situation, a different form of case observation should be constructed. For example, it is possible to introduce remote live surgical observation using recently developed imaging systems and simulated surgical observation using virtual reality [14]. In a comparative study of training methods for robotic surgery, virtual reality was found to be more effective than e-learning; therefore, the introduction of a virtual reality system should also be considered [15]. Moreover, such training methods have the advantage of reducing the time and costs associated with on-demand observation and viewing from a distance, along with improving infection control measures [16].
The JSES guidelines state that to introduce robot-assisted surgery as an independent team, the team must include a member with JSES technical certification, performance of at least one case of robot-assisted endoscopic surgery at another facility for the relevant procedure, and performance of one case under the guidance of a JSES-certified proctor. During the COVID-19 pandemic, however, it was difficult to invite the proctor because his movement to other medical institutions was restricted. No other proctors were available nearby, so a proctor located approximately 1,160 km away from our hospital was invited. Although the number of JSES-certified proctors is increasing, an optimal method for inviting and making reservations for proctors has not been established. A system that can be easily adapted to facilities that newly introduce robotic surgery is needed. A remote surgery guideline was recently established in Japan. The purpose of this guideline is to set appropriate standards for leading physicians to utilize information and communication technology for providing support and guidance for surgeries performed at various medical institutions. This includes telementoring and telesurgical support, which may enable remote proctor guidance in robotic surgery.
Since COVID-19 was classified as a common infectious disease in Japan, various restrictions in the medical industry have been eased. As a result, the number of robot-assisted surgeries is expected to increase further. Additionally, new models of robots have been developed and are beginning to appear on the market. Although the process of obtaining a da Vinci system certificate is the same worldwide, the systems used to introduce robotic surgery differ between Japan and other countries [17]. Standards for introducing robotic surgery should be created according to the medical circumstances of each country, and a system for introducing robotic surgery through training in other countries should be devised.
In conclusion, it is expected that medical situations similar to COVID-19 will continue to arise in future with the spread of unknown infectious diseases. Even in such situations, it is necessary to create a system that allows for the simple and smooth introduction of robot-assisted surgery in Japan.