This study utilized an anonymous online survey of colorectal fellowship graduates to assess their experience with the APDCRS-sponsored standardized robotic colorectal surgery curriculum. The majority of survey respondents indicated that the curriculum successfully met their expectations and prepared them for post-graduate robotic colorectal surgery. Most were also able to achieve an Equivalency Certificate that allows them to begin their post-fellowship career certified to perform robotic surgery.

The proportion of graduates who reported they were able to complete more than 20 robotic cases during fellowship increased over time. This trend parallels the national increase in robotic general surgery cases observed during general surgery residency training [6]. This may reflect growing interest in the robotic approach to colorectal surgery, increased adoption by colorectal surgery faculty mentors, and favorable evidence-based patient outcomes with the robotic approach, especially lower conversion-to-open rates [7, 8]. In addition, the introduction of the da Vinci Xi surgical system with multi-quadrant access likely increased adoption of the robotic approach by general and colorectal surgeons who train residentsFootnote 1 and fellows, increased the growth in number and quality of publications showing favorable clinical outcomes, and pushed faculty early adopters further along their learning curve [4, 9].

The development of standardized robotic training curriculum has increased in recent years and taken on various approaches [10,11,12,13,14]. A robotic curriculum for novice residents in training was implemented in a German university hospital in 2020 with outcome measures that included surgical competency, nontechnical skills, progression, organizational, and patient aspects. The authors found that this curriculum met the needs of young surgeons in training [10]. Another university hospital reported on the development of a formal institutional thoracic surgery curriculum characterized by simulation, video review, and coaching. These authors suggested that their curriculum has expedited surgical training at their institution leading to more advanced robotic thoracic surgery skill sets prior to fellowship graduation [11]. In contrast to these valuable intuitional training programs, our APDCRS-sponsored colorectal surgery robotic training program was designed to offer national standardized training relevant for all colorectal surgery fellowship programs that are currently 73 in number.

We observed a shift toward higher proportion of robotic equivalency certificates awarded to trainees during general surgery residency in more recent years. Those fellows with higher general surgery robotic experience tended to perform more robotic cases during their fellowship year [14]. This may represent a bidirectional self-selection of interested residents and high-volume programs as a mutual fit of individuals with an interest and aptitude for robotic surgery. It also indicates that less basic and more advanced robotic training during fellowship is needed for many fellows who can build on their general surgery residency training experience.

Those fellows who reported high robotic experience in fellowship also reported high robotic volume in practice after graduation. This may reflect self-selection of those who have an interest in robotic colorectal surgery. It further demonstrates the national trend of increasing institutional access to the robotic platform that enables higher volumes by robotic surgeons and increased adoption by surgeons interested in the robotic approach. Numerous studies have shown that higher volumes in a surgical approach result in more favorable clinical outcomes [15, 16].

This APDCRS curriculum has demonstrated the ability to enhance exposure to robotic colorectal training in fellowship while preparing fellows for the transition into independent practice. However, there remain opportunities to continue guiding future improvements and course modifications based on fellow feedback. The respondents identified the desire for exposure to several other skills and techniques during fellowship year. This feedback has been incorporated into the next iteration of the curriculum to include the robotic approach to ventral mesh rectopexy and lateral pelvic lymph node dissection, beginning in 2024. Furthermore, recent changes in accreditation policies, such as the separate logging of laparoscopic and robotic cases by both the Fellowship Council accrediting body for non-ACGME surgical specialties and the ACGME-accredited colorectal specialty, signify the evolving recognition of the role of robotics in resident and fellow education. These changes aim to provide trainees with more comprehensive surgical skillsets and experience as they transition into independent practice.

Trainees have requested more robotic experience during training years and there are several factors that make adoption of robotics during residency and fellowship years an attractive option rather than waiting until practice as an attending surgeon [17]. The process of training as an attending surgeon requires significant time and resource investment that includes traveling to a robotic training course, pursuing independent simulation training, and completing hands-on skills development. Executing this process efficiently can be challenging, particularly for a young surgeon transitioning into independent practice. In addition, when adopting robotics as an attending surgeon, much of the learning curve is experienced independently rather than under the supervision of an expert. A previous survey study showed that CRS residents largely valued mentorship and learning from expert faculty more so than rapid development of autonomy [17]. These are significant influencers of the robotic learning curve that highlight the importance and value of a society-sponsored standardized robotics fellowship curriculum.

Our study is limited by small sample size and by recall bias of respondents. Due to travel restrictions and constraints created by COVID-19, the 2020 fellowship course was unable to be implemented in its entirety. We elected to omit the 2020 cohort from our primary analysis because of the impact of COVID on trainee experience. An additional potential study limitation is the variation in robotic curriculum and variation in opportunities experienced by colorectal fellows during their general surgery residency with some general surgery residents starting colorectal fellowship with no robotic experience [1]. With the expansion of 4th generation robotic systems, the accessibility to robotic surgery increased throughout the study period and this may have contributed to increased numbers of cases for those in the later study years, Colorectal fellows graduate and move on to varied university and non-university practice settings and this may also impact the number of cases performed beyond course training.

Operative skills and surgical decision training extend beyond preparation for and participation in an in-person laboratory. Our current curriculum depends on the fellow gaining post-course systematic progressive experience at their training institution and continued development after completing fellowship training. Continued evaluation and supplemental additions to the training paradigm will be imperative for further effective skill set development following fellowship training. In-person and remote monitored simulation, post-case video review, mentorship, and surgical coaching are examples of post-course training options implemented by thoracic surgery that warrant evaluation by colorectal surgery and other disciplines [11]. Surgical educational applications that include virtual case and topic presentations and expertly performed case videos are valuable additions to robotic education. We currently use SurgeOn®, an application that includes a colorectal surgery community equipped with video review and case presentations, to provide mandatory virtual APDCRS-sponsored course preparation prior to attending the procedure-specific in-person lab course component. Data capturing methods built into the robotic system may soon add to skill assessment and require formal evaluation for educational value. Should artificial intelligence gain clinical application in robotic surgery, the future role in resident and fellowship training will likely warrant assessment [13, 14].