Measurement of trainee autonomy in robotic-assisted lung resections using objective performance indicators

Trainee autonomy in robotic-assisted thoracic surgery is critical for growth but difficult to quantify. Robotic platforms can log intraoperative kinematic and event data that can be transformed into metrics known as objective performance indicators (OPIs). This study sought to use OPIs obtained during robotic-assisted anatomic lung resections to assess trainee console autonomy at a high-volume robotic center. OPI data were obtained from 59 lobectomies and segmentectomies performed on a multi-port robotic platform between March 2022 and May 2023. Cases were divided into anatomic steps and annotated by a team of verified video reviewers. Console autonomy was assessed based on average path length (PL) of controllers and active time (AT) on the trainee console as a ratio compared to the overall PL and AT of the operation. Cases included 51 (86%) lobectomies and 8 (13%) segmentectomies. Average overall PL ratio was 0.15 (SD 0.17) and overall AT ratio was 0.23 (SD 0.23) for senior trainees. Autonomy was highest for inferior pulmonary ligament division (PL ratio = 0.39, AT ratio = 0.42) while lowest with pulmonary artery dissection (PL ratio = 0.10, AT ratio = 0.14). There was a significant association between AT and PL ratio with estimated blood loss (PL p = 0.036, AT p = 0.047). AT and PL ratios can provide objective surrogates of autonomy in thoracic surgery and can be stratified by individual case components. OPIs will offer valuable metrics for surgical education and assessment as national accrediting bodies shift graduation requirements towards case component proficiency over volume.