title: The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula.
abstract: BACKGROUND
  There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes.
  
  
  OBJECTIVE
  To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events.
  
  
  METHODS
  From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training.
  
  
  RESULTS
  The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations.
  
  
  CONCLUSIONS
  In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Fabio
authors.initials: F
authors.lastname: Zattoni
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Andrea
authors.initials: A
authors.lastname: Guttilla
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Alessandro
authors.initials: A
authors.lastname: Crestani
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Alberto
authors.initials: A
authors.lastname: De Gobbi
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Francesco
authors.initials: F
authors.lastname: Cattaneo
authors.affiliation: 2 Department of Urology, Urological Research Institute, Vita-Salute University , San Raffaele Scientific Institute, Milan, Italy .
authors.forename: Marco
authors.initials: M
authors.lastname: Moschini
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Fabio
authors.initials: F
authors.lastname: Vianello
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Claudio
authors.initials: C
authors.lastname: Valotto
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Dal Moro
authors.affiliation: 1 Department of Urology, University of Padua , Padua, Italy .
authors.forename: Filiberto
authors.initials: F
authors.lastname: Zattoni
mesh_terms: D061887:Conversion to Open Surgery / Q000193:education*; D003479:Curriculum; D006801:Humans; D008297:Male; D008953:Models, Anatomic; D061646:Operative Time; D011468:Prostatectomy / Q000193:education*; D065287:Robotic Surgical Procedures / Q000193:education*; D000066908:Simulation Training / Q000379:methods*; D014572:Urology / Q000193:education*