The e-volution of the 21st century surgeon

Surgery was born in the Neolithic age as interventional medicine. Trepanation, or creation of a burr hole, was performed to release “evil spirits” and is a procedure that has been documented up to the 20th century. The Egyptians, the Sushrutas, and the Greeks developed scientific principles on surgical technique, trauma care, and anatomy.^1-3 After the fall of the Roman Empire, barber-surgeons worked as general interventionalists.⁴ With the advents of human anatomic dissection, bleeding control, anesthesia, and antisepsis, the last 150 years have seen a transformation in the field of surgery, paving the way for surgeons to successfully perform major operations.⁵ At the peak of this era, Francis D. Moore, MD, FACS, was featured on the cover of Time magazine in 1963 with the caption, “If they can operate, you’re lucky.”⁶

The general approach to interventional medicine has been the basis of surgery since its inception, and a similar concept informs the practice of general surgery today. In fact, clinicians often perform a broad spectrum of procedures, including gastrointestinal, endocrine, breast, vascular, and thoracic, in a variety of patients, from the fetal to the frail. Interestingly, general surgeons performed cardiac procedures until the 1970s. Clinical expertise, experience, and technical skills had previously allowed general surgeons to maintain a broad scope of practice.

Technological advances in medicine during the 20th century led to exponential growth in new surgical procedures. By the end of the century, laparoscopic surgery was being widely performed, and a wealth of newfound information and knowledge led to subspecialization. Concurrently, the electronic revolution and socioeconomic factors have added to the complexity of health care practice and delivery. How do these challenges affect the profession, art, and practice of surgery?

“First, do no harm”

With the advent of laparoscopic surgery in the 1980s, the application of minimally invasive techniques rapidly expanded to all disciplines, particularly general surgery. When new techniques are introduced, though, new complications or indications for procedures also arise. Laparoscopic cholecystectomy is reported to be the most commonly performed procedure on the digestive tract.⁷ The surge in performance of this procedure, which is primarily done on an outpatient basis, is due in part to the ease of the minimally invasive technique, and because patients experience a less painful recovery than an open operation would allow. However, the most worrisome complication, bile duct injury, increased to a 0.4 percent to 0.6 percent occurrence rate from a 0.1 percent to 0.3 percent occurrence rate.^8-11 The increase in biliary tree injury is thought to be a result of the learning curve associated with the new technique; most injuries were reported in the first 100 cases of those surgeons who had been in practice for a while and had learned cholecystectomy at postgraduate courses. At this time, proctoring was encouraged but not mandatory.

The American College of Surgeons (ACS) encourages physicians to evaluate new procedures to gain proficiency. More specifically, surgeons are encouraged to become knowledgeable about the disease and the indications of the new procedure, as well as to develop the necessary technical skills; however, no federal mandates apply to the acquisition of new skills outside a surgeon’s training program. Although most general surgery residents now graduate with proficiency in basic laparoscopic procedures, more advanced procedures require additional training, obtained either through fellowships or postgraduate courses.

Many industry- and association-sponsored programs provide postgraduate training to surgeons in practice, including lecture-based and hands-on formats. After a course is complete, the surgeon’s practice credentialing committee is responsible for determining whether the surgeon is qualified to perform that procedure. Most of these committees have proctoring requirements for surgeons prior to providing full credentials for a procedure, but this standard varies by institution. Although there is no direct federal mandate, hospital credentialing committees must have established protocols to at least reactively assess a surgeon’s quality performance if the institution is to maintain Joint Commission accreditation.

As surgeons continue to push the boundaries of which operations can be performed with minimally invasive techniques, complications will continue to arise. With the addition of single-incision laparoscopic procedures, morbidity due to bile duct injury and hernia rates may, in fact, rise.^12,13 So, as responsible physicians abiding by the Hippocratic Oath, surgeons should educate themselves on new procedures, evaluate their applications and merit, and ensure that they have learned the procedure adequately before applying it to patients.

Gizmos, gadgets, and toys

Given the rapid growth of surgical technology, many clinical practices are in the market for young surgeons trained in minimally invasive surgery. Surgeons trained in the early 1980s learned laparoscopy as the technology evolved to remain compliant with the modern standard of surgical care. Advancements in medical technology have brought many new and exciting techniques and options, but with them, some standard and cherished procedures are slowly being relegated to the senior surgeons who have amassed expertise in these operations.

The trend away from open procedures has forced more senior staff to learn how to perform new operations. Each of us can relate to becoming comfortable with a procedure, as well as the anxiety that accompanies doing something new. Even in residency, when trainees are exposed to new procedures on an almost daily or weekly basis, one anticipates that the learning curve will plateau after graduation.

The following scenarios highlight how senior surgeons may rely on junior surgeons for their expertise and vice-versa. In this example, the senior pediatric surgeon in a busy group practice sought assistance from the junior faculty, and together they completed a laparoscopic Nissen fundoplication. The junior surgeon led the senior surgeon through the procedure, encouraging him to continue at points when it became frustrating. The senior surgeon graciously accepted the junior colleague’s assistance and followed the suggestions provided. A week later, a 1 kg, 24-week infant with both a tracheo-esophageal fistula (TEF) and tetralogy of Fallot required TEF ligation. The infant was unable to tolerate thoracoscopy, so the procedure required an open technique. The junior faculty had less experience with this procedure in such a small infant, so he collaborated with the senior surgeon to successfully treat the patient.

Other senior surgeons have built their careers on the practice of specific procedures that most trainees and young surgeons have rarely seen or even read about in surgical textbooks. These situations are not specific to one discipline in surgery, but rather, are seen in a variety of contexts.

Peptic ulcer was traditionally treated as a surgical disease. The management of gastric and duodenal ulcers via a variety of gastrointestinal resections occupied much of the general surgeon’s operative time. The long list of post-gastrectomy syndromes and complications also required an equal expertise in identification and management. In 1982, Barry Marshall, AC, DSc, and Robin Warren, AC, discovered Helicobacter pylori, which now is recognized as the cause of 90 percent of duodenal ulcers and 80 percent of gastric ulcers; they received the Nobel Prize in Physiology or Medicine in 2005 for this discovery.¹⁴ In essence, Marshall and Warren converted peptic ulcer disease from a surgical condition to an infection that is treated with medication, with only resistant or complicated cases requiring surgery.

Medical advancements are particularly evident in the field of vascular and endovascular surgery. New devices and technologies have changed the way many vascular conditions are surgically treated, allowing for a more minimally invasive and intraluminal approach. In North America, most infrarenal abdominal aortic aneurysms, ruptured or elective, are repaired with endovascular aneurysm repair (EVAR).¹⁵ EVAR is associated with a significant reduction in early perioperative mortality, specifically because aortic cross-clamping and adequate operative exposure are unnecessary. Since the approval of endograft devices, the number of EVARs performed annually has increased by approximately 600 percent.¹⁶ Now, conventional open repair is most often reserved for cases that are not amenable to endovascular approaches, and it remains uncertain how future generations of vascular surgeons will be trained to perform open repairs.

Most surgical procedures are unlikely to become truly obsolete, but already younger trainees are becoming less familiar with certain open procedures due to significant advances in pharmacology and technology, yielding stronger medications, advanced devices for minimally invasive surgery such as laparoscopy, and endoluminal and endovascular methods for the treatment of common vascular diseases.

Procedural specialists

Since 1933, the American Board of Medical Specialties (ABMS) has overseen the board-certification process for physicians by assisting the now 24 medical specialty boards with developing and implementing educational and professional standards to evaluate physicians. There are now several surgical member boards of the ABMS, including the American Boards of Colon and Rectal Surgery, Neurological Surgery, Obstetrics and Gynecology, Ophthalmology, Orthopaedic Surgery, Otolaryngology, Plastic Surgery, Surgery, Thoracic Surgery, and Urology. However, other member boards of the ABMS certify physicians primarily to perform interventional procedures, including but not limited to gastroenterology and interventional cardiology, and interventional and diagnostic radiology.¹⁷

Historically, the first upper endoscopy, colonoscopy, and endoscopic retrograde cholangiopancreatography were performed by surgeons, but now these procedures and further interventions using these technologies are often performed by gastroenterologists. Indeed, the gold standard treatment for achalasia has shifted over time from pneumatic dilatation to laparoscopic Heller myotomy and now, possibly, to other modes. In fact, this issue has become so contested that physicians Marco Allaix, MD, and Marco Patti, MD, FACS, published an article, “What is the best primary therapy for achalasia: Medical or surgical treatment? Who owns achalasia?”¹⁸ The available treatments for achalasia now include calcium channel blockers and nitrates, endoscopic botulinum toxin injection, pneumatic dilatation, per-oral endoscopic esophageal myotomy, and laparoscopic or open Heller myotomy. Although temporary relief can be achieved with traditional endoscopic methods, and myotomy remains the gold standard in medically fit patients, the clinical practice varies with demographics and geography.^19,20 Additionally, new endoscopic therapies for achalasia require advanced technical skills, raising the question of who should be performing these procedures. Unless a practitioner has all the treatment modalities in his or her armamentarium, bias in practice pattern is introduced.

Gastroenterologists are rapidly expanding the scope of pathology that they can treat endoscopically. Pancreatitis with concomitant pancreatic pseudocysts and necrosis have long been exclusively managed with surgery. Now, however, pancreatic sphincterotomy, stenting, dilatation, and stone extraction of the pancreatic duct, sometimes with extra-corporeal shock wave lithotripsy, are being performed.²¹ Endoscopic cyst-gastrostomy, cyst-duodenostomy, or even trans-papillary drainage are also possible approaches to drain pancreatic pseudocysts, in addition to image-guided percutaneous approaches by interventional radiologists. In other words, viable alternatives to open or laparoscopic surgical cyst-gastrostomy or cyst-duodenostomy or pancreatic necrosectomy are now being performed. The patients often prefer minimally invasive options despite unknown or possibly lower efficacy, similar to the trend with laparoscopic cholecystectomy in the early adoption phase.

Another discipline that is being heavily affected by new technology is cardiac surgery, where percutaneous coronary interventions with or without the use of stents have challenged the use of coronary-artery bypass graft (CABG). One-third fewer CABGs were performed in 2008 than one decade earlier. In fact, three out of four revascularization patients had angioplasties instead of CABG in 2008, compared with two out of three 10 years ago. The annual rate of CABG surgeries is decreasing steadily due to the introduction of more advanced percutaneous devices, as well as a drop in patient demand and satisfaction.²² Now there is even transcatheter aortic valve replacement, potentially further limiting the common operations performed by cardiac surgeons.

To successfully eliminate the silos and departmental borders that have developed between interventional cardiologists, gastroenterologists, and radiologists, as well as between cardiac surgeons, general or minimally invasive surgeons, and others, these specialists will need to function as interdisciplinary teams. It has become common practice for surgeons to refer patients with choledocholithiasis to their colleagues in gastroenterology to “clear the duct” via endoscopic retrograde cholangiopancreatogram with sphincterotomy and balloon sweeping of stones before cholecystectomy. Similarly, endoscopic ultrasound by gastroenterologists for staging of pancreatic tumors that will be resected by surgical oncologists, or cardiac catheterizations performed by interventional cardiologists that refer triple vessel or left main disease to cardiac surgeons, are examples where the team approach yields better outcomes for the patients.

Can’t forget the robot

Neurosurgical biopsies and orthopaedic joint replacement were the first procedures to use robotic assistance. The first robotic cholecystectomy was performed nearly 20 years ago, and since then, robotic surgery has been increasingly widespread. Published data from the Nationwide Inpatient Sample show an increase from 2008 to 2009 in the proportion of prostatectomies, nephrectomies, hysterectomies, coronary artery bypasses, and gastrectomies performed robotically.²³ Most prostatectomies and one-third of partial nephrectomies were performed robotically in 2009. Hysterectomy was the second most common (18 percent of total) robotic procedure performed in U.S. hospitals during the period of time examined. A more recent study estimates that 90 percent of prostatectomies and 20 percent of hysterectomies in the U.S. are conducted robotically.²⁴ The diffusion of robotic prostatectomy occurred in the early 2000s, despite the lack of large comparative effectiveness studies (which first appeared in 2009), and without a systematic approach to method adoption.²⁵ Robotic assistance for hysterectomy also has increased in the last five years to almost 10 percent of all procedures performed for benign disorders in the U.S.²⁶ The adoption of robotic surgery for diseases of the colon and rectum has been limited but progressively increasing. Data from the Nationwide Inpatient Sample in 2009 and 2010 reveal that less than 3 percent of all colorectal procedures in the U.S. are done robotically.²⁷

Health care today is focused on value—quality divided by cost. Robotic surgery has a significantly higher perioperative cost, but long-term costs are still being evaluated. Several recent, large population studies have not revealed improvements in complication rates following robotic hysterectomy, colectomy, or prostatectomy.^26,28-30 In fact, two large population studies have suggested worse genitourinary complications and impaired patient safety during the early adoption time for robotic prostatectomy.^31,32 With respect to colectomy, at least two separate database studies have revealed higher postoperative bleeding rate with robotic surgery versus conventional laparoscopy.^27,28

It is important to remember, however, that robotic surgery is still in its infancy. With proper patient selection and cost containment, it may represent a valuable tool for treating different diseases and specific patient populations. A large database analysis of robotic hysterectomy for benign disease suggests shorter hospital length of stay than laparoscopy.²⁶ Shorter hospital stays, in theory, could lead to cost reduction and better use of resources, but, at present, the cost associated with the robotic procedures is higher than the potential savings. In addition, research has suggested that robotic colon surgery is associated with lower conversion to open surgery than is laparoscopy, as well as possibly decreased length of hospital stay and postoperative ileus after left-sided resections.^27,33,34 Furthermore, robotic surgery is associated with improved ergonomics over laparoscopy and may decrease surgeon fatigue.^35,36 The potential benefits and evolution of technology indicate that robotic surgery needs to be further evaluated.

Considering the challenges and issues raised in this article and elsewhere in the literature, the benefit of a formal robotic training curriculum is clear.³⁷ The current recommended training pathway is a result of limited research and opinion, suggesting that experience and medical training to overcome the learning curve are necessary to perform these operations. Interestingly, the learning curve for robotic surgery is not well-established. For example, the minimum number of cases required for competency in robotic prostatectomy—the most commonly performed robotic operation—has been increasing as experience with the procedure has changed over time.²⁵

Moreover, the definition of competence in this area is inconsistent. Experience has been emphasized as a way to obtain technical abilities. However, experience comes from practice, which should occur only after proper education. Beginning with “simple” cholecystectomy procedures has been suggested as a way to enter the clinical field and obtain technical confidence.³⁸ Although this approach certainly seems safer than beginning with more complex procedures, this practice can be disconcerting for patients undergoing practice cholecystectomies. Clearly, education is the key, and a previously published Bulletin article on the topic of the future of robotics underscores this point.³⁹ Urologic fellowships for robotic training have been available for some time now and have contributed to the wide adoption of robotic prostatectomy. To bring fellowship training to a broader range of procedures, various industry leaders are planning to fund the development of clinical robotic fellowships for general surgery starting with the academic year 2016.⁴⁰

The Google effect

Historically, patients visited the physician’s office for expert medical advice. Today, many patients first turn to the Google search engine before seeking medical attention. As a result, patients often obtain fragmented information about their condition, complications, concerns, and hospital stays—which, in turn, sometimes leads to unrealistic expectations.

Take, for example, an obese patient who presents to the surgery clinic with a diagnosis of hyperparathyroidism. Before her visit, she “Googled” hyperparathyroidism treatment options and ultimately landed on trans-axillary robotic parathyroidectomy. She finds that a physician at a nearby tertiary care center performs the operation and requests this treatment modality. However, the surgeon believes that this operation may not be the best option for her and that the traditional approach may allow for the fastest recovery, less operative time, and less discomfort. Dissatisfied with the conflicting recommendation, her experience is negative. Although she goes ahead with a traditional operation with excellent outcomes, the patient feels frustrated because she did not receive the newest, fanciest operation.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scoring system allows patients to provide survey feedback regarding their experience. After their hospitalizations, patients are given a 32-question survey that addresses the following topics: “your care from nurses,” “your care from doctors,” “your experience in this hospital,” “hospital environment,” “overall rating,” “understanding your care when you left the hospital,” and “about you.”⁴¹

Despite serial introductions, names on white boards, and photographs, patients often cannot differentiate physicians from nurses or nurse practitioners. They may be unable to differentiate primary provider from consultant. In addition, patients in tertiary care centers, who typically are more ill, have multiple providers and consultants, and ultimately may be more frustrated with their condition, tend to provide more negative feedback. With only three questions on the survey addressing interactions with the patient (“How often did doctors treat you with courtesy and respect?” “How often did doctors listen carefully to you?” and “How often did doctors explain things in a way you could understand?”) physicians may receive poor “grades” while providing excellent care. With HCAHPS scores becoming more publicly available, patients may receive biased information.

A 2012 study from the University of San Diego, CA, evaluated the “cost of satisfaction.” Fenton and colleagues conducted a prospective cohort study from 2000 to 2007 of more than 50,000 adults who took a medical expenditure panel survey that assessed patient satisfaction, inpatient admissions, emergency department visits, and mortality. Interestingly, the study showed that higher patient satisfaction was associated with less emergency department use, but greater inpatient use, higher overall health care and prescription drug expenditures, and higher mortality.42 Without HCAHPS scores, during a pre-Google era, we may not have known how patients felt about 6:00 am rounds. Now, with the fear of retribution through lack of reimbursement, how will our system change?

Conclusion

Ultimately, it is a surgeon’s duty to learn and safely apply new technology without losing information and skills gleaned from previous training, and to keep in mind the importance of stable, proven practices. As residents and fellows, it is important to advocate for training in both trusted techniques and future innovations because only training in both will ensure that we are able to provide quality, patient-centered care. And as practicing surgeons, we must continue to maintain safety and quality while learning new techniques in a technology-wealthy environment.

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References

1. Atta HM. Edwin Smith Surgical Papyrus: The oldest known surgical treatise. Am Surg. 1999;65(12):1190-1192.
2. von Staden J. The discovery of the body: Human dissection and its cultural context in ancient Greece. Yale J Biol Med. 1992;65(3):223-241.
3. Prakash UB. Shushruta of ancient India. Surg Gynecol Obstet. 1978;146(2):263-272
4. Ackerknecht EH. From barber-surgeon to modern doctor. Bull Hist Med. 1984;58(4):545-553.
5. Gawande A. Two hundred years of surgery. New Eng J Med. 2012;366(18):1716-1723.
6. Moore, Francis. “If they can operate, you’re lucky.” Time. 1963;81(18):cover.
7. Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: Results of a national survey. Ann Surg. 2001;234(4):549-558.
8. Wherry DC, Marohn MR, Malanoski MP, Hetz SP, Rich NM. An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense. Ann Surg. 1996;224(2):145-154.
9. Windsor JA, Pong J. Laparoscopic biliary injury: More than a learning curve problem. ANZ J Surg. 1998;68(3):186-189.
10. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993;218(2):129-137.
11. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-125.
12. Joseph M, Phillips MR, Farrell TM, Rupp CC. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: A review and a word of caution. Ann Surg. 2012;256(1):1-6.
13. Marks JM, Phillips MS, Tacchino R, et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg. 2013;216(6):1037-1047.
14. Konturek JW. Discovery by Jaworski of Helicobacter pylori and its pathogenetic role in peptic ulcer, gastritis and gastric cancer. J Physiol Pharmacol. 2003;54 Suppl 3:23-41.
15. Nedeau AE, Pomposelli FB, Hamdan AD, et al. Endovascular vs open repair for ruptured abdominal aortic aneurysm. J Vasc Surg. 2012;56(1):15-20.
16. Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg. 2009;49(3):543-550.
17. American Board of Medical Specialties. Who we are & what we do. Available at: www.abms.org/About_ABMS/who_we_are.aspx. Accessed June 26, 2014.
18. Allaix ME, Patti MG. What is the best primary therapy for achalasia: Medical or surgical treatment? Who owns achalasia? J Gastrointest Surg. 2013;17(9):1547-1549.
19. Schoenberg MB, Marx S, Kersten JF, et al. Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: A network meta-analysis. Ann Surg. 2013;258(6):943-952.
20. Enestvedt BK, Williams JL, Sonnenberg A. Epidemiology and practice patterns of achalasia in a large multi-centre database. Aliment Pharmacol Ther. 2011;33(11):1209-1214.
21. Heyries L, Sahel J. Endoscopic treatment of chronic pancreatitis. World J Gastroenterol. 2007;13(46):6127-6133.
22. Sibbald B. Declining CABG rate means fewer jobs for surgeons. CMAJ. 2005;173(6):583-584.
23. Anderson JE, Chang DC, Parsons JK, Talamini MA. The first national examination of outcomes and trends in robotic surgery in the United States. J Am Coll Surg. 2012;215(1):107-114.
24. Tsui C, Klein R, Garabrant M. Minimally invasive surgery: National trends in adoption and future directions for hospital strategy. Surg Endosc. 2013;27(7):2253-2257.
25. Mirheydar HS, Parsons JK. Diffusion of robotics into clinical practice in the United States: Process, patient safety, learning curves, and the public health. World J Urol. 2013;31(3):455-461.
26. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
27. Halabi WJ, Kang CY, Jafari MD, et al. Robotic-assisted colorectal surgery in the United States: A nationwide analysis of trends and outcomes. World J Surg. 2013;37(12):2782-2790.
28. Keller DS, Senagore AJ, Lawrence JK, Champagne BJ, Delaney CP. Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection. Surg Endosc. 2014;28(1):212-221.
29. Juo YY, Hyder O, Haider AH, Camp M, Lidor A, Ahuja N. Is minimally invasive colon resection better than traditional approaches? First comprehensive national examination with propensity score matching. JAMA Surg. 2014;149(2):17-84.
30. Jacobs BL, Zhang Y, Schroeck FR, et al. Use of advanced treatment technologies among men at low risk of dying from prostate cancer. JAMA. 2013;309(24):2587-2595.
31. Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557-1564.
32. Agarwal PK, Sammon J, Bhandari A, et al. Safety profile of robot-assisted radical prostatectomy: A standardized report of complications in 3317 patients. Eur Urol. 2011;59(5):684-698.
33. Casillas MA Jr, Leichtle SW, Wahl WL, et al. Improved perioperative and short-term outcomes of robotic versus conventional laparoscopic colorectal operations. Am J Surg. 2013;208(1):33-40.
34. Kang J, Yoon KJ, Min BS, et al. The impact of robotic surgery for mid and low rectal cancer: A case-matched analysis of a 3-arm comparison—open, laparoscopic, and robotic surgery. Ann Surg. 2013;257(1):95-101.
35. Lee GI, Lee MR, Clanton T, Sutton E, Park AE, Marohn MR. Comparative assessment of physical and cognitive ergonomics associated with robotic and traditional laparoscopic surgeries. Surg Endosc. 2014;28(2):456-465.
36. Hubert N, Gilles M, Desbrosses K, Meyer JP, Felblinger J, Hubert J. Ergonomic assessment of the surgeon’s physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot. 2013;9(2):142-147.
37. Chitwood WR Jr, Nifong LW, Chapman WH, et al. Robotic surgical training in an academic institution. Ann Surg. 2001;234(4):475-484.
38. Jayaraman S, Davies W, Schlachta CM. Getting started with robotics in general surgery with cholecystectomy: The Canadian experience. Can J Surg. 2009;52(5):374-378.
39. Griffen FD, Sugar JG. The future of robotics: A dilemma for general surgeons. Bull Am Coll Surg. 2013;98(7):9-15.
40. Intuitive Surgical, Inc. Intuitive Surgical Clinical Robotics Fellowship. Available at: http://intuitivesurgical.com/company/educational-grants/fellowship_grants.html. Accessed June 26, 2014.
41. Hospital Consumer Assessment of Healthcare Providers and Systems. Home page. Available at: www.hcahpsonline.org/. Accessed June 26, 2014.
42. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-411.