Overview and perspectives about the robotic surgical certification process in Brazil: the new statement and a national web-survey

Since its first use in 1985, robotic surgery in humans has been in the spotlight of the surgical community1. The acceptance of robotic surgery has improved the portfolio of minimally invasive surgery and become the counterpoint to laparoscopy. Although its attractiveness has increased, currently with more than 5,000 thousand units worldwide, its cost and access to the robotic certification has limited the robotic use. The robotic platform da Vinci® was approved by the Food and Drug Administration – USA (FDA) in 2000, and its recommendation by the National Institute for Health and Care Excellence – UK (NICE) in 2015. These are two important landmarks for robotic acceptance and worldwide diffusion. Meanwhile, robotic surgery has become more common in Brazil, in many different specialties, and the Associação Médica Brasileira (AMB Brazilian Medical Association) published a statement about the robotic


INTRODUCTION
S ince its first use in 1985, robotic surgery in humans has been in the spotlight of the surgical community 1 .
The acceptance of robotic surgery has improved the portfolio of minimally invasive surgery and become the counterpoint to laparoscopy. Although its attractiveness has increased, currently with more than 5,000 thousand units worldwide, its cost and access to the robotic certification has limited the robotic use. The robotic platform da Vinci® was approved by the Food and

METHODS
A national web-based cross-sectional survey was carried out, and the questionnaires were sent by e-mail to all members of the CBC. The first step was to send an invitation to all members of the College including a link to the survey; and the second step was to resend the invitation for those members who had received the email, but had not opened it, as depicted in Figure 1.

RESULTS
Out of the 6.299 CBC members who received the invitation to participate in the months of March and April 2020, 294 (4.7%) answered the query. The invitation process is described in Figure 1. The answers were split into two groups: 133 (45.3%) answers were of members who had already received robotic console certification, and 161 (54.8%) who did not have it. The overall distribution was also divided into the groups of surgeons who had or did not have robotic certification, and this is depicted in Table   2. Regarding the age of surgeons who answered the query, there was no difference between the two groups, as the overall median age was 46 (interquartile of 41 -55, range of 30 -77). However, when the time of experience as physician (years after graduation) was evaluated, the noncertified robotic group had more surgeons with at least 30 years of experience than the robotic (32.3% versus 23.3%, p=0.033). Although no disparities were seen regarding the major geographic country areas, surgeons with robotic certification more frequently worked in cities with at least one million inhabitants than those who were not certified (85.7 versus 63.4%, p<0.001).
The acquaintance with the robotic recommendations and regulations were also evaluated as depicted in Table 2    The minimum requirements for qualification in robotic surgery regardless the surgical specialty 1. The qualification in robotic surgery must be linked to the surgeon's specialty in the medical council.
2. The training has to be recognized by a specialty society. 7. The preceptor surgeon must demonstrate minimal experience in the specialty, and his certification must be certified by the AMB.
8. The use of animals is not mandatory.

9.
A provisional license will be issued until the surgeon completes the requirements to receive the definitive license 10. The preceptor surgeon will be co-responsible with the training surgeon, for any damage to the patient, caused by robotic surgery.
11. The patient must be informed, in a specific document, that the training surgeon, under the supervision of the preceptor surgeon, will perform the surgery.
12. Hospital's medical director must inform the training surgeon, that the preceptor will coordinate the surgical procedure, documenting with everyone's signature.
13. The preceptor surgeon must direct the surgical actions, whenever he deems convenient, for patient safety.
14. All medical staff, including anesthetist and assistant surgeon, must be trained by the guidelines of the AMB. Regarding the certified robotic surgeons' group, an overview of years of experience as a physician and after robotic training is depicted in Figure 2. The median number of procedures is 20, with a mean number of 115 procedures. Most of the surgeons (65.4%) work in more than one area, as described in Table 4. Upper gastrointestinal (63.2%), hernia (60.9%), and colorectal (57.9%) operations represented the three most common surgical procedures described by the robotic expert group.
The majority of the surgeons (82.7%) who work with robotic surgery have the opinion that the robotic platform has been a useful tool to improve their surgical skills.     Personal impression about the robotic approach in their surgical practice No differences in practice 13 (9.8) More difficult than laparoscopy 10 (7.5) Overall improvement 110 (82.7) are more important than with the laparoscopic approach, which is also limited. The development of new eye-haptic skill for the robotic approach is a common skill usually assimilated in the learning curve 5 .
Another limiting issue of robotic acceptance and diffusion is the higher costs compared to laparoscopy.
Although the costs to pay for the initial investments duty for intervention as much as needed, the agreement proportion for them was higher and the non-robotic group. These answers suggest that the referee physician of the patient is concern about the involvement of the preceptor in the surgical outcome, as well as they, are also a concern to receive the appropriate aid during the intervention as much as necessary.  about this topic. Perhaps the most important limitation of our study was low number of answers, representing 4.7% of CBC members. However, looking at the robotic group, they represent almost 9% of robotic surgeons certified in Brazil. Both numbers of total and robotic groups were beneath our initial expectations, and its fact claims for more participation of CBC members in collaborations from CBC rather than this small subgroup.
By contrast, even this small number was large enough to