Title: ROBOTIC ASSISTED SURGERY
Document Owner: PI Team: Date Created:
Karyn Delgado/Teresa Onken N/A 04/15/2012
Approver(s): Date Approved:
Karyn Delgado/Teresa Onken 05/07/2012
Location: Saint Joseph Regional Medical Center-Mishawaka Department:
Medical Staff Services
Printed copies are for reference only. Please refer to the electronic copy for the latest version.
1. Applicants will submit a written request for this privilege to the Medical Staff Office. Included in this
written request the applicant must identify if they have current daVinci privileges elsewhere. They must also
confirm they are not currently under review beyond the standard Focused Professional Practice Evaluation
(FPPE) for daVinci procedures and lastly, must disclose if they have ever been under review for daVinci
procedures and the purpose of that review. The purpose of this information is for FPPE consideration
2. Education: M.D. or D.O.
A. Completion of an ACGME or ACGOME accredited residency or fellowship training
program in a surgical discipline, and
B. Successful completion of robotic assisted training during residency or fellowship training
program, or completion of a hands-on training practicum in the use of the robotic surgical
system (manufacturer’s designated course).
4. Clinical Experience (Initial)
A. Current unrestricted privileges for the open and laparoscopic procedures that will be performed
B. Applicants with previous experience and privileges must provide evidence of the performance of six
(6) robotic assisted surgical procedures during the previous two (2) year period.
C. Applicants who completed residency/fellowship training during the previous year must be able to
demonstrate evidence of training in robot assisted surgery during residency/fellowship by submitted
evidence of the performance of at least six (6) robotic assisted surgical procedures during the previous
two (2) years, as well as a letter from the program director stating that the applicant is appropriately
trained in robot assisted surgery.
D. Applicants who are non-residency/fellowship trained or have insufficient documentation of six (6)
cases in the past two years must complete off-site Robotic Surgical Skills Training and provide
training course certificate.
5. Proctoring and Focused Professional Practice Evaluation
A. Must perform, at a minimum, the first two (2) procedures under the supervision of a proctor provided
by the manufacturer, or by an experienced medical staff member with current privileges in robotic
surgery and in the same specialty who may act as a co-surgeon. The proctor will complete a proctor
evaluation form which must eventually indicate a satisfactory performance before proctoring will be
B. The results of proctoring will be reviewed by the applicable department chair who will make a
recommendation to terminate proctoring.
Expiration Date: 12/21/2012 Page 1 of 2
Title: ROBOTIC ASSISTED SURGERY
C. Privileges will automatically expire and the physician will be notified if:
1) If the first proctored case does not occur within six (6) months of initial granting of privileges.
2) If the above proctoring is not completed within two (2) years of initial granting of privileges.
D. All cases performed for one year by the surgeon utilizing the robotic surgical system, but no less than
five (5), will be retrospectively reviewed. Any case which exceeds five (5) hours of insufflation time
will trigger immediate review. This information will be forwarded for review by the daVinci Steering
Committee/Medical Director who will determine to recommend to the Department Chair and
Credentials Committee the completion of the FPPE period. The recommendation will be based on,
but not limited to, case volume and outcome data.
6. Current Competency
A. Applicants must demonstrate that they have maintained competence by providing evidence of the
performance of at least six (6) robotic assisted surgery procedures during the previous two (2) years.
If the applicant has insufficient documentation of six (6) cases in the past two (2) years, he/she must
be proctored at least once to demonstrate continued proficiency. If the proctored case does not occur
by the next reappointment cycle, the privileges will automatically expire. Reappointment will be
based on the results of ongoing professional practice evaluation and outcomes.
QUALIFICATIONS OF A SURGICAL ASSISANT FOR ROBOTIC ASSISTED SURGERY
1. Education: M.D. or D.O.
1) Completion of an ACGME or ACGOME accredited residency or fellowship training program
in a surgical discipline, and
2) Provide documentation of the provision of at least 20 laparoscopic or hand assisted laparoscopic
cases as the primary surgeon, or
3) Have attended a training program for a Patient-Side Assistant provided by the manufacturer.
2. RNFA, PA
1) Must be experienced in the open and laparoscopic procedure to be performed, and
2) Have attended a hands-on training practicum or in-service provided by the manufacturer.
Policy Origin Date: April 2012
Effective Date: May 2012
Reviewed/Recommended By: Medical Executive Committee
Expiration Date: 12/21/2012 Page 2 of 2