STS Spells Out Training Pathway for Robotic Surgery

NEW ORLEANS, LA—To ensure quality as robotic surgery expands globally, the Society of Thoracic Surgeons (STS) has outlined a new, dedicated pathway for clinicians and institutions to help them adopt the technology and to achieve optimal outcomes.

“The interest in robotic cardiac surgery is surging and remains high, and we all must be committed to adopting and innovating new technologies, but always remembering that we must pursue quality first,” lead author Vinay Badhwar, MD (West Virginia University, Morgantown), who presented the paper at the recent 2026 STS Annual Meeting, told TCTMD.

Badhwar, who serves as STS president, emphasized that the use of robotic surgery is “not [innovation] for innovation’s sake. [Rather], it is for the ability to improve outcomes of our patients. That is really the holy grail that we all pursue.”

The document, which was simultaneously published in the Annals of Thoracic Surgery, was co-authored by expert robotic surgeons from almost a dozen countries. It defines five phases of advancement through which surgical teams can achieve optimal outcomes with the technology:

• Zero: prerequisites and preparation
• One: baseline team training
• Two: initial clinical application
• Three: progressive case efficiency
• Four: advancement and mastery

While previous consensus papers exist in this domain, especially with regard to training, Badhwar said this document is broader and more detailed. It was designed to help programs that have access to the technology and are dedicated to using it to its full potential. The new teaching paradigm is meant to serve as a “guide to assist surgeons and their teams in ensuring a staged approach to introducing robotic technology to their cardiac operations,” he said.

Specifically, the group recommends having no fewer than 3 years of attending practice or completing a fellowship in robotic surgery before getting started. Also, institutional support is necessary as hospitals work to create a team who will work with the technology.

From there, peer-to-peer training can commence with expert centers either on-site or, potentially, be done remotely. When eventually selecting patients for robotic surgery, a team-based approach should be used, and up to the first five cases should be proctored, with the first 10 cases being completed within 6 months.

Badhwar recommends starting simply: “in other words, not taking on the most complex case in your first cases.” He also stressed the importance of tracking outcomes by case type and ensuring that the observed-to-expected outcomes ratio remains below 1. A minimum of 50 cases of each type is required before moving on to more advanced operations, he said.

At this point, said Badhwar, it’s possible to introduce more novel approaches like percutaneous cannulation, endoballoon technology, total endoscopic coronary artery bypass, and even aortic valve replacement or multivalve procedures.

‘Bringing Everyone Along’

Session moderator Katherine Harrington, MD (The Heart Hospital Baylor, Plano, TX), asked what a “safe” rate of conversion to full sternotomy would be for a robotic surgery program.

That might differ depending on the institution, Badhwar replied. “However, if your rate is 10%, you should really evaluate and maybe go back to the fundamentals. I think conversion should be . . . an almost-never event,” he said, with the caveat that it might be the safest option in certain rare situations.

Tsuyoshi Kaneko, MD (Washington University School of Medicine, St. Louis, MO), who attended the STS session, spoke about the need for collaboration among the entire surgical team when building a robotics program, something Badhwar agreed with.

“The importance of the team cannot be overstated; in any operative field, the team is more important than the surgeon,” Badhwar said. “We’ve talked about that for decades, but in robotics, it’s absolutely true.” Ideally, multiple expert training sites will emerge in the coming years where teams can go to train together, he added, though remote proctoring might also be an option.

Sidney Sanders, MD (Northeast Georgia Medical Center, Norcross), who also attended the session, said that he has dealt with administrative “pushback” in her experience on three different robotic teams.

“Before you even begin, you have to get administrative buy-in,” said Badhwar. “When you start, I strongly recommend you keep it simple. Try not to layer multiple different new technologies and new teams, such as percutaneous and endoscopic. . . . When you bring your team along with you, you can navigate some of these areas of pushback.”