Previous Surgical Experience Research Articles

Initial validation of the ProMIS surgical simulator as an objective measure of robotic task performance.

Virtual reality robotic simulation has gained widespread momentum. In order to determine the value of virtual reality robotic simulation and its objective metrics, a reality-based robotic surgical training platform with similar analytic capabilities must be developed and validated. The ProMIS laparoscopic surgical simulator is a widely available reality-based simulation platform that has been previously validated as an objective measure of laparoscopic task performance. In this study, we evaluated the validity of the ProMIS laparoscopic surgical simulator as an objective measure of robotic task performance. Volunteers were recruited from two experience groups (novice and expert). All subjects completed three tasks (peg transfer, precision cutting, intracorporeal suture/knot) in the ProMIS laparoscopic simulator using the da Vinci robotic surgical system. Motion analysis data was obtained by the ProMIS computerized optical tracking system and objective metrics recorded included time, path length, economy of motion, and observer-recorded penalty scores. The novice group consisted of 10 subjects with no previous robotic surgical experience. The expert group consisted of 10 subjects with robotic experience. The expert group outperformed the novice group in all three tasks. Subjects rated this training platform as easy to use, as an accurate measure of their robotic surgical proficiency, and as relevant to robotic surgery. The experts described the simulator platform as useful for training and agreed with incorporating it into a residency curriculum. This study demonstrates that the ProMIS laparoscopic simulator is a face, content, and construct valid reality-based simulation platform that can be used for objectively measuring robotic task performance.

Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India

Background: The present audit was initiated to evaluate the knowledge, attitude, perception and acceptance of women toward labor analgesia and caesarean section, in a Medical College Hospital in Udaipur, India. Materials and Methods: A semi-structured interview of 200 antenatal women was conducted, to assess the knowledge, attitude and perception regarding labor analgesia and caesarean section (CS) and to estimate the correlation of awareness and acceptability with demographic variables. The data were analyzed using Epi Info 6 and the Likert type scale (0 - 10), as also the chi square test, to calculate the statistical significance. Results: Most of the patients (n = 181, 90.50%) were unaware of labor analgesia. When the option of labor analgesia was offered, only 23% (n = 46) accepted it and the most significant reason for refusal was to experience natural child birth (n = 114 / 154, 74.03%). An educational status of the graduate level had a positive impact on knowledge about labor analgesia (P = 0.0001). When the option for CS was offered, 73.50% women (n = 147; P = 0.008) refused and the most common reasons for refusal were fear of operation (53.06%, n = 78) and delay in resuming household work (46.26%, n = 68). Educational status up to the graduate level and previous surgical experience of CS had a positive correlation with preference for CS (P = 0.0092 and P = 0.0001, respectively). Conclusions: Awareness and acceptance for labor analgesia was relatively low among the prospective parturients. A higher level of education had a significant impact on their decisions regarding delivery.

Assessment of Preclinical Learning on Oral Surgery Using Three Instructional Strategies

The purpose of this investigation was to evaluate three learning methods for teaching basic oral surgical skills. Thirty predoctoral dental students without any surgical knowledge or previous surgical experience were divided into three groups (n=10 each) according to instructional strategy: Group 1, active learning; Group 2, text reading only; and Group 3, text reading and video demonstration. After instruction, the apprentices were allowed to practice incision, dissection, and suture maneuvers in a bench learning model. During the students' performance, a structured practice evaluation test to account for correct or incorrect maneuvers was applied by trained observers. Evaluation tests were repeated after thirty and sixty days. Data from resulting scores between groups and periods were considered for statistical analysis (ANOVA and Tukey-Kramer) with a significant level of a=0.05. Results showed that the active learning group presented the significantly best learning outcomes related to immediate assimilation of surgical procedures compared to other groups. All groups' results were similar after sixty days of the first practice. Assessment tests were fundamental to evaluate teaching strategies and allowed theoretical and proficiency learning feedbacks. Repetition and interactive practice promoted retention of knowledge on basic oral surgical skills.

Does Previous Robot-assisted Radical Prostatectomy Experience Affect Outcomes at Robot-assisted Radical Cystectomy? Results from the International Robotic Cystectomy Consortium

To evaluate the effect of previous robot-assisted radical prostatectomy (RARP) case volume on the outcomes of robot-assisted radical cystectomy. Little is known regarding the effect of previous robotic surgical experience on the implementation and execution of robot-assisted radical cystectomy. Using the International Robotic Cystectomy Consortium database, 496 patients were identified who had undergone robot-assisted radical cystectomy by 21 surgeons at 14 institutions from 2003 to 2009. The surgeons were divided into 4 groups according to their previous RARP experience (≤ 50, 51-100, 101-150, and > 150 cases). The overall operative time, blood loss, lymph node yield, pathologic stage, and surgical margin status were compared among the 4 groups using chi-square analysis. The mean operative time was 386 minutes (range 178-827). The mean estimated blood loss was 408 mL (range 25-3500). The operative time and blood loss were both significantly associated with previous RARP experience (P < .001). The mean lymph node count was 17.8 nodes (range 0-68). Lymph node yield and increased pathologic stage were significantly associated with previous RARP experience (P < .001). Finally, 34 (7.0%) of the 482 patients had a positive surgical margin. Margin status was not significantly associated with previous RARP experience (P = .089). Previous RARP case volume might affect the operative time, blood loss, and lymph node yield at robot-assisted radical cystectomy. In addition, surgeons with increased RARP experience operated on patients with more advanced tumors. Previous RARP experience, however, did not appear to affect the surgical margin status.

Male circumcision: towards a World Health Organisation normative practice in resource limited settings.

There is now grade 1 evidence that male circumcision (MC) reduces the risk of a man acquiring HIV. Modelling studies indicate MC could in the next 10 years save up to 2 million lives in those African countries with high HIV prevalence. Several African countries are now scaling up public health MC programmes. The most effective immediate public health MC programmes in Africa will need to target 18-20 years old men. In the longer term there is a need for infant circumcision programmes. In order to implement more widespread MC there is a need to make the surgical procedures as simple as possible so that safe operations can be performed by paramedical staff. The WHO Manual of Male Circumcision under local anaesthetic was written with these objectives in mind. Included in the manual are three adult techniques and four paediatric procedures. The adult procedures are the dorsal slit, the forceps guided and the sleeve resection methods. Paediatric methods included are the plastibell technique, the Mogen and Gomco shield method and a standard surgical dorsal slit procedure. Each method is described in a step by step manner with photographic and line drawing illustrations. In addition to the WHO manual of surgical technique a teaching course has been developed and using this course it has been possible in one week to train a circumcision surgeon who has had no or minimal previous surgical experience. Further scaling will require training of circumcision surgeons, monitoring performance, training the trainer workshops as well as advocacy at national, international and government meetings. In addition to proceeding with standardised methods work is in progress to assess novel techniques in adults such as stay on ring devices and policies are being formulated as to how to assess new devices. Also work is in progress to explore efficiencies in surgical processing by task sharing. Proper informed consent and safety remain paramount and great care has to be taken as programmes in Africa scale up. In continental China where the HIV epidemic is at a much earlier stage there may be a case for considering infant circumcision but great care will be needed to ensure that there is no harm.

Management of patients' physical health in an acute psychiatric unit

The aim of this study was to help clarify the range of acute medical problems experienced by patients on an acute psychiatric unit during a period of 28 days and nights, as encountered by psychiatric trainees, and to document any difficulties experienced by the trainee during these patient contacts. This survey was carried out prospectively over 28 days and nights in an acute psychiatric ward attached to a teaching University Hospital. Following contact with an individual patient, the trainee recorded diagnosis, intervention and any difficulties encountered. Thirty-three patient contacts were recorded (n = 33). Trainees faced a range of primary care problems 22/33 (67%), but moreover, three patients demonstrated more serious and potentially life threatening problems, leading to 11/33 (33%) patient contacts requiring urgent interventions. While the debate continues as to who is best placed to provide medical healthcare for psychiatric patients, this study provides evidence that psychiatry trainees are required to draw on their previous medical and surgical experience on an almost daily basis. As psychiatrists we should consider our options on how best to manage medical problems on the acute psychiatric unit and consequently ensure confident liaison with our medical and surgical colleagues.

Correlates of Postoperative Pain and Intravenous Patient-Controlled Analgesia Use in Younger and Older Surgical Patients

Age-related patterns in postoperative pain are unclear with reports of no age differences and less pain with age. The objective of this study was to identify correlates of pain and intravenous patient-controlled analgesia (i.v. PCA) morphine use in younger and older patients. 24 hours after surgery, patients completed measures of pain intensity and pain qualities. Surgical factors, i.v. PCA morphine intake, anticholinergic load, polypharmacy, physical status, previous chronic and postoperative pain, and PCA experience were measured. Two academic general hospitals. PATIENTS. Two hundred forty-six general surgery patients ranging in age from 18 to 82 years old. In older patients, higher pain scores were associated with female gender and previous experience of postoperative PCA. In younger patients, higher pain scores were associated with female gender, previous surgery without PCA, and greater morphine intake. Lower pain was associated with being male, and no previous surgical experience in older patients, and lower morphine intake in younger patients. Morphine intake was higher in patients who were younger, had better physical status, higher anticholinergic load, and experience with PCA. Among younger patients, increased morphine use also was associated with surgical procedure and duration. Higher pain scores were more strongly associated with morphine use among younger than older patients. The correlates of postoperative pain and morphine use may differ with age, and the same factor may have different effects across age groups. Research is needed into the mechanisms of these age-specific profiles.

How much feedback is necessary for learning to suture?

Many laparoscopic simulation training systems exist and have been shown to transfer learning of surgical skills to the operating room. The manner in which the training is structured to maximize learning has not been examined. There are many aspects to the acquisition of laparoscopic skills during training, one of which is the availability of knowledge of results (KR). Knowledge of results is information about the outcome of motor skill execution, usually provided to individuals at the end of the execution. The timing and nature of KR can affect how well people learn new motor skills. In addition, detailed instruction during learning can also affect skill acquisition. We studied the effects of KR and instruction on the learning curve of a suturing and knot-tying task. We hypothesized that KR was necessary for skill acquisition, and that detailed instruction would help trainees to learn to perform the task more correctly and reach a performance plateau earlier. In addition, the overall workload of a trainee during training would decrease as skills improved, especially when KR and coaching were provided. Nine medical students with no previous laparoscopic surgical experience were randomly and evenly divided into three groups with different KR conditions: (1) no KR, (2) KR, (3) KR + instruction. Each subject attended a training session for 1 h each day, 6 days a week for 4 consecutive weeks. Performance measures such as task time, smoothness of instrument, and path length were recorded for each trial. Workload was assessed using the NASA-TLX questionnaire. While KR was necessary for learning to suture, continual instruction had limited additional benefits. However, KR + instruction did reduce subjects' perceived overall workload. Surgical training could be carried out effectively with only knowledge of results. These results have implications for the staffing of surgical skills laboratories.

A randomized comparison of conventional vs articulating laparoscopic needle‐drivers for performing standardized suturing tasks by laparoscopy‐naive subjects

To compare the efficacy of conventional and articulating laparoscopic needle-drivers for performing standardized laparoscopic tasks by medical students with no previous surgical experience. Twenty medical students with no surgical experience were randomly assigned to two equal groups, one using a conventional laparoscopic needle-holder (Karl Storz, Tuttlingen, Germany) and the other using a first-generation articulating laparoscopic needle-holder (Cambridge Endo, Framingham, MA, USA). Each student performed a series of four standardized laparoscopic tasks, during which speed and accuracy were assessed. The tasks tested needle passage through rings (1), an oblique running suture model (2), a urethrovesical anastomosis model (3) and a model simulating renal parenchymal reconstruction following partial nephrectomy (4). Tasks 1 and 3 were completed significantly more quickly by those using the conventional instruments (P < 0.05), but there was no statistically significant difference for task 2 and 4 (P > 0.05). Those using conventional instruments were significantly more accurate in all of the tasks than those using the articulated instruments (P < 0.05). The conventional laparoscopic needle-driver allowed laparoscopy-naive medical students to complete a series of standardized suturing tasks more rapidly and accurately than with the novel articulating needle-driver. Laparoscopic suturing with first-generation articulating needle-drivers might be more difficult to learn, secondary to the complexity of physical manoeuvres required for their use.

The Benefit of Force Feedback in Surgery: Examination of Blunt Dissection

Force feedback is widely assumed to enhance performance in robotic surgery, but its benefits have not yet been systematically assessed. In this study we examine the effects of force feedback on a blunt dissection task. Twenty subjects used a telerobotic system to expose an artery in a synthetic model while viewing the operative site with a video laparoscope. Subjects were drawn from a range of surgical backgrounds, from inexperienced to attending surgeons. Performance was compared between three force feedback gains: 0% (no force feedback), 37%, and 75%. The absence of force feedback increased the average force magnitude applied to the tissue by at least 50%, and increased the peak force magnitude by at least 100%. The number of errors that damage tissue increased by over a factor of 3. The rate and precision of dissection were not significantly enhanced with force feedback. These results hold across all levels of previous surgical experience. We hypothesize that force feedback is helpful in this blunt dissection task because the artery is stiffer than the surrounding tissue. This mechanical contrast serves to constrain the subject's hand from commanding inappropriate motions that generate large forces.

Invited commentary

Invited commentary

Porcine Transfer Study: Virtual Reality Simulator Training Compared with Porcine Training in Endovascular Novices

To compare the learning of endovascular interventional skills by training on pig models versus virtual reality simulators. Twelve endovascular novices participated in a study consisting of a pig laboratory (P-Lab) and a virtual reality laboratory (VR-Lab). Subjects were stratified by experience and randomized into four training groups. Following 1 hr of didactic instruction, all attempted an iliac artery stenosis (IAS) revascularization in both laboratories. Onsite proctors evaluated performances using task-specific checklists and global rating scales, yielding a Total Score. Participants completed two training sessions of 3 hr each, using their group's assigned method (P-Lab x 2, P-Lab + VR-Lab, VR-Lab + P-Lab, or VR-Lab x 2) and were re-evaluated in both laboratories. A panel of two highly experienced interventional radiologists performed assessments from video recordings. ANCOVA analysis of Total Score against years of surgical, interventional radiology (IR) experience and cumulative number of P-Lab or VR-Lab sessions was conducted. Inter-rater reliability (IRR) was determined by comparing proctored scores with the video assessors in only the VR-Lab. VR-Lab sessions improved the VR-Lab Total Score (beta = 3.029, p = 0.0015) and P-Lab Total Score (beta = 1.814, p = 0.0452). P-Lab sessions increased the P-Lab Total Score (beta = 4.074, p < 0.0001) but had no effect on the VR-Lab Total Score. In the general statistical model, both P-Lab sessions (beta = 2.552, p = 0.0010) and VR-Lab sessions (beta = 2.435, p = 0.0032) significantly improved Total Score. Neither previous surgical experience nor IR experience predicted Total Score. VR-Lab scores were consistently higher than the P-Lab scores (Delta = 6.659, p < 0.0001). VR-Lab IRR was substantial (r = 0.649, p < 0.0008). Endovascular skills learned in the virtual environment may be transferable to the real catheterization laboratory as modeled in the P-Lab.

Prostatectomía radical robótica: revisión de nuestra curva de aprendizaje

ObjectiveWe present the first cases of our robotic radical prostatectomy with Da Vinci (RRPdaV) that corresponds to the learning curve (LC) of the surgeon that has initiated with this technique. MethodsWe reviewed the first 20 patients that underwent RRPdaV, performed by an expert surgeon, without previous laparoscopic training, but with a wide experience in retropubic and perineal prostatectomy (HV). We analyzed: Surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also: rates and location of surgical margins, as well as functional outcomes with an average follow up of 10 months. ResultsMean operating time was 140 minutes (100-211) and blood loss 180 mL (80-360), and none required a blood transfusion. There were no intraoperative complications and neither any conversion to open surgery. The only postoperative outstanding fact was mean hospital stay were 3,35 days. (3-5). We had 6 cases of positive surgical margins (30%). The most frequent location was postero-lateral. Eighteen out of 20 patients (90%) were early totally continent, 2 (10%) required the use of one pad during the first six months due slight stress incontinence that stopped spontaneously. From 20 cases, two of them (10%) had preoperative erectile dysfunction; 12 out of the remaining 18 (66.6%) preserved potency at review and 6 (33.4%) had postoperative erectile dysfunction. ConclusionsIt has been demonstrated that robotic surgery for radical prostatectomy is clearly an advantage technique (easy maneuver although it is a minimally invasive technique, comfortable and ergonomic position for the surgeon, 3D visualization and short learning curve). The RRPDAv learning curve is significantly shorter if the surgeon has a wide previous surgical experience in open and/or laparoscopic surgery.

Tissue consistency perception in laparoscopy to define the level of fidelity in virtual reality simulation

What degree of fidelity must a laparoscopic simulator have to achieve a training objective? This difficult question is addressed by studying the sensory interaction of surgeons in terms of a surgical skill: tissue consistency perception. A method for characterizing surgeon sensory interaction has been defined and applied in an effort to determine the relative importance of three components of perceptual surgical skill: visual cues, haptic information, and previous surgical knowledge and experience. Expert, intermediate, and novel surgeons were enrolled in the study. Users were asked to rank tissue consistency in four different conditions: a description of the tissue alone (Q), visual information alone (VI), tactile information alone (TI), and both visual and tactile information (VTI). Agreement between these stages was assessed by a coefficient of determination (R2). Tissue is a determinant factor (p < 0.001) in the perception of tissue consistency, whereas the expertise of the surgeon is not (p = 0.289). Tissue consistency perception is based mainly on tactile information (TI-VTI agreement is high, R2 = 0.873), although little sensory substitution is present (VI-VTI agreement is low, R2 = 0.509). Agreement of Q-VI increases with experience (R2 = 0.050, 0.290, and 0.573, corresponding with to novel, intermediate, and expert surgeons), which has been associated with the "visual haptics" concept. Virtual reality simulators need haptic devices with force feedback capability if tissue consistency information is to be delivered. On the other hand, the visual haptics concept has been associated with a kind of tactile memory developed by surgical experience.

Prostatectomía radical laparoscópica extraperitoneal: Experiencia preliminar

Presentation of our initial experience with the practice of the laparoscopic radical prostatectomy through the extraperitoneal access (ELRP). We describe the proceeding and its technical difficulties, time consumption and complications. From January to May 2005 we have indicated 17 ELRP in our institution. Two of them were performed with the help of a mentor. We followed the Brussels technique but without preservation of the neuro vascular bundles. Laparoscopic approach was indicated in 17 patients, 8 of them were completed and 9 converted to open surgery. Of the cases performed without external aid (which are the analysed in this communication), 6 were pure laparoscopic and 9 were permuted to open. Of the last 6, only one was not completed by laparoscopy. Mean operative time was 304 minutes (355 for the pure laparoscopy cases). Transfusion rate was 13%. Positive surgical margins were observed in 26% of the cases (16% of the complete laparoscopic procedures). There were not major complications. Not ileus was observed. In one case, bladder catheter had to be replaced after 7 days because it was not properly placed during surgery. Conversion to open surgery during extraperitoneal laparoscopic proceeding is not very difficult but previous surgical experience is required. ELPR is feasible in an institution like ours but is necessary a team with previous experience in laparoscopic surgery and the aim of invest a big effort, specially regarding operative time. Initial learning curve has not caused any important complication.

Patient Reports of Satisfaction after Microvascular Decompression and Partial Sensory Rhizotomy for Trigeminal Neuralgia

There are no reports of patient satisfaction surveys after either a microvascular decompression (MVD) or a partial sensory rhizotomy (PSR) for trigeminal neuralgia. This study compares patient satisfaction after these two types of posterior fossa surgery for trigeminal neuralgia, because it is postulated that recurrences, complications, and previous surgical experience reduce satisfaction. All patients who had undergone their first posterior fossa surgery at one center were sent a self-complete questionnaire by an independent physician. Among the 44 questions on four standardized questionnaires were 5 questions that related to patient satisfaction and experience of obtaining care. Patients were divided into those having their first surgical procedure (primary) and those who had had previous ablative surgery (nonprimary). Response rates were 90% (220 of 245) of MVD and 88% (53 of 60) of PSR patients. Groups were comparable with respect to age, sex, duration of symptoms, mean duration of follow-up, and recurrence rates. Overall satisfaction with their current situation was 89% in MVD and 72% in PSR patients. Unsatisfied with the outcome were 4% of MVD and 20% of PSR patients, and this is a significant difference (P < 0.01). Satisfaction with outcome was higher in those undergoing this as a primary procedure. In the primary group, satisfaction was dependent on recurrence and complication/side effects status (each P < 0.01), but this was not the case in the nonprimary group. Patients expressed a desire for earlier posterior fossa surgery in 73% of MVD and 58% of PSR patients, and this was highest in the primary group. The final outcome was considered to be better than expected in 80% of MVD and 54% of PSR patients, but 22% of the PSR group (P < 0.01) thought they were worse off. Patients undergoing posterior fossa surgery as a primary procedure are most satisfied and PSR patients are least satisfied, partly because of a higher rate of side effects.

Reasons for Delay of Surgical Intervention in Adult Strabismus

It has been our impression that adult patients with strabismus frequently delay surgical intervention. To determine the length of time adult patients waited before undergoing strabismus surgery and to determine the reasons why these delays occurred. Prospective survey of consecutive patients who delayed strabismus surgery for more than 1 year. Preoperative survey. The primary outcome measure was time between the onset of strabismus and surgery and the reason why surgery had not been previously sought. The mean age among 128 study participants was 45.7 years (age range, 18-86 years). The mean time between the onset of current strabismus and surgery was 19.9 years (range, 1-72 years). The major reasons for delay in seeking surgical treatment included the following: surgery was never offered by eye care specialist (35 patients [27%]), surgery was offered but declined by the patient (29 patients [23%]), the patient had received prior satisfactory nonsurgical care (17 patients [13%]), the patient had never sought care (14 patients [11%]), the patient had a previous poor surgical experience (8 patients [6%]), and the patient had been told by their eye specialist that nothing could be done or that surgery could make them worse (8 patients [6%]). Strabismus surgery is often delayed for many years in adult patients who could potentially benefit from it. Almost half of such delays could be avoided by better education of the lay public and the medical community.

A pressão arterial e a freqüência cardíaca não são bons parâmetros para avaliação do nível de ansiedade pré-operatória

JUSTIFICATIVA E OBJETIVOS: Os pacientes cirurgicos sofrem graus variados de estresse psicologico no periodo pre-operatorio. Pacientes ansiosos podem apresentar reacoes psicossomaticas como hipertensao arterial e taquicardia. O objetivo deste estudo foi avaliar o nivel de ansiedade pre-operatoria em uma populacao de pacientes cirurgicos, detectar alteracoes de frequencia cardiaca e pressao arterial e sua relacao com idade, sexo, grau de instrucao e experiencia cirurgica previa. METODO: A 145 pacientes adultos, de ambos os sexos, estado fisico (ASA) I, II ou III, escolhidos aleatoriamente, perfeitamente orientados no tempo e no espaco, alfabetizados e escalados para cirurgias eletivas, foi aplicado o questionario de ansiedade pre-operatoria de Amsterda durante a consulta pre-anestesica. Foram considerados ansiosos os pacientes com escore igual ou maior que onze. Para cada paciente anotou-se o sexo, a idade, o grau de instrucao, a pressao arterial sistolica (PAS) e diastolica (PAD), a frequencia cardiaca (FC), a experiencia cirurgica previa e a historia de hipertensao arterial. RESULTADOS: Sessenta e nove pacientes (47,58%) apresentaram escores de ansiedade igual ou maior que onze (ansiosos), enquanto 76 pacientes (52,41%) apresentaram escores menores que onze (nao ansiosos). Nao houve diferenca significativa entre pacientes ansiosos e nao ansiosos quanto a idade, PAS, PAD e FC. Entre os pacientes ansiosos, 68,12% foram do sexo feminino e 31,88%, do sexo masculino, p < 0,05. Os pacientes ansiosos nao diferiram significativamente dos nao ansiosos em relacao as prevalencias de experiencia cirurgica previa, graus de instrucao e historia de hipertensao arterial. CONCLUSOES: A pressao arterial e a frequencia cardiaca nao refletem o nivel de ansiedade pre-operatoria. Pacientes do sexo feminino tem maiores probabilidades de apresentar ansiedade pre-operatoria do que pacientes do sexo masculino.

Surgical robotics: Impact of motion scaling on task performance

Robotic systems have been shown to enhance surgical dexterity, and the advantage has been hypothesized to result from the removal of tremor and addition of motion scaling. But these purported gains over traditional laparoscopic instrumentation have not been quantified. This study was designed to compare the surgical accuracy between conventional laparoscopic instruments and a robotic surgical system and evaluate the importance of tremor filtration (TF) and motion scaling (MS) in these robotic systems. Fifteen participants with no previous surgical experience were enrolled. To simulate microsurgical techniques, a 29-gauge needle was used to puncture the center of 6 microscopic archery targets (circle diameters 0.5, 1.5, and 2.5 mm). The robotic system was configured to three different degrees of MS and compared with the unassisted laparoscopic platforms in accuracy. Accuracy with robotic assistance with TF alone (1:1 MS) was not significantly different from unassisted laparoscopic control. Both moderate (2.5:1) and fine (7:1) MS significantly improved accuracy over traditional laparoscopic control (p < 0.001 for both). Robotic assistance with MS equalized the performance of both hands (p = 0.03) in precision, and manual laparoscopy demonstrated no statistical difference in handedness (p = 0.80). Motion scaling, rather than tremor filtration, plays the major role in the enhanced accuracy seen in robotic surgical systems. Robotic assistance with MS significantly improved accuracy above laparoscopic instruments alone and robotic assistance with tremor filtration alone. MS also creates ambidexterity in an otherwise unidextrous population, optimizing the surgeon's ability to undertake tasks requiring microsurgical accuracy.

Cost-adjusted surgical robotic performance: The plea for a cheaper robot

Despite their high cost, surgical robotic systems continue to gain prominence in the operating room. In this study, the initial performance of a diverse population of surgeons and surgical residents with no previous surgical robotics experience was characterized. The objectives of this study were (1) To compare the initial performance of different surgical robotic systems; (2) To determine the inter-robot transferability of skills acquired on a surgical robot; and (3) To determine if differences exist in the initial robotic surgery learning curve among surgeons of varying levels of surgical experience. A multi-institutional group of 38 surgeons and 28 surgeons-in-training were evaluated using three surgical skill tests: “paper cut,” “ring swap,” and “thread the needle.” Every participant was timed on each of two robots, Intuitive Surgical’s daVinci Surgical System and endoVia’s Laprotek System. The order in which the subjects were tested on each of the two robots was determined at random. Composite scores representing participant performance on each of the two robots and overall performance were calculated. The “paper cut” test took participants twice as long and the “ring swap” test took over three times as long on the Laprotek robot compared to the daVinci robot ( P < 0.0001 for both). However, when adjusted for robot cost ($1.25M for daVinci and $250K for Laprotek), scores were significantly better on the Laprotek robot for both tests ( P < 0.0001 for both). Participant times were significantly faster on each of the two robots among participants who had used the other robot first ( P < 0.05 for daVinci and P < 0.01 for Laprotek). A trend toward better overall performance on both robots was found among inexperienced surgeons compared to more experienced surgeons. Among surgeons with little or no previous surgical robotic experience, basic surgical tasks are easier to perform using the daVinci robot than using the Laprotek robot. However, daVinci’s relative ease of use may not justify its 5-fold greater cost. Basic surgical robotic skills acquired on one robot are transferable to use on a second robot. Less experienced “younger” surgeons may acquire basic surgical robotic skills faster than their more experienced “older” colleagues.