Use of targeted educational resources to improve robotic bariatric surgery training.

BACKGROUND: Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures. METHODS: Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied. RESULTS: From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5). CONCLUSION: Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

Video Interviews and Surgical Applicants' Ability to Assess Fit to Residency Programs.

INTRODUCTION: Due to the COVID-19 pandemic, the recruitment cycle for the 2021 Match was performed virtually. This Association for Surgical Education (ASE)-sponsored survey set out to study applicants' ability to assess the factors contributing to fit through video interviews. METHODS: An IRB-approved, online, anonymous survey was distributed to surgical applicants at a single academic institution and through the ASE clerkship director distribution list between the rank order list certification deadline and Match Day. Applicants used 5-point Likert-type scales to rate factors for importance to fit and their ease of assessment through video interviewing. A variety of recruitment activities were also rated by applicants for their perceived helpfulness in assessment of fit. RESULTS: One hundred and eighty-three applicants responded to the survey. The three most important factors for applicant fit were how much the program cared, how satisfied residents seem with their program, and how well residents get along. Resident rapport, diversity of the patient population, and quality of the facilities were hardest to assess through video interviews. In general, diversity-related factors were more important to female and non-White applicants, but not more difficult to assess. Interview day and resident-only virtual panels were the most helpful recruitment activities, while virtual campus tours, faculty-only panels, and a program's social media were the least helpful. CONCLUSIONS: This study provides valuable insight into the limitations of virtual recruitment for surgical applicants' perception of fit. These findings and the recommendations herein should be taken into consideration by residency program leadership to ensure successful recruitment of diverse residency classes.

Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. METHODS: This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. RESULTS: A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. CONCLUSIONS: Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.

The use of advanced robotic simulation labs to advance and assess senior resident robotic skills and operating room leadership competency: a pilot study.

BACKGROUND: General surgery has the fastest growing robotic operative volume in the United States, but most robotic curricula are focused on basic psychomotor skills. There are limited curricula focused on advanced robotic technical and related non-technical skills. We describe a novel pilot curriculum for robotic hiatal hernia repair developed for senior surgical residents to provide training and standardized assessment of higher-order robotic technical and leadership skills. METHODS: Twelve senior residents, post-graduate year (PGY) 4 & 5, participated in a robotic hiatal hernia repair skills curriculum. Residents completed a pre- and post-survey on confidence and ability ratings on a 5-point Likert-type Scale, and a knowledge assessment. An informal faculty-led didactic was provided prior to the simulation. Residents were scored on two validated assessment tools: Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) and Global Ratings Scale of Operative Performance (GRS) by faculty proctors. RESULTS: Confidence in ability to independently complete a robotic hiatal hernia case increased from mean of 2.6 ± 0.8 to 3.3 ± 0.6 (p = 0.0007). Following the simulation, residents reported increased overall confidence and ability to operate independently with mean scores of 3.3 ± 0.8 and 3.8 ± 0.9, respectively. Mean O-SCORE and GRS scores were 3.6 (range 2 - 4) and 25.4 (range 12 - 31), respectively. Number of prior live robotic cases was strongly positively correlated to O-SCORE (R = 0.84, p = 0.0006) and GRS (R = 0.88, p = 0.0002). CONCLUSION: Our pilot study suggests live-operative robotic training is not sufficient alone for advanced robotic skill training. Simulations such as this can be used to (1) practice advanced robotic technical and relevant non-technical skills such as communication and operating room leadership in a low stake setting and (2) assess residents in a standardized environment to eventually evaluate robotic competency.

Patient Factors Affect Ergonomic Strain of Endoscopists During Colonoscopy.

INTRODUCTION: Endoscopic procedures place a great deal of muscular strain on providers, especially over the span of their careers. In this study we quantitatively analyzed the effects of patient factors such as age, body mass index, and sex on the ergonomics of endoscopists performing colonoscopies. METHODS: Surface electromyography (sEMG) was used to measure ergonomic strain of physicians while performing colonoscopies in several key muscle groups. The percent of the maximum voluntary contraction (%MVC) was used as a measure of muscular strain. Data was then analyzed based on the patient characteristics above. RESULTS: Endoscopists performing colonoscopies on female patients (n = 47) experienced significantly higher ergonomic strain in their right trapezius and right posterior forearm muscle groups when compared to colonoscopies performed on males (n = 35) (%MVC R-trapezius: Male: 8.2; Female: 8.9; p = 0.048); (%MVC R-posterior forearm: Male: 10.4; Female: 11.6; p = 0.0006). Operators experienced greater strain in the same muscle groups when performing colonoscopies on patients with BMI ≤ 25 (n = 25) when compared to patients with BMI > 25 (n = 57) (%MVC R-trapezius: BMI < 25: 9.7; BMI ≥ 25: 8.2; p = 0.0002); (%MVC R-posterior forearm: BMI < 25: 11.9; BMI ≥ 25: 10.8; p = 0.0001). CONCLUSION: Physicians experienced greater ergonomic strain when performing colonoscopies on female patients and on patients with a BMI < 25. We believe that these factors potentially impact the tortuosity of the colon and therefore influence the difficulty of navigating the endoscope. These results may aid physicians in gauging the anticipated difficulty of colonoscopies based on patient factors. Increased awareness of their posturing and ergonomics during challenging cases will alleviate musculoskeletal injuries in the long run.

The case for a new post-graduate hernia designation: a review of fellowship council case logs from the past twelve-years.

BACKGROUND: The Fellowship Council (FC) is a robust accreditation body with numerous fellowships; however, no specific criteria exist for hernia fellowships. This study analyzed the case log database to evaluate trends in fellowship exposure to hernia repairs. METHODS: FC hernia case log records (2007-2019) were coded as inguinal or ventral hernias and with or without mesh repair. Retrospective analysis examined total hernia repairs logged, type of repair, program designation, and robotic adoption. Robotic adoption was categorized by quartiles of program performance according to the final year of analysis (2018-2019); yearly performance was then graphed by quartiles. RESULTS: Over this twelve-year period, 93,334 hernia repairs, 5 program designations, 152 unique programs and 1,558 unique fellows were analyzed. The number of fellows grew from 106 (2007-2008) to > 130 (2018-2019). Total hernias repairs per fellow increased from an average of 41.2 in 2007-2008 to 75.7 in 2018-2019 (183.7%). Open and robotic hernia repairs increased by 241.9% and 266.3%, respectively; laparoscopic hernia repairs decreased by 14.8%. Inguinal and ventral hernia repairs comprised 48.1% and 51.9% of total cases, respectively. Advanced GI/MIS and Advanced GI/MIS/Bariatrics programs logged the majority of hernia repairs (86.0-90.2%). 2014 began an exponential rise in robotic adoption, with fellows averaging < 1 robotic repairs before and > 25 repairs in 2019. A significant difference was found between all groups when comparing quartiles of robotic adopters (median robotic repairs per fellow; IQR): first quartile (72.0; 47.9-108.8), second quartile (25.5; 21.0-30.6), third quartile (13.0; 12.0-14.3) and fourth quartile (3.5; 0.5-5.0) (p-value < 0.05). CONCLUSIONS: This twelve-year analysis shows a near doubling in the growth of total hernia repairs, with a decrease in laparoscopic repairs as robotic repairs increased. These data show the importance of hernia repairs in FC fellows' training and warrant further granular analysis to determine specific accreditation criteria for hernia fellowship designations.

The Impact of Simulation Training on Operative Performance in General Surgery: Lessons Learned from a Prospective Randomized Trial.

BACKGROUND: Practice in the simulated environment can improve surgical skills. However, the transfer of open complex surgical skills to the operating room is unclear. This study evaluated the effect of resident operative performance following a simulation experience on a hand-sewn small bowel anastomosis and determined the impact of utilizing proficiency-based training. METHODS: Nine categorical interns performed a hand-sewn small bowel anastomosis in the operating room prior to (pre-test) and following (post-test) a 3-h simulation training session with an assessment at the end. Participants were randomly assigned to 1of 2 simulation training groups: proficiency-based or standard. Operative performance was videotaped. 2 independent, blinded faculty surgeons assessed performances by a global rating scale. Pre- and post-confidence levels were obtained on a 5-point Likert scale. RESULTS: Overall, pre-test and post-test operative performance was similar (3 [IQR, 2.5 -3.5] versus 3 [IQR, 3 -3], P = 0.59). Furthermore, no difference was observed in the post-test performance with proficiency-based or standard training (3 [IQR, 3 -3] versus 3 [IQR, 3 -3], P = 0.73). Self-reported confidence with the skills, however, significantly improved (median 1 versus 4, P = 0.007). CONCLUSIONS: In this prospective, randomized study, we did not observe an improvement in operative performance following simulation instruction and assessment, with both training groups. Overcoming barriers to skills transfer will be paramount in the future to optimize simulation training in general surgery. These findings highlight the importance of continued study for the ideal conditions and timing of technical skills training.

Smaller hands and less experience are associated with greater ergonomic strain during endoscopic procedures.

INTRODUCTION: Up to 89% of physicians who routinely perform endoscopy experience some type of musculoskeletal pain. In this study, we sought to quantitatively analyze provider factors that influence ergonomic strain during live endoscopic procedures. METHODS: Surface electromyography (sEMG) was used to measure ergonomic strain on physicians while performing upper and lower endoscopies. EMG data were normalized to a maximal voluntary contraction (MVC) recording for each muscle group, yielding a %MVC value. Subgroup analyses were performed based on glove size, physician training level, specialty, and handedness. RESULTS: A total of 165 upper (n = 68) and lower (n = 97) endoscopies were recorded. Endoscopists with small hand sizes had significantly higher ergonomic strain in the left anterior and posterior forearm muscle compartments as compared to endoscopists with medium or large hands (%MVC L-anterior: small: 9.1 ± 1.1; medium: 6.4 ± 1.2; large: 5.9 ± 1.6; p < 0.001); (%MVC L-posterior: small: 12.0 ± 0.8; medium: 9.4 ± 1.3; large: 8.8 ± 1.4; p < 0.001). Additionally, upper body muscle groups had significantly higher ergonomic strain in endoscopists with less lifetime endoscopic experience (%MVC R-trapezius: expert: 8.4 ± 1.2; novice: 9.3 ± 1.2; p < 0.05); (%MVC R-deltoid: expert: 6.1 ± 1.4; novice: 8.5 ± 1.3; p < 0.001). There were no significant ergonomic differences between surgeons or gastroenterologists and no differences between right- and left-handed dominant individuals. CONCLUSIONS: Endoscopists with small hands experienced great ergonomic strain in their left forearm. Our data support the widely held belief that "one size does not fit all" and will hopefully spark change in the design of future endoscopes by device manufacturers. Our data also support that the experience level of the endoscopist contributed significantly to ergonomic performance, likely due to postural differences leading to decreased upper body strain. Therefore, it remains critically important to educate young proceduralists on strategies for ergonomic relief early in his or her endoscopic training program that can ameliorate ergonomic strain that accrues over the lifetime of a physician's career.

Video is better: why aren't we using it? A mixed-methods study of the barriers to routine procedural video recording and case review.

INTRODUCTION: Video-based case review for minimally invasive surgery is immensely valuable for education and quality improvement. Video review can improve technical performance, shorten the learning curve, disseminate new procedures, and improve learner satisfaction. Despite these advantages, it is underutilized in many institutions. So far, research has focused on the benefits of video, and there is relatively little information on barriers to routine utilization. METHODS: A 36-question survey was developed on video-based case review and distributed to the SAGES email list. The survey included closed and open-ended questions. Numeric responses and Likert scales were compared with t-test; open-ended responses were reviewed qualitatively through rapid thematic analysis to identify themes and sub-themes. RESULTS: 642 people responded to the survey for a response rate of 11%. 584 (91%) thought video would improve the quality of educational conferences. 435 qualitative responses on the value of video were analyzed, and benefits included (1) improved understanding, (2) increased objectivity, (3) better teaching, and (4) better audience engagement. Qualitative comments regarding specific barriers to recording and editing case video identified challenges at all stages of the process, from (1) the decision to record a case, (2) starting the recording in the OR, (3) transferring and storing files, and (4) editing the file. Each step had its own specific challenges. CONCLUSION: Minimally invasive surgeons want to increase their utilization of video-based case review, but there are multiple practical challenges to overcome. Understanding these barriers is essential in order to increase use of video for education and quality improvement.

Applicants' perception of fit to residency programmes in the video-interview era: A large multidisciplinary survey.

INTRODUCTION: 'Fit' refers to an applicants' perceived compatibility to a residency programme. A variety of structural, identity-related and relational factors contribute to self-assessments of fit. The 2021 residency recruitment cycle in the USA was performed virtually due to the COVID-19 pandemic. Little is known about how video-interviewing may affect residency applicants' ability to gauge fit. METHODS: A multidisciplinary, anonymous survey was distributed to applicants at a large academic institution between rank order list (ROL) certification deadline and Match Day 2021. Using Likert-type scales, applicants rated factors for importance to 'fit' and their ease of assessment through video-interviewing. Applicants also self-assigned fit scores to the top-ranked programme in their ROL using Likert-type scales with pairs of anchoring statements. RESULTS: Four hundred seventy-three applicants responded to the survey (25.7% response rate). The three most important factors to applicants for assessment of fit (how much the programme seemed to care, how satisfied residents seem with their programme and how well the residents get along) were also the factors with the greatest discrepancy between importance and ease of assessment through video-interviewing. Diversity-related factors were more important to female applicants compared with males and to non-White applicants compared with White applicants. Furthermore, White male applicants self-assigned higher fit scores compared with other demographic groups. CONCLUSION: There is a marked discrepancy between the most important factors to applicants for fit and their ability to assess those factors virtually. Minoritised trainees self-assigned lower fit scores to their top-ranked programme, which should raise concern amongst medical educators and highlights the importance of expanding current diversity, equity and inclusion efforts in academic medicine.

Favorable peri-operative outcomes observed in paraesophageal hernia repair with robotic approach.

BACKGROUND: The robotic surgical approach offers enhanced visualization, dexterity and reach, which may facilitate the more technically demanding portions of paraesophageal hernia (PEH) repair such as hiatal reconstruction and mediastinal dissection. We sought to compare the peri-operative clinical outcomes of the laparoscopic vs. robotic approach to PEH repair. METHODS: A prospective, IRB-approved database was maintained for all robotic PEH repairs performed by a single surgeon at a tertiary academic hospital from 2009 to 2019. A retrospective review of laparoscopic PEH over this same time period was used as a comparison group. Outcome measures included: operative time, conversion to open, need for an esophageal lengthening procedure, operative equipment costs and length of stay (LOS). RESULTS: 1854 patients underwent PEH repair during this time period (830 robotic; 1024 laparoscopic). Demographics of both groups were similar, including BMI and PEH type, although a higher proportion of robotic cases were re-operative PEH repairs (32.5% vs 24.0%; p < 0.001). Patients who underwent a robotic PEH had a significant reduction in esophageal lengthening procedures performed (0.1% vs. 11.0%; p < 0.001), conversion to open (0% vs. 7.0%; p < 0.001), and LOS (1.8 days vs. 3.1 days; p < 0.001). Intra-operative equipment costs were similar. CONCLUSIONS: In one of the largest robotic PEH case series reported to date, there were significant improvements in peri-operative outcomes in patients undergoing a robotic-assisted approach. Although a greater number of patients in the robotic group were redo PEH repairs, when compared to the laparoscopic group, there were no conversions to open and significantly fewer esophageal lengthening procedures, both of which carry significant morbidity. The similar intra-operative costs were likely balanced by the higher costs associated with stapling equipment and conversions in the laparoscopic group. Our findings show that the robotic PEH repair is safe and can result in improved peri-operative outcomes.

Ergonomic analysis of laparoscopic and robotic surgical task performance at various experience levels.

INTRODUCTION: Traditional laparoscopic surgery (TLS) has increasingly been associated with physical muscle strain for the operating surgeon. Robot-assisted laparoscopic surgery (RALS) may offer improved ergonomics. Ergonomics for the surgeon on these two platforms can be compared using surface electromyography (sEMG) to measure muscle activation, and the National Aeronautics and Space Administration Task Load Index (NTLX) survey to assess workload subjectively. METHODS: Subjects were recruited and divided into groups according to level of expertise in traditional laparoscopic (TLS) and robot-assisted laparoscopic surgery (RALS): novice, traditional laparoscopic surgeons (TL surgeons), robot-assisted laparoscopic surgeons (RAL surgeons). Each subject performed three fundamentals of laparoscopic surgery (FLS) tasks in randomized order while sEMG data were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. After completing all tasks, subjects completed the NTLX survey. sEMG data normalized to the maximum voluntary contraction of each muscle (MVC%), and NTLX data were compared with unpaired t tests and considered significant with a p ≤ 0.05. RESULTS: Muscle activation was higher during TLS compared to RALS in most muscle groups for novices except for the trapezius muscles. Muscle activation scores were also higher for TLS among the groups with more experience, but the differences were less significant. NTLX scores were higher for the TLS platform compared to the RALS platform for novices. DISCUSSION: TLS is associated with higher muscle activation in all muscle groups except for trapezius muscles, suggesting greater strain on the surgeon. Increased trapezius muscle activation on RALS has previously been documented and is likely due to the position of the eye piece. The differences seen in muscle activation diminish with increasing levels of expertise. Experience likely mitigates the ergonomic disadvantage of TLS. NTLX survey data suggest there are subjective benefits to RALS, namely in the perception of temporal demand. Further research to correlate NTLX data and sEMG measurements, and to investigate whether these metrics affect patient outcomes is warranted.

Comparison of precision and speed in laparoscopic and robot-assisted surgical task performance.

BACKGROUND: Robotic platforms have the potential advantage of providing additional dexterity and precision to surgeons while performing complex laparoscopic tasks, especially for those in training. Few quantitative evaluations of surgical task performance comparing laparoscopic and robotic platforms among surgeons of varying experience levels have been done. We compared measures of quality and efficiency of Fundamentals of Laparoscopic Surgery task performance on these platforms in novices and experienced laparoscopic and robotic surgeons. METHODS: Fourteen novices, 12 expert laparoscopic surgeons (>100 laparoscopic procedures performed, no robotics experience), and five expert robotic surgeons (>25 robotic procedures performed) performed three Fundamentals of Laparoscopic Surgery tasks on both laparoscopic and robotic platforms: peg transfer (PT), pattern cutting (PC), and intracorporeal suturing. All tasks were repeated three times by each subject on each platform in a randomized order. Mean completion times and mean errors per trial (EPT) were calculated for each task on both platforms. Results were compared using Student's t-test (P < 0.05 considered statistically significant). RESULTS: Among novices, greater errors were noted during laparoscopic PC (Lap 2.21 versus Robot 0.88 EPT, P < 0.001). Among expert laparoscopists, greater errors were noted during laparoscopic PT compared with robotic (PT: Lap 0.14 versus Robot 0.00 EPT, P = 0.04). Among expert robotic surgeons, greater errors were noted during laparoscopic PC compared with robotic (Lap 0.80 versus Robot 0.13 EPT, P = 0.02). Among expert laparoscopists, task performance was slower on the robotic platform compared with laparoscopy. In comparisons of expert laparoscopists performing tasks on the laparoscopic platform and expert robotic surgeons performing tasks on the robotic platform, expert robotic surgeons demonstrated fewer errors during the PC task (P = 0.009). CONCLUSIONS: Robotic assistance provided a reduction in errors at all experience levels for some laparoscopic tasks, but no benefit in the speed of task performance. Robotic assistance may provide some benefit in precision of surgical task performance.

Which causes more ergonomic stress: Laparoscopic or open surgery?

BACKGROUND: There is increasing awareness of potential ergonomic challenges experienced by the laparoscopic surgeon. The purpose of this study is to quantify and compare the ergonomic stress experienced by a surgeon while performing open versus laparoscopic portions of a procedure. We hypothesize that a surgeon will experience greater ergonomic stress when performing laparoscopic surgery. METHODS: We designed a study to measure upper-body muscle activation during the laparoscopic and open portions of sigmoid colectomies in a single surgeon. A sample of five cases was recorded over a two-month time span. Each case contained significant portions of laparoscopic and open surgery. We obtained whole-case electromyography (EMG) tracings from bilateral biceps, triceps, deltoid, and trapezius muscles. After normalization to a maximum voltage of contraction (%MVC), these EMG tracings were used to calculate average muscle activation during the open and laparoscopic segments of each procedure. Paired Student's t test was used to compare the average muscle activation between the two groups (*p < 0.05 considered statistically significant). RESULTS: Significant reductions in mean muscle activation in laparoscopic compared to open procedures were noted for the left triceps (4.07 ± 0.44% open vs. 2.65 ± 0.54% lap, 35% reduction), left deltoid (2.43 ± 0.45% open vs. 1.32 ± 0.16% lap, 46% reduction), left trapezius (9.93 ± 0.1.95% open vs. 4.61 ± 0.67% lap, 54% reduction), right triceps (2.94 ± 0.62% open vs. 1.85 ± 0.28% lap, 37% reduction), and right trapezius (10.20 ± 2.12% open vs. 4.69 ± 1.18% lap, 54% reduction). CONCLUSIONS: Contrary to our hypothesis, the laparoscopic approach provided ergonomic benefit in several upper-body muscle groups compared to the open approach. This may be due to the greater reach of laparoscopic instruments and camera in the lower abdomen/pelvis. Patient body habitus may also have less of an effect in the laparoscopic compared to open approach. Future studies with multiple subjects and different types of procedures are planned to further investigate these findings.

Ergonomic analysis of primary and assistant surgical roles.

BACKGROUND: Laparoscopic surgery is associated with a high degree of ergonomic stress. However, the stress associated with surgical assisting is not known. In this study, we compare the ergonomic stress associated with primary and assistant surgical roles during laparoscopic surgery. We hypothesize that higher ergonomic stress will be detected in the primary operating surgeon when compared with the surgical assistant. METHODS: One right-hand dominant attending surgeon performed 698 min of laparoscopic surgery over 13 procedures (222 min primary and 476 min assisting), whereas electromyography data were collected from bilateral biceps, triceps, deltoids, and trapezius muscles. Data were analyzed in 1-min segments. Average muscle activation as quantified by maximal voluntary contraction (%MVC) was calculated for each muscle group during primary surgery and assisting. We compared mean %MVC values with unpaired t-tests. RESULTS: Activation of right (R) biceps and triceps muscle groups is significantly elevated while operating when compared with assisting (R biceps primary: 5.47 ± 0.21 %MVC, assistant: 3.93 ± 0.11, P < 0.001; R triceps primary: 6.53 ± 0.33 %MVC, assistant: 5.48 ± 0.18, P = 0.002). Mean activation of the left trapezius muscle group is elevated during assisting (primary: 4.33 ± 0.26 %MVC, assistant: 5.70 ± 0.40, P = 0.024). No significance difference was noted in the other muscle groups (R deltoid, R trapezius, left [L] biceps, L triceps, and L deltoid). CONCLUSIONS: We used surface electromyography to quantify ergonomic differences between operating and assisting. Surgical assisting was associated with similar and occasionally higher levels of muscle activation compared with primary operating. These findings suggest that surgical assistants face significant ergonomic stress, just as operating surgeons do. Steps must be taken to recognize and mitigate this stress in both operating surgeons and assistants.

Transfer and priming of surgical skills across minimally invasive surgical platforms.

BACKGROUND: Robot-assisted laparoscopic surgery (RALS) uses 3-dimensional visualization and wristed instruments that provide more degrees of freedom than rigid traditional laparoscopic (TLS) instrumentation. These features have been touted to improve accuracy and efficiency during surgical task performance. Little is known, however, about the transferability of skills between the two platforms or whether task performance on one platform primes surgeons for task performance on the other. METHODS: Twenty-six subjects naïve to RALS were recruited to perform three Fundamentals of Laparoscopic Surgery tasks on both TLS and RALS platforms: peg transfer, pattern cutting (PC), and intracorporeal suturing. All tasks were performed within Fundamentals of Laparoscopic Surgery testing parameters and repeated three times by each subject on each platform. Platform and task order were randomized. Errors in task performance were defined as drops in the peg transfer task, faults 5 mm or more from the defined pattern during PC, and faults greater than 1 mm in suture placement from the defined points in intracorporeal suturing. Mean completion times and mean errors per trial (EPT) were calculated for each task on both platforms. Results were compared between those who performed TLS first (LF) and those who performed RALS first (RF) using unpaired Student's t-test (P < 0.05 considered statistically significant). RESULTS: No statistically significant differences in task completion time were noted between the LF and RF groups. RF subjects had fewer errors during robotic PC than LF subjects (1.02 EPT versus 1.86 EPT, respectively; P = 0.02). No other differences in task quality were noted. CONCLUSIONS: In surgeon's naïve to RALS, there is no evidence that skills acquired on RALS or TLS platforms are transferable to the other platform or that performing tasks on one platform primes a subject for task performance on the other. Performing TLS PC may have had a negative impact on subsequent RALS PC performance. These findings suggest that distinct programs for skills acquisition are necessary for both the TLS and RALS platforms.

FLS tasks can be used as an ergonomic discriminator between laparoscopic and robotic surgery.

INTRODUCTION: Robotic surgery may result in ergonomic benefits to surgeons. In this pilot study, we utilize surface electromyography (sEMG) to describe a method for identifying ergonomic differences between laparoscopic and robotic platforms using validated Fundamentals of Laparoscopic Surgery (FLS) tasks. We hypothesize that FLS task performance on laparoscopic and robotic surgical platforms will produce significant differences in mean muscle activation, as quantified by sEMG. METHODS: Six right-hand-dominant subjects with varying experience performed FLS peg transfer (PT), pattern cutting (PC), and intracorporeal suturing (IS) tasks on laparoscopic and robotic platforms. sEMG measurements were obtained from each subject's bilateral bicep, tricep, deltoid, and trapezius muscles. EMG measurements were normalized to the maximum voluntary contraction (MVC) of each muscle of each subject. Subjects repeated each task three times per platform, and mean values used for pooled analysis. Average normalized muscle activation (%MVC) was calculated for each muscle group in all subjects for each FLS task. We compared mean %MVC values with paired t tests and considered differences with a p value less than 0.05 to be statistically significant. RESULTS: Mean activation of right bicep (2.7 %MVC lap, 1.3 %MVC robotic, p = 0.019) and right deltoid muscles (2.4 %MVC lap, 1.0 %MVC robotic, p = 0.019) were significantly elevated during the laparoscopic compared to the robotic IS task. The mean activation of the right trapezius muscle was significantly elevated during robotic compared to the laparoscopic PT (1.6 %MVC lap, 3.5 %MVC robotic, p = 0.040) and PC (1.3 %MVC lap, 3.6 %MVC robotic, p = 0.0018) tasks. CONCLUSIONS: FLS tasks are validated, readily available instruments that are feasible for use in demonstrating ergonomic differences between surgical platforms. In this study, we used FLS tasks to compare mean muscle activation of four muscle groups during laparoscopic and robotic task performance. FLS tasks can serve as the basis for larger studies to further describe ergonomic differences between laparoscopic and robotic surgery.