A Study on the Knowledge, Awareness, Perceptions and Behaviour (KAPB) of Students of the University of the West Indies, St. Augustine (UWI-STA) Towards Climate Change and its Impact on Human Health

Climate change (CC) is defined as long-term weather changes in the Earth's climate. CC has been linked to increased global temperatures. This affects human health both directly and indirectly: Directly, via increased risk of cardiovascular, respiratory, and vector-borne diseases. Indirectly, via reduced agricultural crop yields and accessibility to healthcare due to extreme weather events. Studies show that spreading awareness on the health impacts of CC encourages motivation towards mitigation (1). Early awareness of climate change and its health impacts is necessary for future generations to mitigate its effects.

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention.

BACKGROUND: The prevalence of diabetes is increasing rapidly. Given its pro-inflammatory nature, comorbid diabetes may affect the course of Crohn's disease (CD). AIM: To determine whether comorbid diabetes influences the natural history of CD. METHODS: We compared a cohort with CD and comorbid diabetes to a nondiabetic control population and calculated the period prevalence of surgical intervention over a 5-year period. Unadjusted and adjusted odds-ratios were calculated regarding the need for surgical intervention using univariate and multivariate logistic regression. RESULTS: A total of 240 patients were identified, 16 of whom were diabetics (6.7%). The period prevalence of CD-specific surgery in the diabetic cases was 75.0% and in the nondiabetic controls, 31.7%. The diabetic patients were more obese than the controls (44% vs. 10%; P < 0.0001) and older than the controls (47.4 years vs. 38.6; P < 0.01). There was no difference in the frequency of biologic therapy use, immunomodulator use, smoking, perianal disease, ileal involvement or corticosteroid use between the diabetics and controls. Univariate analysis revealed that diabetes (OR 6.46 [95% CI 2.01-20.8]), smoking (OR 2.46 [95% CI 1.24-4.90]), ileal disease (OR 2.21 [95% CI 1.15-4.24]) and obesity (OR 2.22 [95% CI 1.04-4.77]) were risk factors for needing surgery. After adjustment for covariates, the OR for surgical intervention in diabetics was 5.4 (95% CI 1.65-17.64). CONCLUSION: Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention.

Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis.

Surgical intervention in patients with infected necrotizing pancreatitis generally consists of laparotomy and necrosectomy. This is an invasive procedure that is associated with high morbidity and mortality rates. In this report, we present an alternative minimally invasive technique: videoscopic assisted retroperitoneal debridement (VARD). This technique can be considered a hybrid between endoscopic and open retroperitoneal necrosectomy. A detailed technical description is provided and the advantages over various other minimally invasive retroperitoneal techniques are discussed.

Identifying and reducing errors with surgical simulation.

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Robotic surgery: identifying the learning curve through objective measurement of skill.

BACKGROUND: The incorporation of new devices into surgical practice often requires that surgeons acquire and master new skills. We studied the learning curve for intracorporeal knot tying in robotic surgery. METHODS: We developed an objective scoring system to evaluate knot tying and tested eight attending surgeons during 3 weeks of training on a surgical robot. Each performed intracorporeal knot tying tasks both before and after robotic skills training. These performances were compared to their laparoscopic knots and analyzed to determine and define skill improvement. RESULTS: Baseline laparoscopic knot completion took 140 sec (range, 47-432), with a mean composite score of 77 (100 possible), whereas robotic knot tying took 390 sec, with a mean composite score of 40. After initial robotic training, times decreased by 65% to 139 sec and scores increased to 71. With more training, completion times and composite scores were improved and errors were reduced. CONCLUSION: Like any new technology, surgical robotics requires dedicated training to achieve mastery. Initially, even experienced laparoscopists may register an inferior performance. However, after adequate training, surgeons can exceed their laparoscopic performance, completing intracorporeal knots better and faster using robotics.

Combined use of high-frequency jet ventilation and abdominal lift for laparoscopic cholecystectomy in a patient with glottic impairment.

Effective airway management during laparoscopic anesthesia is important to minimize the adverse consequences of the carbon dioxide (CO2) pneumoperitoneum (PP). During PP, reduced respiratory excursion and tidal volumes with increased CO2 absorption may lead to hypoxia, hypercapnia, and respiratory acidosis. Although these problems can usually be avoided by use of positive pressure ventilation and an endotracheal tube, patients with a restricted airway who cannot be intubated pose a unique challenge. High-frequency jet ventilation (HFJV) has been described as an alternative to endotracheal intubation in other settings. The use of the small-diameter jet tube allows relatively unobstructed access to the larynx during laryngeal surgery. In patients with glottic impairment related to vocal fold immobility, jet ventilation allows positive pressure ventilation without the use of an endotracheal tube or tracheostomy in cases where lung and diaphragmatic compliance permit adequate excursion for ventilation and glottal diameter permits an adequate outflow of air. In this report, we describe the successful use of HFJV combined with an abdominal lifting technique and low-pressure PP for laparoscopic surgery in a patient with glottic compromise related to vocal fold immobility. Using these techniques, a laparoscopic cholecystectomy was performed successfully without endotracheal intubation or the need for a tracheostomy.

A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess.

BACKGROUND: Percutaneous drainage has been shown to be an acceptable method for treating both pancreatic abscesses and infected pancreatic necrosis. However, percutaneous techniques have certain shortcomings, including the time and labor required and failure of the catheters to adequately drain the particulate debris. Growing experience around the world indicates that there is a role for retroperitoneal laparoscopy as a means of facilitating the percutaneous drainage of infected pancreatic fluid collections and avoiding a laparotomy. Our technique is discussed in this paper. METHODS: Once infection is documented in a pancreatic fluid collection by fine-needle aspiration, one or more percutaneous drains are placed into the fluid collection(s). A computed tomography (CT) scan is repeated. If further drainage is indicated, retroperitoneoscopic debridement is performed. Using a combination of the percutaneous drain(s) and the post-drain CT scan, ports are placed and retroperitoneoscopic debridement of the necrosectum is performed under direct visualization. Prior to completion of the operation, a postoperative lavage system is created. RESULTS: Six patients with infected pancreatic necrosis have been treated with this technique. Prior to commencement of our laparoscopic protocol, all six patients would have required open necrosectomy. Four of the six patients were managed with retroperitoneoscopic debridement and catheter drainage alone. Complications included a colocutaneous fistula and a small flank hernia. There were no bleeding complications and no deaths. CONCLUSION: Although open necrosectomy remains the standard of care for the treatment of infected pancreatic necrosis and pancreatic abscess, there is growing evidence that laparoscopic retroperitoneal debridement is feasible.

Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography: adverse outcome or preventable error?

BACKGROUND: Common bile duct (CBD) injury is a serious complication of laparoscopic cholecystectomy (LC). Predictors of this adverse outcome have not been well documented. HYPOTHESIS: Surgeon experience and the use of intraoperative cholangiography (IOC) are associated with a decreased rate of major CBD injury during LC. DESIGN: A retrospective population-based cohort study. SETTING: Washington State hospital discharge database reports from 1991 through 1998. PATIENTS: Discharge reports were searched for International Classification of Diseases, Ninth Revision, procedure codes consistent with LC and then evaluated for procedure codes for CBD repair and reconstruction within 90 days of LC. MAIN OUTCOME MEASURE: The rate of CBD injury in patients undergoing LC based on the surgeon's experience and IOC use. RESULTS: In all, 30 630 LCs and 76 major CBD injuries (2.5/1000 operations) were identified in this analysis. There were no significant differences between injured and noninjured patients in demographics, disease, payer status, or hospital variables. A CBD injury occurred in 3.2 of 1000 LCs in the early case order of surgeons compared with 1.7 per 1000 at later points (P = .01) (relative risk, 1.81; 95% confidence interval, 1.44-2.88). The rate of injury in LCs performed without IOC was 3.3 per 1000 compared with 2.0 per 1000 in LCs with IOC (P = .02) (relative risk, 1.7; 95% confidence interval, 1.1-2.6). Surgeon's experience and IOC use were independent predictors of injury. CONCLUSIONS: The rate of CBD injury is significantly lower when IOC is used. This effect is magnified during the early experience of surgeons. Systematic use of IOC may significantly reduce the rate of CBD injury.

Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis.

BACKGROUND: Percutaneous drainage of infected pancreatic fluid collections is often unsuccessful. Alternatively, open necrosectomy techniques are very morbid. We hypothesized that in selected cases, laparoscopic techniques could be used to facilitate percutaneous drainage of the residual particulate necrosectum and avoid a laparotomy. We report our experience with laparoscopic assisted retroperitoneal debridement as an adjunct to percutaneous drainage for patients with infected pancreatic necrosis. METHODS: Case studies were reviewed retrospectively. We analyzed the course of six patients undergoing laparoscopic assisted debridement of infected pancreatic necrosis after failure of percutaneous drainage. With the drains and computed tomography (CT) scan used as a guide, laparoscopic debridement of the necrosectum was performed. RESULTS: Between November 1995 and December 1999, six patients were treated with this method. In four patients, laparoscopic assisted percutaneous drainage was successful. Two patients required open laparotomy. Complications included a self-limited enterocutaneous fistula and a small flank hernia. No deaths occurred. CONCLUSIONS: This early, limited experience has demonstrated the feasibility of laparoscopic assisted percutaneous drainage for infected pancreatic necrosis. With this technique, two-thirds of our patients avoided the morbidity of a laparotomy.

Markov modeling of minimally invasive surgery based on tool/tissue interaction and force/torque signatures for evaluating surgical skills.

The best method of training for laparoscopic surgical skills is controversial. Some advocate observation in the operating room, while others promote animal and simulated models or a combination of surgery-related tasks. A crucial process in surgical education is to evaluate the level of surgical skills. For laparoscopic surgery, skill evaluation is traditionally performed subjectively by experts grading a video of a procedure performed by a student. By its nature, this process uses fuzzy criteria. The objective of the current study was to develop and assess a skill scale using Markov models (MMs). Ten surgeons [five novice surgeons (NS); five expert surgeons (ES)] performed a cholecystectomy and Nissen fundoplication in a porcine model. An instrumented laparoscopic grasper equipped with a three-axis force/torque (F/T) sensor was used to measure the forces/torques at the hand/tool interface synchronized with a video of the tool operative maneuvers. A synthesis of frame-by-frame video analysis and a vector quantization algorithm, allowed to define F/T signatures associated with 14 different types of tool/tissue interactions. The magnitude of F/T applied by NS and ES were significantly different (p < 0.05) and varied based on the task being performed. High F/T magnitudes were applied by NS compared with ES while performing tissue manipulation and vise versa in tasks involved tissue dissection. From each step of the surgical procedures, two MMs were developed representing the performance of three surgeons out of the five in the ES and NS groups. The data obtained by the remaining two surgeons in each group were used for evaluating the performance scale. The final result was a surgical performance index which represented a ratio of statistical similarity between the examined surgeon's MM and the MM of NS and ES. The difference between the performance index value, for a surgeon under study, and the NS/ES boundary, indicated the level of expertise in the surgeon's own group. Using this index, 87.5% of the surgical procedures were correctly classified into the NS and ES groups. The 12.5% of the procedures that were misclassified were performed by the ES and classified as NS. However in these cases the performance index values were very close to the NS/ES boundary. Preliminary data suggest that a performance index based on MM and F/T signatures provides an objective means of distinguishing NS from ES. In addition, this methodology can be further applied to evaluate haptic virtual reality surgical simulators for improving realism in surgical education.

Effects of geared motor characteristics on tactile perception of tissue stiffness.

Endoscopic haptic surgical devices have shown promise in addressing the loss of tactile sensation associated with minimally invasive surgery. However, these devices must be capable of generating forces and torques similar to those applied on the tissue with a standard endoscopic tool. Geared motors are a possible solution for actuation; however, they possess mechanical characteristics that could potentially interfere with tactile perception of tissue qualities. The aim of the current research was to determine how the characteristics of a geared motor suitable for a haptic surgical device affect a user's perception of stiffness. The experiment involved six blindfolded subjects who were asked to discriminate the stiffness of six distinct silicone rubber samples whose mechanical properties are similar to those of soft tissue. Using a novel testing device whose dimensions approximated those of an endoscopic grasper, each subject palpated 30 permutations of sample pairs for each of three types of mechanical loads; the motor (friction and inertia), a flywheel (with the same inertia as motor), and a control (no significant mechanical interference). One factor ANOVA of the error scores and palpation time showed that no significant difference existed among error scores, but mean palpation time for the control was significantly less than for the other two methods. These results indicated that the mechanical characteristics of a geared motor chosen for application in a haptic surgical device did not interfere with the subjects' perception of the silicone samples' stiffness, but these characteristics may significantly affect the energy expenditure and time required for tissue palpation. Therefore, before geared motors can be considered for use in haptic surgical devices, consideration should be given to factors such as palpation speed and fatigue.

Objective laparoscopic skills assessments of surgical residents using Hidden Markov Models based on haptic information and tool/tissue interactions.

UNLABELLED: Laparoscopic surgical skills evaluation of surgery residents is usually a subjective process, carried out in the operating room by senior surgeons. By its nature, this process is performed using fuzzy criteria. The objective of the current study was to develop and assess an objective laparoscopic surgical skill scale using Hidden Markov Models (HMM) based on haptic information, tool/tissue interactions and visual task decomposition. METHODS: Eight subjects (six surgical trainees: first year surgical residents 2 x R1, third year surgical residents 2 x R3 fifth year surgical residents 2 x R5; and two expert laparoscopic surgeons: 2 x ES) performed laparoscopic cholecystectomy following a specific 7 steps protocol on a pig. An instrumented laparoscopic grasper equipped with a three-axis force/torque sensor located at the proximal end with an additional force sensor located on the handle, was used to measure the forces and torques. The hand/tool interface force/torque data was synchronized with a video of the tool operative maneuvers. A synthesis of frame-by-frame video analysis was used to define 14 different types of tool/tissue interactions, each one associated with unique force/torque (F/T) signatures. HMMs were developed for each subject representing the surgical skills by defining the various tool/tissue interactions as states and the associated F/T signatures as observations. The statistical distance between the HMMs representing residents at different levels of their training and the HMMs of expert surgeons were calculated in order to generate a learning curve of selected steps during laparoscopic cholecystectomy. RESULTS: Comparison of HMM's between groups showed significant differences between all skill levels, supporting the objective definition of a learning curve. The major differences between skill levels were: (i) magnitudes of F/T applied (ii) types of tool/tissue interactions used and the transition between them and (iii) time intervals spent in each tool/tissue interaction and the overall completion time. The objective HMM analysis showed that the greatest difference in performance was between R1 and R3 groups and then decreased as the level of expertise increased, suggesting that significant laparoscopic surgical capability develops between the first and the third years of their residency training. The power of the methodology using HMM for objective surgical skill assessment arises from the fact that it compiles enormous amount of data regarding different aspects of surgical skill into a very compact model that can be translated into a single number representing the distance from expert performance. Moreover, the methodology is not limited to in-vivo condition as demonstrated in the current study. It can be extended to other modalities such as measuring performance in surgical simulators and robotic systems.

Computed tomography-guided neurolytic celiac plexus block with alcohol complicated by superior mesenteric venous thrombosis.

Neurolytic celiac plexus block (CPB) under radiological guidance is often performed to manage pain associated with pancreatic cancer. Serious complications related to the block are rare. Computed Tomography (CT)-guided neurolytic CPB is advocated to improve the efficacy of the block and to reduce the incidence of associated complications. We describe a case of superior mesenteric vein thrombosis associated with neurolytic CPB performed under CT guidance.

Laparoscopic surgical simulator and port placement study.

We have developed a virtual laparoscopic surgical simulator and gathered data during student trial runs. The students performed simulated surgical dissections from 3 pairs of port positions with angles between the cutting and grasping instruments set to 60, 90, and 120 degrees. Preliminary data indicates improved performance at the 90 degree angle. Study updates can be found at http:¿www.hitl.washington.edu/research/lss

Hidden Markov models of minimally invasive surgery.

A crucial process in surgical education is to evaluate the level of surgical skills. For laparoscopic surgery, skill evaluation is traditionally preformed subjectively by experts grading a video of a procedure performed by a student. By its nature, this process is preformed using fuzzy criteria. The objective of the current study was to develop and assess a skill scale using Discrete Hidden Markov Models (DHMM). Ten surgeons (5 Novice Surgeons--NS; 5 Expert Surgeons--ES) performed a cholecystectomy and Nissen fundoplication in a porcine model. An instrumented laparoscopic grasper equipped with a three-axis force/torque sensor was used to measure the forces/torques at the hand/tool interface synchronized with a video of the tool operative maneuvers. A synthesis of frame-by-frame video analysis and a vector quantization algorithm, defined force/torque signatures for 14 types of tool/tissue interactions. From each step of the surgical procedures, two DHMM were developed representing the performance of 3 surgeons randomly selected from the 5 in the ES and NS groups. The data obtained by the remaining 2 surgeons in each group were used for evaluating the performance scale. The final result was a surgical performance index which represented a ratio of statistical similarity between the examined surgeon's DHMM and the DHMM of NS and ES. The difference between the performance index value, for a surgeon under study, and the NS/ES boundary, was considered to indicate the level of expertise in the surgeon's own group. Using this index, 87.5% of the surgical procedures were correctly classified into the NS and ES groups. The 12.5% of the procedures that were misclassified were preformed by the ES and classified as NS. However, in these cases the performance index values were very close to the NS/ES boundary. Preliminary data suggest that a performance index based on DHMM and force/torque signatures provides an objective means of distinguishing NS from ES. In addition this methodology can be further applied to evaluate haptic virtual reality surgical simulators for improving realism in surgical education.

Videoendoscopic techniques for collection of multiple, serial intra-abdominal biopsy specimens in HIV-negative and HIV-positive pigtail macaques (Macaca nemestrina).

Tissue biopsy sampling by laparotomy is considered major surgery, which precludes serial sampling. This increases variability and requires a larger n value for pathogenesis studies. To address this problem, a study was conducted to develop and validate the feasibility of performing multiple, serial biopsy sampling by laparoscopy in pigtail macaques. Tissues were obtained laparoscopically from 2 HIV-negative and 2 HIV-positive (late postinoculation) macaques on days 0, 3, and 7, followed by necropsy on day 21. Anesthesia was induced with ketamine and atropine and maintained with isoflurane. Carbon dioxide pneumoperitoneum was maintained at 6 mm Hg. A triangulated threeport technique was used for insertion of pediatric (3.5-5.0 mm) laparoscopic instrumentation. Biopsies of kidney and spleen were obtained with a core-sampling biopsy needle, of small intestine and mesenteric lymph node with a pretied loop, and of liver with 3.5-5.0 mm biopsy forceps. Analgesics were administered for 24 h post operation, and animals were evaluated for postoperative complications. All monkeys maintained a good appetite. Mild postoperative pain was observed in one animal after the second surgery. There was no excessive bleeding or intestinal stenosis at biopsy sites. Skin infection, observed in 1/36 (2.8%) port sites, resolved with systemic antibiotics. Significant adhesions formed at 23/114 (20.2%) sites. Out of 34 samples evaluated for histopathology, 29 (85.3%) were satisfactory (minimal to mild tissue crushing). In situ hybridization results revealed few (4 of 29 samples tested) positive cells, which is consistent with the low level of HIV-2 virus found in cells late in the postinoculation period in pigtail macaques. The results of this study suggest that laparoscopic serial abdominal biopsy collection in healthy and immunocompromised pigtail macaques may be considered a minor procedure, and can be used to expedite serial tissue collection in survival studies.

Skills evaluation in minimally invasive surgery using force/torque signatures.

BACKGROUND: One of the more difficult tasks in surgical education is to teach the optimal application of instrument forces and torques necessary to facilitate the conduct of an operation. For laparoscopic surgery, this type of training has traditionally taken place in the operating room, reducing operating room efficiency and potentially affecting the safe conduct of the operation. The objective of the current study was to measure and compare forces and torques (F/T) applied at the tool/hand interface generated during laparoscopic surgery by novice (NS) and experienced (ES) surgeons using an instrumented laparoscopic grasper and to use this data for evaluating the skill level. METHODS: Ten surgeons (five-NS, five-ES) performed a cholecystectomy and Nissen fundoplication in a porcine model. An instrumented laparoscopic grasper with interchangeable standard surgical tips equipped with a three-axis F/T sensor located at the proximal end of the grasper tube was used to measure the F/T at the hand/tool interface. In addition, one axis force sensor located at the grasper's handle was used to measure the grasping force. F/T data synchronized with visual view of the tool operative maneuvers were collected simultaneously via a novel graphic user interface incorporated picture-in-picture video technology. Subsequent frame-by-frame video analysis of the operation allowed a definition of states associated with different tool/tissue interactions within each step of the operation. F/T measured within each state were further analyzed using vector quantization (VQ). The VQ analysis defines characteristic sets of F/T in the database that were defined as F/T signature. RESULTS: The magnitude of F/T applied by NS and ES were significantly different (p < 0.05) and varied based on the task being performed. Higher F/T magnitudes were applied by NS than by ES when performing tissue manipulation, whereas lower F/T magnitudes were applied by NS than by ES during tissue dissection. Furthermore, the time to complete the surgical procedure was longer for NS by a factor of 1.5-4.8 when compared to the time for ES. State analysis suggests that most of this time is consumed in an [idle] state, in which movements of the surgeon make no tissue contact. CONCLUSIONS: Preliminary data suggest that F/T magnitudes associated with the tool/tissue interactions provide an objective means of distinguishing novices from skilled surgeons. Clinical F/T analysis using the proposed technology and methodology may be helpful in training, developing surgical simulators, and measuring technical proficiency during laparoscopic surgery.

Formula for surgical practice resuscitation in an academic medical center.

BACKGROUND: Managing patient referrals for surgical consultation in an academic practice has traditionally emphasized clinical rather than service expertise. However, assuring both efficiency and accuracy in the initial consultation have become critical early measures of quality care. METHODS: In partnership with the academic medical center administration, current practice was analyzed. Performance and communication standards were established around an ideal patient experience. A new ambulatory consultation process was developed; and flowcharting methods for resource allocation, statistical process control, and pre-visit data collection were used to reduce patient administrative time. Automated referral reports engaged referring physicians throughout the consultation. RESULTS: Accurate insurance and referral authorization have been provided for all patients, including the 4% who are underinsured. Patient, provider, and referring physician satisfaction has increased significantly. Staff time investment has progressively declined from 52 +/- 11 (95% confidence) minutes to 34 +/- 10 minutes for most patients. Realignment of tasks has reduced the administrative time spent by the patient by 32% without compromising clinical time. New patient volume increased by 29% per year, maintaining regional market share. CONCLUSIONS: Expertise in the process of consultation delivery is feasible and will be increasingly critical to the survival of academic surgical practice in a competitive market.

Surgeon-tool force/torque signatures--evaluation of surgical skills in minimally invasive surgery.

The best method of training for laparoscopic surgical skills is controversial. Some advocate observation in the operating room, while others promote animal and simulated models or a combination of surgical related tasks. The mode of proficiency evaluation common to all of these methods has been subjective evaluation by a skilled surgeon. In order to define an objective means of evaluating performance, an instrumented laparoscopic grasper was developed measuring the force/torque at the surgeon hand/tool interface. The measured database demonstrated substantial differences between experienced and novice surgeon groups. Analyzing forces and torques combined with the state transition during surgical procedures allows an objective measurement of skill in MIS. Teaching the novice surgeon to limit excessive loads and improve movement efficiency during surgical procedures can potentially result in less injury to soft tissues and less wasted time during laparoscopic surgery. Moreover the force/torque database measured in this study may be used for developing realistic virtual reality simulators and optimization of medical robots performance.