Simulator training is an efficient method for the development of basic laparoscopic skills. We aimed to investigate if low-cost simulators are comparable to more expensive box trainers regarding surgeons usability, likability, and performance. This multi-center, randomized crossover study included 16 medical students, seven abdominal surgeons, and seven urological surgeons. Participants performed four laparoscopic tasks (peg transfer, circle cutting, balloon resection, suture and knot) on both, a “Low cost trainer” (LCT) or a “high cost trainer” (HCT) in a randomized order. The primary endpoint was the subjective rating of both training simulators in terms of camera view, depth perception, movement of instruments, pricing, and usability for training. Secondary endpoints were force parameters, task completion time, surgical errors, and psychological workload. Participants rated the LCT better concerning view (p < 0.001), depth perception (p = 0.003), pricing (p < 0.001), and usability for digital training (p < 0.001), but worse in terms of instrument movement (p = 0.004). Overall, the LCT was rated better than the HCT (p = 0.015). Regarding force parameters, participants showed a significantly lower force exertion on the HCT during the peg transfer task (p = 0.008). The force exertion in the other tasks were comparable between both trainers. Participants were significantly faster using the HCT during the peg transfer (p = 0.049) and significantly slower in balloon resection (p = 0.049) and suture and knot task (p = 0.026). The assessment of the participants’ workload showed no differences. The LCT was generally rated better than the HCT. The differences concerning force exertion and task completion time showed better results during peg transfer at the HCT but were generally inconclusive and without systemic advantage for either trainer. However, the LCT could be a promising and cost-effective augmentation for modern laparoscopic training.

Introduction Surgeons are often exposed to different types of operative room (OR) noise, for instance machine alarms, phone calls, and interacting objects. The aim of this study was to evaluate the effect of OR noise on the surgeons’ laparoscopic performance. Methods A total of 30 laparoscopic novices participated in this single-center, prospective, randomized cross-over trial after completing a standardized laparoscopic training until reaching proficiency. Afterward, all participants performed four different laparoscopic tasks (peg transfer, circle cutting, balloon resection, suture, and knot) twice, once under noise exposure (intervention group), and once without any noise (control group). Primary endpoints were the force exertion and motion analyses. To assess the psychological workload the NASA task load index score was used. Results The error rates varied and were significantly different between the noise and the control group. More complex tasks like the circle cutting and suture and knot task revealed higher error rates concerning precision (circle cutting: P < 0.01; suture and knot: P < 0.01). In line with increased error rates in the circle cutting task, increased NASA task load index scores were observed in this task (P = 0.03). However, no significant differences were found in force parameters, such as the maximal force exertion (peg transfer: P = 0.43; circle cutting: P = 0.54; balloon resection: P = 0.64; suture and knot: P = 0.63) and the mean force exertion (peg transfer: P = 0.43; circle cutting: P = 0.54; balloon resection: P = 0.64; suture and knot: P = 0.63) between the groups. Conclusions Exposure to normal OR noise led to higher error rates in two of four tasks. This effect could be linked to an increased psychological workload that was present under normal OR noise exposure. However, normal OR noise does not appear to impact surgical novices' laparoscopic task performance regarding applied forces and instrument motion.

Background:Simulator training is an efficient training tool to develop surgical novice's basic laparoscopic skills.Currently simulator training takes mainly place in simulation centers at hospitals and universities.Additionally, most trainees have to use overtime for training purposes since it is mostly not included during normal working hours.Recent studies also indicated the possibility of low cost at-home training for laparoscopic surgery, opening up new personalized training possibilities.Such modalities support surgeons' initial acquisitions of basic laparoscopic skills as well as continuous development.Furthermore training at home could facilitate the possibility of skill retention, which might be important for longer times without specialized surgical training.This could for example include research time, maternity leave or gaining further education.Nevertheless, most currently available simulators are expensive and require additional equipment (e.g.monitors, stands, PCs) and, therefore, are not feasible for at-home training.Recently developed low-cost simulators show great promise to bridge this gap.We aimed to investigate if low-cost simulators are comparable to more expensive box trainers regarding surgeons performance and likability. Materials and methods:This randomized, open-label crossover multi-center study was performed at Dresden and Mannheim's university hospitals.Participants were randomly assigned either to the "Laparoscopy Boxx-Pro" (LBX) or "Lübecker Toolbox" (LBT) simulator and switched afterwards.The "Laparoscopy Boxx-Pro" is developed by the Dutch "Laparoscopy Boxx" company.The simulator consists of wooden parts, can be stored and shipped easily and is simple to build up.The simulator costs 309€ including instruments and does not have a built in camera device but allows for the use of a phone or tablet with a build-in camera.The "Lübecker Toolbox'' on the other hand is a laparoscopic box trainer produced by the German company "Lübecker Toolbox''.This simulator costs about 4,200€ without instruments and a screen.Each participant performed four laparoscopic tasks (Peg transfer, circle cutting, laparoscopic suture and knot, Balloon resection) on both the LBX and LBT.During the tasks, force exertion and completion time were measured using the ForceTrap system (Medishield B.V., Delft, The Netherlands).Additionally, errors were recorded, and the psychological workload was assessed using the NASA-TLX score.Furthermore, participants were tasked to rate the simulator regarding usability, view, and ease of performing the tasks in a self-designed questionnaire using a five-point Likert Skala, with one being the best and five the worst. Results:In total, seven abdominal surgeons, seven urologists, and sixteen medical students participated in the evaluation of the simulators.Of the 30 participants, the majority (80%) rated their laparoscopic skill level as beginners, whereas six participants (20%) rated their skills as proficient.The PEG task was performed significantly slower using the LBX compared to the LBT (192,1s vs 175,3 s; p=0.049).In contrast, the amount of time for the balloon resection were significantly faster performed with the LBX (compared to the LBT (198,6s vs 223,1s; p=0.049;).Similar, for the surgical knot and suturing taks a s18

Background Virtual reality is a frequently chosen method for learning the basics of robotic surgery. However, it is unclear whether tissue handling is adequately trained in VR training compared to training on a real robotic system. Methods In this randomized controlled trial, participants were split into two groups for “Fundamentals of Robotic Surgery (FRS)” training on either a DaVinci VR simulator (VR group) or a DaVinci robotic system (Robot group). All participants completed four tasks on the DaVinci robotic system before training (Baseline test), after proficiency in three FRS tasks (Midterm test), and after proficiency in all FRS tasks (Final test). Primary endpoints were forces applied across tests. Results This trial included 87 robotic novices, of which 43 and 44 participants received FRS training in VR group and Robot group, respectively. The Baseline test showed no significant differences in force application between the groups indicating a sufficient randomization. In the Midterm and Final test, the force application was not different between groups. Both groups displayed sufficient learning curves with significant improvement of force application. However, the Robot group needed significantly less repetitions in the three FRS tasks Ring tower (Robot: 2.48 vs. VR: 5.45; p < 0.001), Knot Tying (Robot: 5.34 vs. VR: 8.13; p = 0.006), and Vessel Energy Dissection (Robot: 2 vs. VR: 2.38; p = 0.001) until reaching proficiency. Conclusion Robotic tissue handling skills improve significantly and comparably after both VR training and training on a real robotic system, but training on a VR simulator might be less efficient.

Tissue handling is a crucial skill for surgeons and is challenging to learn. The aim of this study was to develop laparoscopic instruments with different integrated tactile vibration feedback by varying different tactile modalities and assess its effect on tissue handling skills. Standard laparoscopic instruments were equipped with a vibration effector, which was controlled by a microcomputer attached to a force sensor platform. One of three different vibration feedbacks (F1: double vibration > 2 N; F2: increasing vibration relative to force; F3: one vibration > 1.5 N and double vibration > 2 N) was applied to the instruments. In this multicenter crossover trial, surgical novices and expert surgeons performed two laparoscopic tasks (Peg transfer, laparoscopic suture, and knot) each with all the three vibration feedback modalities and once without any feedback, in a randomized order. The primary endpoint was force exertion. A total of 57 subjects (15 surgeons, 42 surgical novices) were included in the trial. In the Peg transfer task, there were no differences between the tactile feedback modalities in terms of force application. However, in subgroup analysis, the use of F2 resulted in a significantly lower mean-force application (p-value = 0.02) among the student group. In the laparoscopic suture and knot task, all participants exerted significantly lower mean and peak forces using F2 (p-value < 0.01). These findings remained significant after subgroup analysis for both, the student and surgeon groups individually. The condition without tactile feedback led to the highest mean and peak force exertion compared to the three other feedback modalities. Continuous tactile vibration feedback decreases the mean and peak force applied during laparoscopic training tasks. This effect is more pronounced in demanding tasks such as laparoscopic suturing and knot tying and might be more beneficial for students. Laparoscopic tasks without feedback lead to increased force application.

Background Minimally invasive surgery (MIS) requires intense education and training with structured supervision and feedback. However, a standardized training structure is lacking in Germany. This nationwide survey aimed to assess the current state of minimally invasive surgery (MIS) training and factors impacting surgeons' satisfaction. Methods Between July and October 2021, an online survey was conducted among general, abdominal, and thoracic surgeons in Germany. The survey collected data on department size, individual operative experience, availability of MIS training equipment and curricula, and individual satisfaction with training. A linear regression analysis was conducted to investigate factors influencing the surgeons’ satisfaction with the MIS training. Results A total of 1008 surgeons participated in the survey, including residents (26.1%), fellows (14.6%), attendings (43.8%), and heads of departments (15.2%). Of the respondents, 57.4% reported having access to MIS training equipment, 29.8% and 26% had a curriculum for skills lab MIS training and intraoperative MIS training, respectively. In multivariate linear regression analysis, strongest predictors for surgeons’ satisfaction with skills lab MIS training and intraoperative training were the availability of respective training curricula (skills lab: β 12.572; p < 0.001 & intraoperative: β 16.541; p < 0.001), and equipment (β 5.246; p = 0.012 & β 4.295; p = 0.037), and experience as a first surgeon in laparoscopy (β 12.572; p < 0.001 & β 3.748; p = 0.007). Additionally, trainees and teachers differed in their satisfaction factors. Conclusion Germany lacks standardized training curricula and sufficient access to MIS training equipment. Trainees and teachers have distinct factors influencing their satisfaction with MIS training. Standardized curricula, equipment accessibility, and surgical experience are crucial for improving surgeons’ satisfaction with training.

Training improves skills in minimally invasive surgery. This study aimed to investigate the learning curves of complex motion parameters for both hands during a standardized training course using a novel measurement tool. An additional focus was placed on the parameters representing surgical safety and precision. Fifty-six laparoscopic novices participated in a training course on the basic skills of minimally invasive surgery based on a modified Fundamentals of Laparoscopic Surgery (FLS) curriculum. Before, twice during, and once after the practical lessons, all participants had to perform four laparoscopic tasks (peg transfer, precision cut, balloon resection, and laparoscopic suture and knot), which were recorded and analyzed using an instrument motion analysis system. Participants significantly improved the time per task for all four tasks (all p < 0.001). The individual instrument path length decreased significantly for the dominant and non-dominant hands in all four tasks. Similarly, both hands became significantly faster in all tasks, with the exception of the non-dominant hand in the precision cut task. In terms of relative idle time, only in the peg transfer task did both hands improve significantly, while in the precision cut task, only the dominant hand performed better. In contrast, the motion volume of both hands combined was reduced in only one task (precision cut, p = 0.01), whereas no significant improvement in the relative time of instruments being out of view was observed. FLS-based skills training increases motion efficiency primarily by increasing speed and reducing idle time and path length. Parameters relevant for surgical safety and precision (motion volume and relative time of instruments being out of view) are minimally affected by short-term training. Consequently, surgical training should also focus on safety and precision-related parameters, and assessment of these parameters should be incorporated into basic skill training accordingly.

Introduction During laparoscopic surgery, surgeons may experience prolonged periods without fluid intake, which might impact surgical performance, yet there are no objective data investigating this issue. Therefore, the aim of this study was to elucidate the effect of prolonged dehydration on laparoscopic surgical performance and tissue handling. Methods A total of 51 laparoscopic novices participated in a single-center, open-label, prospective randomized cross-over trial. All participants were trained to proficiency using a standardized laparoscopic training curriculum. Afterward, all participants performed four different laparoscopic tasks twice, once after 6 h without liquid intake (dehydrated group) and once without any restrictions (control group). Primary endpoints were tissue handling defined by force exertion, task time, and error rate. The real hydration status was assessed by biological parameters, like heart rate, blood pressure, and blood gas analysis. Results 51 laparoscopic novices finished the curriculum and completed the tasks under both hydrated and dehydrated conditions. There were no significant differences in mean non-zero and peak force between the groups. However, dehydrated participants showed significantly slower task times in the Peg transfer task (hydrated: 139.2 s vs. dehydrated: 147.9 s, p = 0.034) and more errors regarding the precision in the laparoscopic suture and knot task (hydrated: 15.7% accuracy rate vs. dehydrated: 41.2% accuracy rate, p < 0.001). Conclusion Prolonged periods of dehydration do not appear to have a substantial effect on the fundamental tissue handling skills in terms of force exertion among surgical novices. Nevertheless, the observed impact on speed and precision warrants attention.

Background Coffee can increase vigilance and performance, especially during sleep deprivation. The hypothetical downside of caffeine in the surgical field is the potential interaction with the ergonomics of movement and the central nervous system. The objective of this trial was to investigate the influence of caffeine on laparoscopic performance. Methods Fifty laparoscopic novices participated in this prospective randomized, blinded crossover trial and were trained in a modified FLS curriculum until reaching a predefined proficiency. Subsequently, all participants performed four laparoscopic tasks twice, once after consumption of a placebo and once after a caffeinated (200 mg) beverage. Comparative analysis was performed between the cohorts. Primary endpoint analysis included task time, task errors, OSATS score and a performance analysis with an instrument motion analysis (IMA) system. Results Fifty participants completed the study. Sixty-eight percent of participants drank coffee daily. The time to completion for each task was comparable between the caffeine and placebo cohorts for PEG transfer (119 s vs 121 s; p = 0.73), precise cutting (157 s vs 163 s; p = 0.74), gallbladder resection (190 s vs 173 s; p = 0.6) and surgical knot (171 s vs 189 s; p = 0.68). The instrument motion analysis showed no significant differences between the caffeine and placebo groups in any parameters: instrument volume, path length, idle, velocity, acceleration, and instrument out of view. Additionally, OSATS scores did not differ between groups, regardless of task. Major errors occurred similarly in both groups, except for one error criteria during the circle cutting task, which occurred significantly more often in the caffeine group (34% vs. 16%, p < 0.05). Conclusion The objective IMA and performance scores of laparoscopic skills revealed that caffeine consumption does not enhance or impair the overall laparoscopic performance of surgical novices. The occurrence of major errors is not conclusive but could be negatively influenced in part by caffeine intake.