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      Robot assisted versus laparoscopic suturing learning curve in a simulated setting

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          Abstract

          Background

          Compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills like minimally invasive suturing. This study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted suturing.

          Method

          Novice participants performed three suturing tasks on the EoSim laparoscopic augmented reality simulator or the RobotiX robot assisted virtual reality simulator. Each participant performed an intracorporeal suturing task, a tilted plane needle transfer task and an anastomosis needle transfer task. To complete the learning curve, all tasks were repeated up to twenty repetitions or until a time plateau was reached. Clinically relevant and comparable parameters regarding time, movements and safety were recorded. Intracorporeal suturing time and cumulative sum analysis was used to compare the learning curves and phases.

          Results

          Seventeen participants completed the learning curve laparoscopically and 30 robot assisted. Median first knot suturing time was 611 s (s) for laparoscopic versus 251 s for robot assisted ( p < 0.001), and this was 324 s versus 165 (sixth knot, p < 0.001) and 257 s and 149 s (eleventh knot, p < 0.001) respectively on base of the found learning phases. The percentage of ‘adequate surgical knots’ was higher in the laparoscopic than in the robot assisted group. First knot: 71% versus 60%, sixth knot: 100% versus 83%, and eleventh knot: 100% versus 73%. When assessing the ‘instrument out of view’ parameter, the robot assisted group scored a median of 0% after repetition four. In the laparoscopic group, the instrument out of view increased from 3.1 to 3.9% (left) and from 3.0 to 4.1% (right) between the first and eleventh knot ( p > 0.05).

          Conclusion

          The learning curve of minimally invasive suturing shows a shorter task time curve using robotic assistance compared to the laparoscopic curve. However, laparoscopic outcomes show good end results with rapid outcome improvement.

          Electronic supplementary material

          The online version of this article (10.1007/s00464-019-07263-2) contains supplementary material, which is available to authorized users.

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          Most cited references25

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          A comparison of laparoscopic and robotic assisted suturing performance by experts and novices.

          Venita Chandra, Deepika Nehra, Richard Parent … (2010)
          Surgical robotics has been promoted as an enabling technology. This study tests the hypothesis that use of the robotic surgical system can significantly improve technical ability by comparing the performance of both experts and novices on a complex laparoscopic task and a robotically assisted task. Laparoscopic experts (LE) with substantial laparoscopic and robotic experience (n = 9) and laparoscopic novices (LN) (n = 20) without any robotic experience performed sequentially 10 trials of a suturing task using either robotic or standard laparoscopic instrumentation fitted to the ProMIS surgical simulator. Objective performance metrics provided by ProMIS (total task time, instrument pathlength, and smoothness) and an assessment of learning curves were analyzed. Compared with LNs, the LEs demonstrated significantly better performance on all assessment measures. Within the LE group, there was no difference in smoothness (328 +/- 159 vs 355 +/- 174; P = .09) between robot-assisted and standard laparoscopic tasks. An improvement was noted in total task time (113 +/- 41 vs 132 +/- 55 sec; P < .05) and instrument pathlengths (371 +/- 163 vs 645 +/- 269 cm; P < .05) when using the robot. This advantage in terms of total task time, however, was lost among the LEs by the last 3 trials (114 +/- 40 vs 118 +/- 49 s; P = .84), while instrument pathlength remained better consistently throughout all the trials. For the LNs, performance was significantly better in the robotic trials on all 3 measures throughout all the trials. The ProMIS surgical simulator was able to distinguish between skill levels (expert versus novice) on robotic suturing tasks, suggesting that the ProMIS is a valid tool for measuring skill in robot-assisted surgery. For all the ProMIS metrics, novices demonstrated consistently better performance on a suturing task using robotics as compared to a standard laparoscopic setup. This effect was less evident for experts who demonstrated improvements only in their economy of movement (pathlength), but not in the speed or smoothness of performance. Robotics eliminated the early learning curve for novices, which was present when they used standard laparoscopic tools. Overall, this study suggests that, when performing complex tasks such as knot tying, surgical robotics is most useful for inexperienced laparoscopists who experience an early and persistent enabling effect. For experts, robotics is most useful for improving economy of motion, which may have implications for the highly complex procedures in limited workspaces (eg, prostatectomy). Copyright 2010 Mosby, Inc. All rights reserved.
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            An appraisal of the learning curve in robotic general surgery

            Luise I M Pernar, Faith C. Robertson, Ali Tavakkoli … (2017)
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              Augmented versus Virtual Reality Laparoscopic Simulation: What Is the Difference?

              Sanne Botden, Sonja Buzink, Marlies P. Schijven … (2007)
              Background Virtual reality (VR) is an emerging new modality for laparoscopic skills training; however, most simulators lack realistic haptic feedback. Augmented reality (AR) is a new laparoscopic simulation system offering a combination of physical objects and VR simulation. Laparoscopic instruments are used within an hybrid mannequin on tissue or objects while using video tracking. This study was designed to assess the difference in realism, haptic feedback, and didactic value between AR and VR laparoscopic simulation. Methods The ProMIS AR and LapSim VR simulators were used in this study. The participants performed a basic skills task and a suturing task on both simulators, after which they filled out a questionnaire about their demographics and their opinion of both simulators scored on a 5-point Likert scale. The participants were allotted to 3 groups depending on their experience: experts, intermediates and novices. Significant differences were calculated with the paired t-test. Results There was general consensus in all groups that the ProMIS AR laparoscopic simulator is more realistic than the LapSim VR laparoscopic simulator in both the basic skills task (mean 4.22 resp. 2.18, P < 0.000) as well as the suturing task (mean 4.15 resp. 1.85, P < 0.000). The ProMIS is regarded as having better haptic feedback (mean 3.92 resp. 1.92, P < 0.000) and as being more useful for training surgical residents (mean 4.51 resp. 2.94, P < 0.000). Conclusions In comparison with the VR simulator, the AR laparoscopic simulator was regarded by all participants as a better simulator for laparoscopic skills training on all tested features.
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                Author and article information

                Contributors
                Erik Leijte:
                ORCID: http://orcid.org/0000-0003-4014-1986
                Erik.leijte@radboudumc.nl
                Journal
                Journal ID (nlm-ta): Surg Endosc
                Journal ID (iso-abbrev): Surg Endosc
                Title: Surgical Endoscopy
                Publisher: Springer US (New York )
                ISSN (Print): 0930-2794
                ISSN (Electronic): 1432-2218
                Publication date (Electronic): 21 November 2019
                Publication date PMC-release: 21 November 2019
                Publication date (Print): 2020
                Volume: 34
                Issue: 8
                Pages: 3679-3689
                Affiliations
                [1 ]GRID grid.461578.9, Department of Pediatric Surgery, , Radboud University Medical Centre - Amalia Children’s Hospital, ; Geert Grooteplein 10 Route 618, 6500HB Nijmegen, The Netherlands
                [2 ]GRID grid.10417.33, ISNI 0000 0004 0444 9382, Department of Surgery, , Radboud University Medical Centre, ; Nijmegen, The Netherlands
                Author information
                http://orcid.org/0000-0003-4014-1986
                Article
                Publisher ID: 7263
                DOI: 10.1007/s00464-019-07263-2
                PMC ID: 7326898
                PubMed ID: 31754849
                SO-VID: c0fc0f4b-9988-4ceb-8049-aef8273376ff
                Copyright © © The Author(s) 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 11 July 2019
                Date accepted : 11 November 2019
                Categories
                Subject: 2019 EAES Oral
                Custom metadata
                issue-copyright-statement © Springer Science+Business Media, LLC, part of Springer Nature 2020

                ScienceOpen disciplines: Surgery
                Keywords: laparoscopy training,simulation,robotics training,learning curve
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: laparoscopy training, simulation, robotics training, learning curve

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