The effects of laparoscopic graspers with enhanced haptic feedback on applied forces: a randomized comparison with conventional graspers

Feeling of pulsations in artificial arteries with a real time haptic feedback laparoscopic grasper: a validation study

INTRODUCTION

Despite the advancements in technology and organized training for surgeons in laparoscopic surgery, the persistent challenge of not being able to feel the resistance and characteristics of the tissue, including pulsations, remains unmet. A recently developed grasper (Optigrip®) with real time haptic feedback, based on photonic technology, aims to address this issue by restoring the tactile sensation for surgeons. The key question is whether pulsations can be detected and at what minimal size level they become clinical significant.

METHODS

To simulate arterial conditions during laparoscopic procedures, four different silicone tubes were created, representing the most prevalent arteries. These tubes were connected to a validated pressure system, generating a natural pulse ranging between 80 and 120 mm Hg. One control tube without pressure was added. The surgeons had to grasp these tubes blindly with the conventional grasper or the haptic feedback grasper in a randomized order. They then indicated whether they felt the pressure or not and the percentage of correct answers was calculated.

RESULTS

The haptic grasper successfully detected 96% of all pulsations, while the conventional grasper could only detect 6%. When considering the size of the arteries, the Optigrip® identified pulsations in 100% the 4 and 5 mm arteries and 92% of the smallest arteries. The conventional grasper was only able to feel the smallest arteries in 8%. These differences were highly significant (p < 0.0001).

CONCLUSION

This study demonstrated that the newly developed haptic feedback grasper enables detection of arterial pulsations during laparoscopy, filling an important absence in tactile perception within laparoscopic surgery.

Can you feel the force just right? Tactile force feedback for training of minimally invasive surgery-evaluation of vibration feedback for adequate force application

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Effects of a force feedback function in a surgical robot on the suturing procedure

BACKGROUND

Currently, widely used robotic surgical systems do not provide force feedback. This study aimed to evaluate the impact and benefits of a force feedback function on the suturing procedure.

METHODS

Twenty surgeons were recruited and divided into young (Y-group, n = 11) and senior (S-group, n = 9) groups, based on their years of surgical experience. The effect of the force feedback function on suturing quality was evaluated using an objective assessment system (A-LAP mini, Kyoto Kagaku Co., Ltd., Kyoto, Japan). Each participant completed the suturing task on intestinal model sheets with the robotic contact force feedback on and off. The task accomplishment time (s), maximal force (Newton, N) applied to the robotic forceps, and quality of suturing (assessed by A-LAP mini) were recorded as performance parameters.

RESULTS

In total, the maximal force applied to the robotic forceps was significantly decreased with the robotic force feedback switched on (median [interquartile range]: 2.8 N (2.3-3.2)) as compared with when the feedback was switched off (3.4 N (2.7-4.0), P < 0.001). The contact force feedback function did not affect the objectively assessed suturing score (18 points (17.7-19.0) versus 18 points (17.0-19.0), P = 0.421). The contact force feedback function slightly shortened the task accomplishment time in the Y-group (552.5 s (466.5-832) versus 605.5 s (476.2-689.7), P = 0.851) but not in the S-group (566 s (440.2-703.5) versus 470.5 s (419.7-560.2), P = 0.164).

CONCLUSIONS

With the contact force feedback function, the suturing task was completed with a smaller maximal force, while maintaining the quality of suturing. Because the benefits are more apparent in young surgeons, robots with the contact force feedback function will facilitate the educational process in novice surgeons.

The benefits of haptic feedback in robot assisted surgery and their moderators: a meta-analysis

Robot assisted surgery (RAS) provides medical practitioners with valuable tools, decreasing strain during surgery and leading to better patient outcomes. While the loss of haptic sensation is a commonly cited disadvantage of RAS, new systems aim to address this problem by providing artificial haptic feedback. N = 56 papers that compared robotic surgery systems with and without haptic feedback were analyzed to quantify the performance benefits of restoring the haptic modality. Additionally, this study identifies factors moderating the effect of restoring haptic sensation. Overall results showed haptic feedback was effective in reducing average forces (Hedges' g = 0.83) and peak forces (Hedges' g = 0.69) applied during surgery, as well as reducing the completion time (Hedges' g = 0.83). Haptic feedback has also been found to lead to higher accuracy (Hedges' g = 1.50) and success rates (Hedges' g = 0.80) during surgical tasks. Effect sizes on several measures varied between tasks, the type of provided feedback, and the subjects' levels of surgical expertise, with higher levels of expertise generally associated with smaller effect sizes. No significant differences were found between virtual fixtures and rendering contact forces. Implications for future research are discussed.

Vibro-acoustic sensing of tissue-instrument-interactions allows a differentiation of biological tissue in computerised palpation

BACKGROUND

The shift towards minimally invasive surgery is associated with a significant reduction of tactile information available to the surgeon, with compensation strategies ranging from vision-based techniques to the integration of sensing concepts into surgical instruments. Tactile information is vital for palpation tasks such as the differentiation of tissues or the characterisation of surfaces. This work investigates a new sensing approach to derive palpation-related information from vibration signals originating from instrument-tissue-interactions.

METHODS

We conducted a feasibility study to differentiate three non-animal and three animal tissue specimens based on palpation of the surface. A sensor configuration was mounted at the proximal end of a standard instrument opposite the tissue-interaction point. Vibro-acoustic signals of 1680 palpation events were acquired, and the time-varying spectrum was computed using Continuous-Wavelet-Transformation. For validation, nine spectral energy-related features were calculated for a subsequent classification using linear Support Vector Machine and k-Nearest-Neighbor.

RESULTS

Indicators derived from the vibration signal are highly stable in a set of palpations belonging to the same tissue specimen, regardless of the palpating subject. Differences in the surface texture of the tissue specimens reflect in those indicators and can serve as a basis for differentiation. The classification following a supervised learning approach shows an accuracy of >93.8% for the three-tissue classification tasks and decreases to 78.8% for a combination of all six tissues.

CONCLUSIONS

Simple features derived from the vibro-acoustic signals facilitate the differentiation between biological tissues, showing the potential of the presented approach to provide information related to the interacting tissue. The results encourage further investigation of a yet little-exploited source of information in minimally invasive surgery.

Vibro-Acoustic Sensing of Instrument Interactions as a Potential Source of Texture-Related Information in Robotic Palpation

The direct tactile assessment of surface textures during palpation is an essential component of open surgery that is impeded in minimally invasive and robot-assisted surgery. When indirectly palpating with a surgical instrument, the structural vibrations from this interaction contain tactile information that can be extracted and analysed. This study investigates the influence of the parameters contact angle α and velocity v→ on the vibro-acoustic signals from this indirect palpation. A 7-DOF robotic arm, a standard surgical instrument, and a vibration measurement system were used to palpate three different materials with varying α and v→. The signals were processed based on continuous wavelet transformation. They showed material-specific signatures in the time-frequency domain that retained their general characteristic for varying α and v→. Energy-related and statistical features were extracted, and supervised classification was performed, where the testing data comprised only signals acquired with different palpation parameters than for training data. The classifiers support vector machine and k-nearest neighbours provided 99.67% and 96.00% accuracy for the differentiation of the materials. The results indicate the robustness of the features against variations in the palpation parameters. This is a prerequisite for an application in minimally invasive surgery but needs to be confirmed in realistic experiments with biological tissues.

Measuring interaction forces in surgical telemanipulation using conventional instruments

Minimally invasive surgery (MIS) has been an essential tool in the surgical sector for many years due to its crucial advantages compared to open surgery. To overcome remaining limitations, teleoperated MIS experienced a strong emergence. However, the widespread usage of such systems is hindered by the enormous financial hurdle. The use of standard components and conventional tools for teleoperated MIS can facilitate integration into existing hospital workflows and can be a cost-efficient and versatile approach for research purposes. To compensate for the lack of haptic feedback, some teleoperation setups inherit a sensor system allowing them to record interaction forces and display them at the user interface. In research and in commercially available systems, different positions for the sensor can be found. In this paper, mechanical interfaces for the guidance and actuation of non-wristed and wristed standard instruments are presented. Furthermore, a method for the extracorporeal measurement of interaction forces is presented, characterized, and discussed. The overall mean relative error of the magnitude of the interaction force is 9.4%, while the overall mean absolute error of the force vector is 14.4 $^{\circ }$ , both below the respective human differential perception threshold. The presented measurement method is a simple, yet sufficiently accurate approach to measure interaction forces in surgical telemanipulation.

Smart laparoscopic grasper integrated with fiber Bragg grating based tactile sensor for real-time force feedback

Minimally invasive surgery, such as laparoscopic surgery, has developed rapidly due to its small wound, less bleeding and quick recovery. However, a lack of force feedback, which leads to tissue damage, is still unsolved. Many sensors have been used to offer force feedback but still limited by their large size, low security and high complexity. Based on the advantages of small size, high sensitivity and immunity to electromagnetic interferences, we propose a tactile sensor integrated with fiber Bragg gratings (FBGs) at the tip of laparoscopic grasper to offer real-time force feedback in the laparoscopic surgery. The tactile sensor shows a force sensitivity of 0.076 nm/N with a repeatable accuracy of 0.118 N. A bench test is conducted in a laparoscopic training box to verify its feasibility. Test results illustrate that gripping force exerted on the laparoscopic grasper in terms of peak and standard deviation values reduce significantly for the novice subjects with force feedback compared to those without force feedback. The proposed sensor integrated at the tip of the laparoscopic grasper demonstrates a better control of the gripping force among the novice surgeons and indicates that the smart grasper can help surgeons achieve precise gripping force to reduce unnecessary tissue trauma.

Tool-tissue forces in surgery: A systematic review

Background

Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels.

Materials & methods

A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases.

Results

Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%.

Conclusions

The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

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This review explores tool-tissue forces during surgery, a new and expanding field.

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Forces were lowest in ophthalmology (0.04N) and highest in orthopaedics (210N).

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Forces were lowest during sharp dissection (0.03N) and highest when drilling (14N).

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Being an expert (vs. novice) and having feedback mechanisms (e.g. haptic) reduced exerted forces.

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Development of force metrics will facilitate training, assessment & novel technology.

Detection of adverse events leading to inadvertent injury during laparoscopic cholecystectomy using convolutional neural networks

Uncontrolled movements of laparoscopic instruments can lead to inadvertent injury of adjacent structures. The risk becomes evident when the dissecting instrument is located outside the field of view of the laparoscopic camera. Technical solutions to ensure patient safety are appreciated. The present work evaluated the feasibility of an automated binary classification of laparoscopic image data using Convolutional Neural Networks (CNN) to determine whether the dissecting instrument is located within the laparoscopic image section. A unique record of images was generated from six laparoscopic cholecystectomies in a surgical training environment to configure and train the CNN. By using a temporary version of the neural network, the annotation of the training image files could be automated and accelerated. A combination of oversampling and selective data augmentation was used to enlarge the fully labeled image data set and prevent loss of accuracy due to imbalanced class volumes. Subsequently the same approach was applied to the comprehensive, fully annotated Cholec80 database. The described process led to the generation of extensive and balanced training image data sets. The performance of the CNN-based binary classifiers was evaluated on separate test records from both databases. On our recorded data, an accuracy of 0.88 with regard to the safety-relevant classification was achieved. The subsequent evaluation on the Cholec80 data set yielded an accuracy of 0.84. The presented results demonstrate the feasibility of a binary classification of laparoscopic image data for the detection of adverse events in a surgical training environment using a specifically configured CNN architecture.

Haptic exploration improves performance of a laparoscopic training task

BACKGROUND

Laparoscopy has reduced tactile and visual feedback compared to open surgery. There is increasing evidence that visual and haptic information converge to form a more robust mental representation of an object. We investigated whether tactile exploration of an object prior to executing a laparoscopic action on it improves performance.

METHODS

A prospective cohort study with 20 medical students randomized in two different groups was conducted. A silicone ileocecal model, on which a laparoscopic action had to be performed, was used inside an outside a ForceSense box trainer. During the pre-test, students either did a combined manual and visual exploration or only visual exploration of the caecum model. To track performance during the trials of the study we used force, motion and time parameters as representatives of technical skills development. The final trial data were used for statistical comparison between groups.

RESULTS

All included time and motion parameters did not show any clear differences between groups. However, the force parameters Mean force non-zero (p = 004), Maximal force (p = 0.01) Maximal impulse (p = 0.02), Force volume (p = 0.02) and SD force (p = 0.01) showed significant lower values in favour of the tactile exploration group for the final trials.

CONCLUSIONS

By adding haptic sensation to the existing visual information during training of laparoscopic tasks on life-like models, tissue manipulation skills improve during training.

Potential Value of Haptic Feedback in Minimally Invasive Surgery for Deep Endometriosis

Introduction. Laparoscopic treatment of deep endometriosis (DE) is associated with intra- and post-operative morbidity. New technological developments, such as haptic feedback in laparoscopic instruments, could reduce the rate of complications. The aim of this study was to assess the room for improvement and potential cost-effectiveness of haptic feedback instruments in laparoscopic surgery. Methods. To assess the potential value of haptic feedback, a decision analytical model was constructed. Complications that could be related to the absence of haptic feedback were included in the model. Costs of complications were based on the additional length of hospital stay, operating time, outpatient visits, reinterventions, and/or conversions to laparotomy. The target population consists of women who are treated for DE in the Netherlands. A headroom analysis was performed to estimate the maximum value of haptic feedback in case it would be able to prevent all selected intra- and post-operative complications. Results. A total of 9.7 intraoperative and 47.0 post-operative complications are expected in the cohort of 636 patients annually treated for DE in the Netherlands. Together, these complications cause an additional length of hospital stay of 432.1 days, 10.2 additional outpatient visits, 73.9 reinterventions, and 4.2 conversions. Most consequences are related to post-operative complications. The total additional annual costs due to complications were €436 623, amounting to €687 additional costs per patient. Discussion. This study demonstrated that the potential value for improvement in DE laparoscopic surgery by using haptic feedback instruments is considerable, mostly caused by the potential prevention of major post-operative complications.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Image-guided minimally invasive endopancreatic surgery using a computer-assisted navigation system

BACKGROUND

Minimally invasive endopancreatic surgery (EPS), performing a pancreatic resection from inside the pancreatic duct, has been proposed as an experimental alternative to duodenum-preserving pancreatic head resection in benign diseases such as chronic pancreatitis, but is complicated by difficult spatial orientation when trying to reach structures of interest. This study assessed the feasibility and potential benefits of image-guided EPS using a computer-assisted navigation system in artificial pancreas silicon model.

METHODS

A surgical navigation system displayed a 3D reconstruction of the original computed tomography (CT) scan and the endoscope in relation to a selected target structure. In a first step, different surface landmark (LM)-based and intraparenchymal LM-based approaches for image-to-physical space registration were evaluated. The accuracy of registration was measured as fiducial registration error (FRE). Subsequently, intrapancreatic lesions (n = 8) that were visible on preoperative imaging, but not on the endoscopic view, were targeted with a computer-assisted, image-guided endopancreatic resection technique in pancreas silicon models. After each experiment, a CT scan was obtained for measurement of the shortest distance from the resection cavity to the centre of the lesion.

RESULTS

Intraparenchymal LM registration [FRE 2.24 mm (1.40-2.85)] was more accurate than surface LM registration [FRE 3.46 mm (2.25-4.85); p = 0.035], but not more accurate than combined registration of intraparenchymal and surface LM [FRE 2.46 mm (1.60-3.35); p = 0.052]. Using image-guided EPS, six of seven lesions were successfully targeted. The median distance from the resection cavity to the centre of the lesion on CT was 1.52 mm (0-2.4). In one pancreas, a lesion could not be resected due to the fragility of the pancreas model.

CONCLUSION

Image-guided minimally invasive EPS using a computer-assisted navigation system enabled successful targeting of pancreatic lesions that were invisible on the endoscopic image, but detectable on preoperative imaging. In the clinical setting, this tool could facilitate complex minimally invasive and robotic pancreatic procedures.

Trainee Performance After Laparoscopic Simulator Training Using a Blackbox versus LapMentor

BACKGROUND

Training using laparoscopic high-fidelity simulators (LHFSs) to proficiency levels improves laparoscopic cholecystectomy skills. However, high-cost simulators and their limited availability could negatively impact residents' laparoscopic training opportunities. We aimed to assess whether motivation and surgical skill performance differ after basic skills training (BST) using a low-cost (Blackbox) versus LHFS (LapMentor) among medical students.

MATERIALS AND METHODS

Sixty-three medical students from Karolinska Institutet volunteered, completing written informed consent, questionnaire regarding expectations of the simulation training, and a visuospatial ability test. They were randomized into two groups that received BST using Blackbox (n = 32) or LapMentor (n = 31). However, seven students absence resulted in 56 participants, followed by another 9 dropouts. Subsequently, after training, 47 students took up three consecutive tests using the minimally invasive surgical trainer-virtual reality (MIST-VR) simulator, finalizing a questionnaire.

RESULTS

More Blackbox group participants completed all MIST-VR tests (29/31 versus 18/25). Students anticipated mastering LapMentor would be more difficult than Blackbox (P = 0.04). In those completing the simulation training, a trend toward an increase was noted in how well participants in the Blackbox group liked the simulator training (P = 0.07). Subgroup analysis of motivation and difficulty in liking the training regardless of simulator was found only in women (Blackbox [P = 0.02]; LapMentor [P = 0.06]). In the Blackbox group, the perceived difficulty of training, facilitation, and liking the Blackbox training (significant only in women) were significantly correlated with the students' performance in the MIST-simulator. No such correlations were found in the LapMentor group.

CONCLUSIONS

Results indicate an important role for low-tech/low-cost Blackbox laparoscopic BST of students in an otherwise high-tech surrounding. Furthermore, experience of Blackbox BST procedures correlate with students' performance in the MIST-VR simulator, with some gender-specific differences.

Evaluation of a Virtual Reality Percutaneous Nephrolithotomy (PCNL) Surgical Simulator

Percutaneous Nephrolithotomy is the standard surgical procedure used to remove large kidney stones. PCNL procedures have a steep learning curve; a physician needs to complete between 36 and 60 procedures, to achieve clinical proficiency. Marion Surgical K181 is a virtual reality surgical simulator, which emulates the PCNL procedures without compromising the well-being of patients. The simulator uses a VR headset to place a user in a realistic and immersive operating theater, and haptic force-feedback robots to render physical interactions between surgical tools and the virtual patient. The simulator has two modules for two different aspects of PCNL kidney stone removal procedure: kidney access module where the user must insert a needle into the kidney of the patient, and a kidney stone removal module where the user removes the individual stones from the organ. In this paper, we present user trials to validate the face and construct validity of the simulator. The results, based on the data gathered from 4 groups of users independently, indicate that Marion's surgical simulator is a useful tool for teaching and practicing PCNL procedures. The kidney stone removal module of the simulator has proven construct validity by identifying the skill level of different users based on their tool path. We plan to continue evaluating the simulator with a larger sample of users to reinforce our findings.

Multi-DOF (Degree of Freedom) Articulating Laparoscopic Instrument is an Effective Device in Performing Challenging Sutures

Purpose

Although laparoscopic surgery had been performed in clinical practice for over 30 years, there has not been much improvement on instruments. Several articulating laparoscopic instruments have been developed including the robotic system. A new multi-degree of freedom (DOF) articulating laparoscopic device has been developed. We compared the ability to perform challenging sutures between the new device and the robotic system.

Methods

Five experienced surgeons with over 100 laparoscopic surgery cases performed the suture task with both instruments. Everyone was new at articulating instruments including a robotic system. The suturing task consisted of two vertical sutures, downward and upward vertical direction. The duration of needle grabbing, first surgical tie, square tie, and the final reverse tie was measured.

Results

When doing the downward suture, the median time to complete the suture was 127 vs. 136 seconds for ArtiSential^® and the robot, respectively (p=0.754). Other measurements such as needle grabbing, first tie, second tie and final knot did not show any significant difference between the two instruments. Upward suture also did not show a significant difference. The total completion time was 127 vs. 112 seconds for for ArtiSential^® and the robot, respectively (p=0.675). Time taken in each interval did not show any significant difference.

Conclusion

Both instruments performed the suturing tasks with no difference in duration. ArtiSential^® can be mixed up with usual instruments. Surgeons can choose any device, but when articulation is needed, ArtiSential^® could be an alternative choice to the robotic system.

Performance of a Haptic Feedback Grasper in Laparoscopic Surgery: A Randomized Pilot Comparison With Conventional Graspers in a Porcine Model

Background. Compared with open surgery, minimally invasive surgery is limited by reduced sensation of tissue properties. A laparoscopic grasper with integrated haptic feedback technology that improves the ability to sense tissue properties might provide a solution. The force reflecting operation instrument (FROI) is a new laparoscopic grasper, designed to provide information about the interaction forces between the instrument and tissue through resistance in the handle. This pilot study aimed to assess the functionality of the FROI compared with a conventional grasper in an in vivo setting. Methods. In this randomized trial, we used a standard laparoscopic surgical setup to perform laparoscopic surgery in pigs. In all, 11 surgeons performed colorectal, gynecological, or urological procedures, once with the FROI and once with a conventional grasper. Participants were asked to complete the NASA Task Load Index Rating Scale and rate 5 specific features for both graspers. To capture opinions on the overall functionality of the FROI, participants were asked to answer 8 open questions. Results. The surgeons reported that the use of the FROI significantly improved tissue consistency perception, arterial pulse detection, and force control compared with the conventional grasper. No significant differences were found in surgeons' muscular strain or operative time. The most emphasized topics in the open questions were improved soft-tissue handling and importance for complex procedures. Conclusion. Through this first in vivo analysis of the functionality of the FROI, a multispecialty group of laparoscopic surgeons confirmed the added value of haptic feedback technology in a live surgical setting.