Assessment of Laparoscopic Skills Performance

Handheld robotic device for endoscopic neurosurgery: system integration and pre-clinical evaluation

The Expanded Endoscopic Endonasal Approach, one of the best examples of endoscopic neurosurgery, allows access to the skull base through the natural orifice of the nostril. Current standard instruments lack articulation limiting operative access and surgeon dexterity, and thus, could benefit from robotic articulation. In this study, a handheld robotic system with a series of detachable end-effectors for this approach is presented. This system is comprised of interchangeable articulated 2/3 degrees-of-freedom 3 mm instruments that expand the operative workspace and enhance the surgeon's dexterity, an ergonomically designed handheld controller with a rotating joystick-body that can be placed at the position most comfortable for the user, and the accompanying control box. The robotic instruments were experimentally evaluated for their workspace, structural integrity, and force-delivery capabilities. The entire system was then tested in a pre-clinical context during a phantom feasibility test, followed up by a cadaveric pilot study by a cohort of surgeons of varied clinical experience. Results from this series of experiments suggested enhanced dexterity and adequate robustness that could be associated with feasibility in a clinical context, as well as improvement over current neurosurgical instruments.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE

To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system.

METHODS

Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups.

RESULTS

Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected.

CONCLUSION

The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

Robotic Handle Prototypes for Endoscopic Endonasal Skull Base Surgery: Pre-clinical Randomised Controlled Trial of Performance and Ergonomics

Endoscopic endonasal skull base surgery is a promising alternative to transcranial approaches. However, standard instruments lack articulation, and thus, could benefit from robotic technologies. The aim of this study was to develop an ergonomic handle for a handheld robotic instrument intended to enhance this procedure. Two different prototypes were developed based on ergonomic guidelines within the literature. The first is a forearm-mounted handle that maps the surgeon's wrist degrees-of-freedom to that of the robotic end-effector; the second is a joystick-and-trigger handle with a rotating body that places the joystick to the position most comfortable for the surgeon. These handles were incorporated into a custom-designed surgical virtual simulator and were assessed for their performance and ergonomics when compared with a standard neurosurgical grasper. The virtual task was performed by nine novices with all three devices as part of a randomised crossover user-study. Their performance and ergonomics were evaluated both subjectively by themselves and objectively by a validated observational checklist. Both handles outperformed the standard instrument with the rotating joystick-body handle offering the most substantial improvement in terms of balance between performance and ergonomics. Thus, it is deemed the more suitable device to drive instrumentation for endoscopic endonasal skull base surgery.

Evaluation of new motorized articulating laparoscopic instruments by laparoscopic novices using a standardized laparoscopic skills curriculum

Background

Motorized articulating laparoscopic instruments (ALI) offer more degrees of freedom than conventional laparoscopic instruments (CLI). However, a difficult learning curve and complex instrument handling are still a problem of ALI. We compared the performance of new prototypes of motorized ALI with CLI in a series of standardized laparoscopic tasks performed by laparoscopic novices. Further, usability of the new ALI was assessed.

Methods

A randomized cross-over study with 50 laparoscopic novices who either started with CLI and then changed to ALI (CA) or vice versa (AC) was conducted. All participants performed the European training in basic laparoscopic urological skills (E-BLUS) with each instrument in given order. Time and errors were measured for each exercise. Instrument usability was assessed.

Results

Overall, using CLI was significantly faster (CLI 4:27 min vs. ALI 4:50 min; p-value 0.005) and associated with fewer exercise failures in needle guidance (CLI 0 vs. ALI 12; p-value 0.0005) than ALI. Median amount of errors was similar for both instruments. Instrument sequence did not matter, as CA and AC showed comparable completion times. Regarding the learning effect, participants were significantly faster in the second attempt of exercises than in the first. In the needle guidance task, participants using CLI last demonstrated a significant speed improvement, whereas ALI were significantly slower in the second run. Regarding usability, CLI were preferred over ALI due to lighter weight and easier handling. Nevertheless, participants valued ALI’s additional degrees of freedom.

Conclusion

Using new motorized ALI in the E-BLUS examination by laparoscopic novices led to a worse performance compared to CLI. An explanation could be that participants felt overwhelmed by ALI and that ALI have an own distinct learning curve. As participants valued ALI’s additional degrees of freedom, however, a future application of ALI could be for training purposes, ideally in combination with CLI.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08086-2) contains supplementary material, which is available to authorized users.

Laparoscopy with augmented reality adaptations

One of the most promising applications of Optical See-Through Augmented Reality is minimally laparoscopic surgery, which currently suffers from problems such as surgeon discomfort and fatigue caused by looking at a display positioned outside the surgeon's visual field, made worse by the length of the procedure. This fatigue is especially felt on the surgeon's neck, as it is strained from adopting unnatural postures in order to visualise the laparoscopic video feed. Throughout this paper, we will present work in Augmented Reality, as well as developments in surgery and Augmented Reality applied to both surgery in general and laparoscopy in particular to address these issues. We applied user and task analysis methods to learn about practices performed in the operating room by observing surgeons in their working environment in order to understand, in detail, how they performed their tasks and achieved their intended goals. Drawing on observations and analysis of video recordings of laparoscopic surgeries, we identified relevant constraints and design requirements. Besides proposals to approach the ergonomic issues, we present a design and implementation of a multimodal interface to enhance the laparoscopic procedure. Our method makes it more comfortable for surgeons by allowing them to keep the laparoscopic video in their viewing area regardless of neck posture. Also, our interface makes it possible to access patient imaging data without interrupting the operation. It also makes it possible to communicate with team members through a pointing reticle. We evaluated how surgeons perceived the implemented prototype, in terms of usefulness and usability, via a think-aloud protocol to conduct qualitative evaluation sessions which we describe in detail in this paper. In addition to checking the advantages of the prototype as compared to traditional laparoscopic settings, we also conducted a System Usability Scale questionnaire for measuring its usability, and a NASA Task Load Index questionnaire to rate perceived workload and to assess the prototype effectiveness. Our results show that surgeons consider that our prototype can improve surgeon-to-surgeon communication using head pose as a means of pointing. Also, surgeons believe that our approach can afford a more comfortable posture throughout the surgery and enhance hand-eye coordination, as physicians no longer need to twist their necks to look at screens placed outside the field of operation.

Concurrent Learning Curves of 3-Dimensional and Robotic-Assisted Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer Using 2-Dimensional Laparoscopic Radical Hysterectomy as a Benchmark: A Single Surgeon's Experience

Background

For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer.

Material/Methods

Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2–IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients’ demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs.

Results

Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time.

Conclusions

Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.

Articulated Instruments and 3D Visualization: A Synergy? Evaluation of Execution Time, Errors, and Visual Fatigue

Objective. The introduction of advanced endoscopic systems, such as the Storz Image1S and the Olympus Endoeye, heralds a new era of 3-dimensional (3D) visualization. The aim of this report is to provide a comprehensive overview of the neurophysiology of 3D view, its relevance in videoscopy, and to quantify the benefit of the new 3D technologies for both rigid and articulated instruments. Method. Sixteen medical students without any laparoscopic experience were trained each for a total of 27 hours. Proficiency scores were determined for rigid and articulated instruments under 2D and 3D visualization conditions. Results. A reduction in execution time of 14%, 28%, and 36% was seen for the rigid instruments, the da Vinci, and Steerable instruments, respectively. A reduction in errors of 84%, 92%, and 87% was seen for the rigid instruments, the da Vinci, and Steerable instruments, respectively. Conclusion. 3D visualization greatly augments endoscopic procedures. The advanced endoscopic systems employed in the recent study caused no visual fatigue or discomfort. The benefit of 3D was most distinct with articulated instruments.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018

BACKGROUND

The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.

RESULTS

9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.

CONCLUSION

We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018

BACKGROUND

The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community.

METHODS

Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018.

RESULTS

9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I² 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I² 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I² 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D.

CONCLUSION

We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

Laser visual guidance versus two-dimensional vision in laparoscopy: a randomized trial

Background

During laparoscopy, the surgeon’s loss of depth perception and spatial orientation is problematic. Laser visual guidance (LVG) is an innovative technology that improves depth perception to enhance the visual field. In this trial, we examined the effect of LVG on surgical novices’ motor skills, quality of task performance, and cognitive workload.

Methods

We designed a randomized controlled trial following the CONSORT statement. Thirty-two surgical novices completed the Training and Assessment of Basic Laparoscopic Techniques (TABLT) test. The first attempt allowed participants to familiarize themselves with the exercises. We then randomized the participants, and they completed a test session using either LVG or conventional two-dimensional vision.

Results

We found no significant difference between using the LVG tool and conventional 2D vision; however, both the mean completion time and movements used were less in the LVG group: Mean time used in the LVG group was 1288 s (95 % CI 1188–1388) versus 1354 s (95 % CI 1190–1518) (p = 0.45); mean angular path length used in the LVG group was 24,049° (95 % CI 20,761–27,336) versus 26,014° (95 % CI 22,059–29,970) (p = 0.42); mean path length in the LVG group was 4560 cm (95 % CI 3971–5,149 cm) versus 5062 cm (95 % CI 4328–5797), (p = 0.26). Moreover, the mean TABLT performance score was higher in the LVG group compared with the 2D group, although not significant: 379 (95 % CI 352–405) versus 338 (95 % CI 288–387) (p = 0.14). No significant difference was found between the groups’ cognitive workloads.

Conclusion

We found no significant improvement of laparoscopic motor skills when using LVG, although a tendency toward improved performance was seen. LVG could have the potential to help novice surgeons acquire basic laparoscopic; however, further development of the concept and validation is needed to confirm this.