Laparoscopic Simulation in Reverse and Side Alignment Does Not Improve Task Performance in Forward Alignment: A Randomized Controlled Trial

Nashwa Khogali, DO, Pam Haan, RN, BSN, Cheryl Anderson, RN, BSN, MSA, Rama Gupta, BS, Caroline Moon, BS, David Henry, MD, Srinivas Kavuturu, MD. Michigan State University Department of Surgery.

Introduction: Because the influence of visual-spatial discordance during training on laparoscopic skills acquisition is poorly understood, we hypothesized that forward alignment surgical skills performed on a laparoscopic trainer would improve following simulation experiences that create a situation of extreme visual-spatial discordance (e.g., reverse and side alignment). We conducted a randomized controlled trial to test this hypothesis.

Methods: A trainer box was configured to view forward, side, and reverse camera angles of the visual field to perform Fundamentals of Laparoscopic Surgery peg transfers. Medical students (n=60) without laparoscopic experience were randomized to one of three groups, each group practicing in a different order of alignment (forward, side, reverse). Each group had four peg transfer practice sessions and was tested at the end of each session in forward alignment only (Table 1). Group A practiced all four sessions in the forward alignment. Group B practiced in the forward, forward, side, and reverse alignment. Group C practiced in the forward, side, reverse, and forward alignment. The practice and testing was completed in one session. Test scores for each group were compared using General Linear Modeling (P < 0.05). Likert-based pre- and post-trial surveys were completed by participants (e.g., demographics, dexterity, video-gaming experience), analyzed by x2 (P < 0.05).

Table 1.  Algorithm

Group A (n=20)
 Group B (n=20) Group C (n=20)
 3 practices – forward  3 practices – forward  3 practices – forward
 Pre-test peg transfer – forward alignment
 10 practices – forward 10 practices – forward10 practices – side 
 1st test peg transfer – forward alignment
 10 practices – forward 10 practices – side 10 practices – reverse
 2nd test peg transfer – forward alignment
 10 practices – forward 10 practices – reverse 10 practices – forward
 3rd test peg transfer – forward alignment

Results: Group A students performed better when compared to Group B and C students (Table 2) in their final test (p = < 0.001). Group B and C students’ test performance in forward alignment was significantly worse after side and reverse practice sessions (p = 0.044). Since Group C students’ last practice session was in forward alignment, their final test performance was the same as Group A (p = >.999). We found no significant difference in test performance related to dexterity, gender, age, or video-gaming experience.

Table 2. Final test scores after three practice sessions

GroupsMean ScoreP Value
A vs. C70.7 ± 12.9 vs. 74.2 ± 16.4>0.999
A vs. B+C70.7 ± 12.9 vs. 101.8 ± 32.0 & 74.2 ± 16.40.01

Conclusions: Our results show that side and reverse alignment practice does not improve laparoscopic skills in forward alignment, refuting our hypothesis. The visual-spatial discordance caused by the side and reverse alignment practice resulted in no improvement in forward alignment testing. Since the statistical final tests for Group C were the same as Group A, it proves that once the visual-spatial discordance is corrected by practicing in the forward alignment, students performed the same as those who never experienced the discordance.

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