Characteristics and precision of needle driving for right-handed pediatric surgeons comparing right and left driving using a model of infant laparoscopic diaphragmatic hernia repair

Shun Onishi, MD, Motoi Mukai, MD, PhD, Takamasa Ikee, MD, Koji Yamada, MD, Takafumi Kawano, MD, Waka Yamada, MD, Ryuta Masuya, MD, Seirou Machigashira, MD, Kazuhiko Nakame, MD, Tatsuru Kaji, MD, PhD, Satoshi Ieiri, MD, PhD, FACS. Department of Pediatric Surgery, Kagoshima University

PURPOSE: Late-presenting diaphragmatic hernia is treated by both thoracoscopic and laparoscopic approaches. In cases with no herniation of the spleen into the thoracic cavity, a laparoscopic approach is easier for repairing the diaphragm because of no costal restriction and a more spacious working space compared with the thoracic approach. In a laparoscopic approach, left needle driving is better than right driving for a few reasons;1) the right hand port is too close to the defect of the diaphragm, 2) left needle driving uses co-axial suturing while right driving uses para-axial suturing. (Fig. 1a). This study aimed to verify the characteristics and precision of needle driving for right-handed pediatric surgeons comparing right (Rt) and left (Lt) needle driving using an infant laparoscopic diaphragmatic repair model simulator.

METHODS: We developed a model of a 1-year-old infant body (body weight: 10 kg) based on computed tomography data. The pneumoperitoneum was reproduced based on the clinical situation. A detachable diaphragmatic defect (Bochdalek hernia, 3.0 × 1.5 cm), stomach, liver and spleen were made of styrene and placed in this model (Fig. 1b). The examinees were 18 pediatric surgeons. The task required the examinee to perform needle driving three times without any knot tying. They were all right-handed and had to perform the technique with both hands (Fig. 2a and 2b). We evaluated the required time and conducted an image analysis (suturing balance and the gap of the suturing interval; the results of these assessments determined that a smaller gap was superior, Fig. 2c). Additionally, we evaluated the total path length, velocity, and acceleration of needle driver using a three-dimensional position measurement instrument with an electromagnetic tracking system (TrackStar, Northern Digital Inc., Ontario, Canada). A statistical analysis was performed using the two-tailed paired and unpaired t-tests, and a value of p < 0.05 was considered to be statistically significant.

RESULTS: Table 1 shows the findings for the required time (sec, Rt: 310.78 ± 148.93 vs. Lt: 308.61 ± 122.53, p = 0.93), suture balances (1st, Rt: 1.59 ± 1.13 vs. Lt: 1.88±1.84, p = 0.564, 2nd, Rt: 1.4 ± 1.02 vs. Lt: 1.65 ± 1.81, p = 0.614, 3rd, Rt: 2.24 ± 1.46 vs. Lt: 1.52 ± 1.28, p = 0.150), the gap of the suturing interval (Rt: 1.2 ± 0.93vs Lt: 2.17 ± 1.67, p = 0.036), total path length (mm, Rt: 594.03 ± 205.29 vs. Lt: 1641.07 ± 670.68, p = 0.0000018), velocity (mm/sec, Rt: 1.92 ± 0.54 vs. Lt: 5.3 ± 1.39, p=0.0000000066), and acceleration (mm/sec2, Rt: 13.6 ± 15.84 vs. Lt: 63.66 ± 62.8, p = 0.0031).

CONCLUSION: There were no significant differences in the required time and suture precision without any gap in the suturing interval. For right-handed pediatric surgeons, left needle driving showed fast but not economical movement, implying rough and risky forceps manipulation in a small working space, such as in neonates and infant patients. Given these results, non-dominant hand training is necessary in advanced pediatric endo-surgery to avoid organ injury due to fast and excessive forceps manipulation.