Ahmed M Zihni, MD, MPH, Jaime A Cavallo, MD, MPHS, Jason Chiu, BA, Ikechukwu Ohu, BS, Sohyung Cho, PhD, L. Michael Brunt, MD, FACS, Michael M Awad, MD, PhD. Washington University in St Louis, Southern Illinois University Edwardsville.
INTRODUCTION: Robot-assisted laparoscopic surgery (RALS) utilizes wristed instruments that provide more degrees of freedom than rigid traditional laparoscopic (TLS) instrumentation and 3-D visualization. These features have been touted to improve accuracy and efficiency during surgical performance. However, there have been few quantitative evaluations of surgical task performance on RALS and TLS platforms among both novice and experienced surgeons. We compared objective measures of quality and efficiency of Fundamentals of Laparoscopic Surgery (FLS) task performance on RALS and TLS platforms in surgical novices and experienced laparoscopic surgeons. We hypothesized that both quality (as measured by errors per trial) and efficiency (as measured by completion time) would be significantly enhanced by task performance on the RALS platform compared to the TLS platform among novices and experts.
METHODS: Twelve novices (< 100 laparoscopic procedures performed) and sixteen expert laparoscopic surgeons (≥ 100 laparoscopic procedures performed) were recruited to perform three FLS tasks on both the TLS and the RALS platforms: peg transfer (PT), pattern cutting (PC), and intracorporeal suturing (IS). All tasks were performed using FLS testing parameters and repeated three times by each subject on each platform in a randomized order. Errors in task performance were defined as drops in the PT task, faults ≥ 5mm cut from the defined pattern during PC, and faults ≥ 1mm in suture placement from the defined points in IS. Errors were evaluated in a blinded manner. Mean errors per trial (EPT) and mean completion time (seconds) were calculated for each task on both platforms. Results were compared using unpaired student’s t-test, with p<0.05 considered the threshold of significance.
RESULTS: Among novices, significantly fewer errors occurred during PC on the RALS compared to the TLS platform (2.3 EPT, 0.8 EPT, respectively; p<0.001). No statistically significant differences in errors were seen for PT or IS tasks, or in mean completion times for PC, PT, or IS tasks when comparing RALS and TLS platforms. Among experts, no statistically significant differences in errors were noted during performance of any of the three FLS tasks. Among experts, PT (TLS 80.0 s, RALS 100.6s, p=0.007) and PC (TLS 116.1s, RALS 145.2s, p=0.040) tasks were completed significantly faster on the TLS platform; no significant difference in completion time was noted for the IS task.
CONCLUSIONS: Novice surgeons demonstrate reduced errors in task performance on the RALS platform when performing the PC task, and performed tasks at comparable speeds on the TLS and RALS platforms. Among expert laparoscopic surgeons, no qualitative benefit in task performance was noted, and PT and PC task performance were significantly faster on the TLS platform. These findings suggest that the dexterity of the RALS platform may provide a slight performance advantage compared to the TLS platform among surgical novices but not for expert laparoscopic surgeons. Further studies comparing task performance in expert laparoscopic surgeons and a robust sample of expert robotic surgeons with comparable levels of experience are under way.