Comparison of FLS Surgical Skills Performance Using a Motorised Instrument by Conventional Laparoscopy and by Single Port Access

Patrice Crochet, MD, Rajesh Aggarwal, PhD, Sophie Knight, MD, Karine Baumstarck, MD, Maxime Marcelli, MD, Jean-Philippe Estrade, MD, Eric Lambaudie, PhD, Alexandre Lazard, MD, Aubert Agostini, MD. 1. Department of Gynecology, La Conception Hospital, Assistance Publique des Hopitaux de Marseille, France. 2. Department of Surgery, Perelman School of Medicine, University of Pennsylvania.

Introduction :
Single Port Access laparoscopy (SPA) has been suggested as a safe and less invasive alternative to standard laparoscopic surgery (LS). In spite of an increasing number of publications reporting a good feasibility in different surgical specialties, the limited ergonomics raise the question of operative quality as well as adapted instruments for use through a single port. This study aimed to compare performances of expert laparoscopic surgeons performing in LS or in SPA. The impact of the use of an articulated motorised laparoscopic instrument was additionally studied.

Methods and procedures :
In this study, six expert laparoscopic surgeons were recruited. All these subjects completed four tasks (1, 2, 4, 5) from the validated Fundamentals of laparoscopic surgery (FLS) curriculum. The tasks were performed using 4 consecutive operating setups with a randomized crossover design: LS or SPA using conventional straight instruments, LS or SPA using a 10 mm motorised articulated instrument (Kymerax, Terumo*). Assessment of the tasks was performed with standardized FLS metrics. Operative time (secs) and error scores were compared between the 4 operative setups using Mann-Whitney tests, and multiple comparisons were performed using Bonferonni corrections.

Results :
Operative time was significantly longer in SPA than in LS for tasks 1 and 4, using either conventional straight instruments (196 vs 70 secs, p=0.013 and 206 vs 100, p=0.013) or using motorised articulated instrument (229 vs 57, p=0.013 and 255 vs 115, p=0.026). Operative times were not statistically different between SPA and LS for task 2 and 5. By SPA, knot tying tasks 4 and 5 could not be performed within the maximum predefined cut off time (600 secs): once for task 4 and four times for tasks 5. By SPA, operative times were not significantly different using motorised articulated instrument compared to conventional straight instruments (task 1: 229 vs 196, p=1.00; task 2: 330 vs 324, p=1.00; task 4: 255 vs 206, p=0.311; task 5: 284 vs 457, p=1.00). No statistical difference was found in terms of error score for any of the tasks.

Conclusion :
This study demonstrated that SPA surgery required significantly longer operative time for expert surgeons and does not provide good operative conditions for knot tying. The use of the motorised articulated instrument tested does not provide a solution to counterbalance impaired operative ergonomics.