Comparison of learning curves and skill transfer between classical and robotic laparoscopy according to the viewing conditions: implications for training.

Abstract

The purpose of this study was to evaluate the perceptual (2-dimensional [2D] vs. 3-dimensional [3D] view) and instrumental (classical vs. robotic) impacts of new robotic system on learning curves.
Forty medical students without any surgical experience were randomized into 4 groups (classical laparoscopy with 3D-direct view or with 2D-indirect view, robotic system in 3D or in 2D) and repeated a laparoscopic task 6 times. After these 6 repetitions, they performed 2 trials with the same technique but in the other viewing condition (perceptive switch). Finally, subjects performed the last 3 trials with the technique they never used (technical switch). Subjects evaluated their performance answering a questionnaire (impressions of mastery, familiarity, satisfaction, self-confidence, and difficulty).
Our study showed better performance and improvement in 3D view than in 2D view whatever the instrumental aspect. Participants reported less mastery, familiarity, and self-confidence and more difficulty in classical laparoscopy with 2D-indirect view than in the other conditions.
Robotic surgery improves surgical performance and learning, particularly by 3D view advantage. However, perceptive and technical switches emphasize the need to adapt and pursue training also with traditional technology to prevent risks in conversion procedure.

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Manuscript Number:

Title: Comparison of learning curves and skill transfer between classical and robotic laparoscopy according
to the viewing conditions: Implications for training

Article Type: Bench Laboratory Research

Section/Category:

Keywords: Robotic surgery; depth perception; movement freedom; learning curves; Skill transfer;
Laparoscopic training

Corresponding Author: Mrs Adélaïde Blavier,

Corresponding Author's Institution: National Funds of Scientific Research, University of Liège

First Author: Adélaïde Blavier

Order of Authors: Adélaïde Blavier; Quentin Gaudissart, MD; Guy-Bernard Cadière, MD, PhD; Anne-Sophie
Nyssen, PhD

Manuscript Region of Origin:

Abstract: Background: The purpose of this study was to evaluate the perceptual (2D versus 3D view) and
instrumental (classical versus robotic) impacts of robotic system on surgical skill acquisition and, in a second
time, to determine whether skills were transferred between conventional laparoscopy and robotic system.
Methods: 40 medical students without any surgical experience were randomized into four groups (classical
laparoscopy with 3D-direct view or with 2D-indirect view, robotic system in 3D or in 2D) and repeated a
complex motor task 6 times. Afterwards, they performed 2 trials with the same technique but in the other
viewing condition (perceptive switch). Finally, subjects performed last three trials with the other technique
(technical switch). Subjects impressions were surveyed by a questionnaire.

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Results: Our study showed better performance and improvement in 3D view than in 2D view whatever
instrumental aspect. Participants reported less mastery, familiarity, self-confidence and more difficulty in
classical laparoscopy with 2D indirect view than in the other conditions.
Conclusions: Robotic surgery improves surgical performance and learning particularly by 3D view advantage.
However, performances after switches emphasize the need to adapt and pursue training also with
conventional laparoscopy in order to prevent risks in conversion procedure.

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FINANCIAL DISCLOSURE: we certify that we have no commercial associations that might pose a
conflict of interest in connection with the submitted article. All funding sources supporting the Work
and all institutional or corporate affiliations of the authors are acknowledged.

Conflict of Interests Statement

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Liège, 18th of January 2006



Please find enclosed our manuscript entitled “Comparison of learning curves and
skill transfer in classical and robotic laparoscopy according to the viewing
conditions: Implications for training” that we would like to submit to the American
Journal of Surgery.
Our manuscript reports a laboratory study on the impact of da Vinci robotic technique
on learning curves and subjective impression of novice subjects (medical students). This
manuscript has been seen and approved by all authors.

We thank you in advance for your comments about this paper.

Best regards,

* Cover Letter

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Introduction

The fundamental change, produced by new technology, in how surgeons perform operations has
educational implications related to learning curves and patient safety [1]. Traditionally, surgeons have
honed their skills in the operating rooms through hands-on experience with veteran mentors [2]. This
manner of teaching effectively trains surgeons in traditional open surgical techniques, but is costly in
terms of time, resources and patient morbidity [3]. Over the past decade, minimally access surgery has
revolutionized general surgery, posing new obstacles for surgeons attempting to acquire laparoscopic
skills [4]. Indeed, laparoscopic surgery requires specialized training and practice in order to acquire
new skills to operate, to manipulate tissues with long instruments and a new knowledge of anatomy
and spatial orientation [5,6]. Moreover, classical laparoscopic surgery is generally a two-dimensional
surgery. The loss of depth perception and spatial orientation are the main drawbacks for the novice to
overcome when facing the television monitor [7]. Advanced complicated laparoscopic surgery
requires precise manipulation of the instruments. The success of surgery, the operating time, and the
morbidity rate are directly related to the manipulation skills and are responsible for the well-described
“learning curve” [1,8,9].
However, minimal invasive surgery was introduced and adopted in a rapid form without precise
appreciation of the long learning curve that constitutes the only existing path to overcome all these
difficulties [10]. Furthermore, very few studies have been done regarding the surgical skills education
and competency testing associated with the use of new and sophisticated technology [11]. In order to
avoid the problems that occurred at the introduction of laparoscopic surgery, several recent studies laid
stress upon the need to understand how new technology affects learning curves in order to establish
appropriate training and assessment [10,11]. Our objective was to answer this question by evaluating
learning curves in a comparative study between classical and robotic laparoscopy. Our study analysed
the perceptual and instrumental impacts of robotic technology on learning surgical performance of
novice subjects using a standard and ecological surgical task developed and validated in several
studies (bench models [12,13,14]). In this paper, we used a new generation of 3D system, the da Vinci
robotic system. This robotic system allows to regain three-dimensional visualization of the operative
field and the degrees of instruments movement freedom lost in classical laparoscopy. Three-
dimensional camera system may improve the efficiency, shorten the learning curve and reduce the
operating time [7]. However, the literature shows contradictory results about the benefits brought by
the 3D vision: some studies showing best motor performances with 3D vision [14-19] while others
failed to obtain difference of performance between 2D and 3D [7,20-22]. In order to precisely identify
the nature of the skills and learning involved with the robotic system, we differentiated and
independently studied the influence of the three-dimensional view (afferent component) comparing 2D
and 3D view and the influence of movement freedom restoration (efferent component) comparing
* Manuscript