Erica Sutton

University of Louisville, Louisville, Kentucky, United States

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Publications (16)41.4 Total impact

  • Erica Sutton
    Endoscopy 07/2014; · 5.74 Impact Factor
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    ABSTRACT: Among surgeons who regularly perform minimally invasive surgery, as many as 87 % report injuries or symptoms related to job performance. Operating room and instrument design have traditionally favored surgeons who are taller and who possess hands that are, in general, large and strong. We hypothesize that women may be experiencing more ergonomic difficulties than men for whom the operating room and surgical instruments, although uniformly perilous, more traditionally have accommodated. A 23-item web-based survey was offered via email to 2,000 laparoscopic surgeons and fellows currently practicing. The survey addressed four categories: demographics, physical symptoms, ergonomics, and environment/equipment. Key questions allowed us to identify which body part experienced which symptoms. There was a 15.7 % overall response rate. Among respondents, 17 % (54/314) were female. Women were significantly younger, shorter, had smaller glove size, and fewer years in practice than men surveyed (all p values < 0.0001). Of women reporting, 86.5 %-comparable to men-attribute physical discomfort to laparoscopic operating. Female surgeons are more likely to receive treatment for their hands, which includes the wrist, thumb, and fingers (odds ratio 3.5, p = 0.028). When men and women of the same glove size were compared, women with a larger glove size (7-8.5) reported more cases of treatment for their hands than men of the same glove size. (21 vs. 3 %, p = 0.016). Women who wore a size 5.5-6.5 surgical glove reported significantly more cases of discomfort in their shoulder area (neck, shoulder, upper back) than men who wore the same size surgical glove (77 vs. 27 %, p = 0.004). Women surgeons are experiencing more discomfort and treatment in their hands than male surgeons. Redesign of laparoscopic instrument handles and improvements to table height comprise the most promising solutions to these ergonomic challenges.
    Surgical Endoscopy 11/2013; · 3.43 Impact Factor
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    ABSTRACT: We conducted this study to investigate how physical and cognitive ergonomic workloads would differ between robotic and laparoscopic surgeries and whether any ergonomic differences would be related to surgeons' robotic surgery skill level. Our hypothesis is that the unique features in robotic surgery will demonstrate skill-related results both in substantially less physical and cognitive workload and uncompromised task performance. Thirteen MIS surgeons were recruited for this institutional review board-approved study and divided into three groups based on their robotic surgery experiences: laparoscopy experts with no robotic experience, novices with no or little robotic experience, and robotic experts. Each participant performed six surgical training tasks using traditional laparoscopy and robotic surgery. Physical workload was assessed by using surface electromyography from eight muscles (biceps, triceps, deltoid, trapezius, flexor carpi ulnaris, extensor digitorum, thenar compartment, and erector spinae). Mental workload assessment was conducted using the NASA-TLX. The cumulative muscular workload (CMW) from the biceps and the flexor carpi ulnaris with robotic surgery was significantly lower than with laparoscopy (p < 0.05). Interestingly, the CMW from the trapezius was significantly higher with robotic surgery than with laparoscopy (p < 0.05), but this difference was only observed in laparoscopic experts (LEs) and robotic surgery novices. NASA-TLX analysis showed that both robotic surgery novices and experts expressed lower global workloads with robotic surgery than with laparoscopy, whereas LEs showed higher global workload with robotic surgery (p > 0.05). Robotic surgery experts and novices had significantly higher performance scores with robotic surgery than with laparoscopy (p < 0.05). This study demonstrated that the physical and cognitive ergonomics with robotic surgery were significantly less challenging. Additionally, several ergonomic components were skill-related. Robotic experts could benefit the most from the ergonomic advantages in robotic surgery. These results emphasize the need for well-structured training and well-defined ergonomics guidelines to maximize the benefits utilizing the robotic surgery.
    Surgical Endoscopy 10/2013; · 3.43 Impact Factor
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    ABSTRACT: Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE EndoscopyVR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners' knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.
    The American surgeon 01/2013; 79(1):14-22. · 0.92 Impact Factor
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    ABSTRACT: OBJECTIVES: Laparoscopic repair of a giant paraesophageal hiatal hernia remains a challenging procedure. Several techniques have been developed in efforts to achieve tension-free reconstruction of the esophageal hiatus. In this report, we describe a technique whereby the falciform ligament is used as an autologous onlay flap to achieve tension-free closure of the crural defect of a giant paraesophageal hernia (GPEH). DISCUSSION: Use of the falciform ligament as a vascularized autologous onlay flap is a safe and effective procedure to obtain closure of the crural defect of a GPEH. The falciform ligament should be adequately mobilized from the anterior abdominal wall to prevent lateral tension on the flap, but care must be taken to avoid devascularization. Interrupted vertical mattress sutures are used to fix the falciform ligament to the left and right hiatal crurae.
    Journal of Gastrointestinal Surgery 05/2012; 16(7):1417-21. · 2.36 Impact Factor
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    ABSTRACT: This study compares surgical techniques and surgeon's standing position during laparoscopic cholecystectomy (LC), investigating each with respect to surgeons' learning, performance, and ergonomics. Little homogeneity exists in LC performance and training. Variations in standing position (side-standing technique vs. between-standing technique) and hand technique (one-handed vs. two-handed) exist. Thirty-two LC procedures performed on a virtual reality simulator were video-recorded and analyzed. Each subject performed four different procedures: one-handed/side-standing, one-handed/between-standing, two-handed/side-standing, and two-handed/between-standing. Physical ergonomics were evaluated using Rapid Upper Limb Assessment (RULA). Mental workload assessment was acquired with the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). Virtual reality (VR) simulator-generated performance evaluation and a subjective survey were analyzed. RULA scores were consistently lower (indicating better ergonomics) for the between-standing technique and higher (indicating worse ergonomics) for the side-standing technique, regardless of whether one- or two-handed. Anatomical scores overall showed side-standing to have a detrimental effect on the upper arms and trunk. The NASA-TLX showed significant association between the side-standing position and high physical demand, effort, and frustration (p<0.05). The two-handed technique in the side-standing position required more effort than the one-handed (p<0.05). No difference in operative time or complication rate was demonstrated among the four procedures. The two-handed/between-standing method was chosen as the best procedure to teach and standardize. Laparoscopic cholecystectomy poses a risk of physical injury to the surgeon. As LC is currently commonly performed in the United States, the left side-standing position may lead to increased physical demand and effort, resulting in ergonomically unsound conditions for the surgeon. Though further investigations should be conducted, adopting the between-standing position deserves serious consideration as it may be the best short-term ergonomic alternative.
    Surgical Endoscopy 03/2011; 25(7):2168-74. · 3.43 Impact Factor
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    ABSTRACT: Minimally invasive surgery requires high-quality imaging to provide effective visual displays to surgeons. Whereas objective measures--pixels, resolution, display size, contrast ratio--are used to compare imaging systems, there are no tools for assessing the perceptual impact of these physical measures. We developed the "Maryland Visual Comfort Scale" (MVCS) to measure perceptual qualities in relation to an imaging system. We theorize that what the surgeon perceives as a high-quality image can be summarized by a scoring of seven characteristics related to human perception, and that image quality is not homogenous across a video display such that object location impacts perception and display quality. We created a rating scale for seven dimensions of display characteristics (contrast, detail, brightness, lighting uniformity, focus uniformity, color, sharpness). For validation, 30 participants viewed test patterns and manipulated physiologic images, rating the image quality for all seven dimensions as well as giving an overall rating. Image ratings for contrast and detail dimensions were assessed across five locations on the video display. For ratings, two imaging systems were used, differing primarily in the 10-mm zero-degree scope's quality: a standard scope and one taken from service for quality degradation. The rating scale was sensitive to differences in scope quality for all seven items in the MVCS (all p values<0.01). Significant differences existed between quality ratings at central and peripheral locations (p<0.05). This seven-item rating scale for assessing visual comfort is reliable and sensitive to scope quality differences. The scale is sensitive to degradation of image quality at video display edges. These seven dimensions of display characteristics can be refined to create a psychometric to serve as a composite of perceptual quality in laparoscopy.
    Surgical Endoscopy 02/2011; 25(2):567-71. · 3.43 Impact Factor
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    ABSTRACT: Laparoscopic incisional hernia repair (LIHR) is a common procedure requiring advanced laparoscopic skills. This study aimed to develop a procedure-specific tool to assess the performance of LIHR and to evaluate its reliability and validity. The Global Operative Assessment of Laparoscopic Skills-Incisional Hernia (GOALS-IH) is a 7-item global rating scale developed by experts to evaluate the steps of LIHR (placement of trocars, adhesiolysis, estimation of mesh size and shape, mesh orientation and positioning, mesh fixation, knowledge and autonomy in use of instruments, overall competence), each rated on a 5-point Likert scale. During LIHR, 13 attending surgeons and fellows experienced in minimally invasive surgery (MIS) and 19 novice surgeons (postgraduate years [PGYs], 3-5) were evaluated at four teaching hospitals by the attending surgeon, a trained observer, and self-assessment using GOALS-IH, and by a previously validated 5-item general laparoscopic rating scale (GOALS). Interrater reliability was assessed by intraclass correlation (ICC), and internal consistency of rating items was assessed by Cronbach's alpha. Known-groups construct validity was assessed by using the t-test and by correlating of the number of self-reported LIHR cases with the total score. Concurrent validity was assessed by correlating the GOALS-IH score with the GOALS general rating scale. Data are presented as mean and 95% confidence interval (CI). Interrater reliability for the total GOALS-IH score was 0.79 (95% CI, 0.60-0.89) between observers and attending surgeons, 0.81 (95% CI, 0.58-0.92) between participants and attending surgeons, and 0.89 (95% CI, 0.76-0.96) between participants and observers. Internal consistency was high (Cronbach's alpha, 0.93). Experienced surgeons performed significantly better than novices as assessed by GOALS-IH (31; 95% CI, 29-33 vs. 21; 95% CI, 19-24; p < 0.01). Very good correlation was found between GOALS-IH and previous LIHR experience (r = 0.82; p < 0.01) and strong correlation between GOALS-IH and generic GOALS total scores (r = 0.90; p < 0.01). Surgical performance during clinical LIHR can be assessed reliably using GOALS-IH. Results can be used to provide formative feedback to the surgeon and to identify steps of the operation that would benefit from specific educational interventions.
    Surgical Endoscopy 02/2011; 25(8):2555-63. · 3.43 Impact Factor
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    ABSTRACT: the role of simulation for training in procedures such as laparoscopic incisional hernia repair (LIHR) is unknown. The purpose of this study was to determine whether performance in simulated LIHR correlates with operating room (OR) performance. subjects performed LIHR in the University of Maryland Surgical Abdominal Wall (SAW) simulator and the OR. Trained observers used a LIHR-specific global rating scale (Global Operative Assessment of Laparoscopic Skills-Incisional Hernia) to assess performance. Global Operative Assessment of Laparoscopic Skills-Incisional Hernia includes 7 domains (trocar placement, adhesiolysis, mesh sizing, mesh positioning, mesh fixation, knowledge and autonomy in instrument use, and overall competence). The correlation between simulator and OR performance was assessed using the Pearson coefficient. fourteen surgeons from 2 surgical departments participated. Experienced surgeons (n = 9) were defined as attending surgeons and minimally invasive surgury (MIS) fellows, and novice surgeons (n = 5) were general surgery residents (postgraduate years 3-5). The correlation between performance in the OR and the simulator for the entire group was .87 (95% confidence interval, .63-.96; P < .001). there was an excellent correlation between LIHR performance in the simulator and clinical LIHR. This suggests that performance in the SAW simulator may predict performance in the operating room.
    American journal of surgery 01/2011; 201(1):40-5. · 2.36 Impact Factor
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    ABSTRACT: Research confirms that surgeons experience physical symptoms due to the unfavorable ergonomics of laparoscopy. The physical effects of performing Natural Orifice Transluminal Endoscopic Surgery (NOTES)-potentially the next evolutionary surgical step-are only now being quantitatively and systematically assessed. This study investigates NOTES- and laparoscopy-related physical workloads through biomechanical analyses. Fourteen surgeons with varying laparoscopic experience were recruited. Each participant completed ring transfer and triangle transfer tasks using two surgical platforms: laparoscopy and NOTES. Motion capture and electromyography (EMG) systems recorded biomechanical data for quantitative physical workload assessment. The normalized cumulative muscular workload (NCMW) and mean muscular workload (MMW) were obtained from EMG data. Then normalized performance time (NPT) was compared between the two surgical platforms. The overall NCMW was considerably greater when participants performed tasks using the NOTES platform (1315.8±116.9%) compared with traditional laparoscopy (153.9±18.8%). Performing NOTES required eight to nine times higher muscular workload (NCMW: NOTES 1315.8%, laparoscopy 153.9%, p<0.05) when compared with traditional laparoscopy. This result was shown to be caused by the following: (1) six to eight times longer NPT with NOTES (p<0.05) and (2) higher average activation levels shown in regard to biceps, extensor digitorum communis, and thenar compartment (p<0.05), the muscles responsible for specific joint movements to hold and operate the scope. This study demonstrated that performing NOTES is significantly more challenging for surgeons than laparoscopy. The greater amount of muscular exertion required is linked to higher ergonomic risks. Based on the depth and strength of our results, we propose that an alternative NOTES platform be designed, one that overcomes the awkward operational mechanism of the dual-working-channel flexible endoscope.
    Surgical Endoscopy 11/2010; 25(5):1585-93. · 3.43 Impact Factor
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    ABSTRACT: Disruptions to surgical workflow have been correlated with an increase in surgical errors and suboptimal outcomes in patient safety measures. Yet, our ability to quantify such threats to patient safety remains inadequate. Data are needed to gauge how the laparoscopic operating room work environment, where the visual and motor axes are no longer aligned, contributes to such disruptions. We used time motion analysis techniques to measure surgeon attention during laparoscopic cholecystectomy in order to characterize disruptive events imposed by the work environment of the OR. In this investigation we identify attention disruptions as they occur in terms of the operating surgeon's gaze. We then quantify such disruptions and also seek to establish what occasioned them. Ten laparoscopic cholecystectomy procedures were recorded with both intra- and extracorporeal cameras. The views were synchronized to produce a video that was subsequently analyzed by a single independent observer. Each time the surgeon's gaze was diverted from the operation's video display, the event was recorded via time-stamp. The reason for looking away (e.g., instrument exchange), when discernable, was also recorded and categorized. Disruptions were then reviewed and analyzed by an interdisciplinary team of surgeons and human factors experts. Gaze disruptions were classified into one of four causal categories: instrument exchange, extracorporeal work, equipment troubleshooting, and communication. On average, 40 breaks occurred in operating surgeon attention per 15 min of operating time. The most frequent reasons for these disruptions involved instrument exchange (38%) and downward gaze for extracorporeal work (28%). This study of laparoscopic cholecystectomy performance reveals a high gaze disruption rate in the current operating room work environment. Improvements aimed at reducing such disruptions-and thus potentially surgical error-should center on better instrument design and realigning the axis between surgeon's eye and visual display.
    Surgical Endoscopy 06/2010; 24(6):1240-4. · 3.43 Impact Factor
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    ABSTRACT: Current laparoscopic images are rich in surface detail but lack information on deeper structures. This report presents a novel method for highlighting these structures during laparoscopic surgery using continuous multislice computed tomography (CT). This has resulted in a more accurate augmented reality (AR) approach, termed "live AR," which merges three-dimensional (3D) anatomy from live low-dose intraoperative CT with live images from the laparoscope. A series of procedures with swine was conducted in a CT room with a fully equipped laparoscopic surgical suite. A 64-slice CT scanner was used to image the surgical field approximately once per second. The procedures began with a contrast-enhanced, diagnostic-quality CT scan (initial CT) of the liver followed by continuous intraoperative CT and laparoscopic imaging with an optically tracked laparoscope. Intraoperative anatomic changes included user-applied deformations and those from breathing. Through deformable image registration, an intermediate image processing step, the initial CT was warped to align spatially with the low-dose intraoperative CT scans. The registered initial CT then was rendered and merged with laparoscopic images to create live AR. Superior compensation for soft tissue deformations using the described method led to more accurate spatial registration between laparoscopic and rendered CT images with live AR than with conventional AR. Moreover, substitution of low-dose CT with registered initial CT helped with continuous visualization of the vasculature and offered the potential of at least an eightfold reduction in intraoperative X-ray dose. The authors proposed and developed live AR, a new surgical visualization approach that merges rich surface detail from a laparoscope with instantaneous 3D anatomy from continuous CT scanning of the surgical field. Through innovative use of deformable image registration, they also demonstrated the feasibility of continuous visualization of the vasculature and considerable X-ray dose reduction. This study provides motivation for further investigation and development of live AR.
    Surgical Endoscopy 02/2010; 24(8):1976-85. · 3.43 Impact Factor
  • Adrian Park, Erica Sutton, Raj Shekhar
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    ABSTRACT: Current generation minimally invasive surgeries present many visualization challenges, including two-dimensional representation of three-dimensional anatomy and a lack of visualization of deeply recessed structures. Coupled with the loss of tactile feedback which places greater emphasis on available visual cues, improved surgical visualization remains a long-standing need. Our response to address this need is Live Augmented Reality (Live AR), in which processed images from live radiologie scans of the surgical field are merged with optical images, accounting for spatial and temporal registration. We have demonstrated the feasibility of Live AR, but its clinical implementation is hampered by many current technical limitations. Ln this report, we have presented guidance of a simple laparoscopic maneuver completely based on computed tomography (CT) scanning and rapid 3D rendering of the acquired images in the CT room. The capability developed here and the reported results constitute a step toward the eventual goal of routine clinical implementation of Live AR.
    11th International Conference on Control, Automation, Robotics and Vision, ICARCV 2010, Singapore, 7-10 December 2010, Proceedings; 01/2010
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    Journal of Surgical Education 01/2010; 67(6):473-6. · 1.07 Impact Factor
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    ABSTRACT: Traditional minimally invasive surgeries use a view port provided by an endoscope or laparoscope. We argue that a useful addition to typical endoscopic imagery would be a global 3-D view providing a wider field of view with explicit depth information for both the exterior and interior of target anatomy. One technical challenge of implementing such a view is finding efficient and accurate means of registering texture images from the laparoscope on prebuilt 3-D surface models of target anatomy derived from magnetic resonance (MR) or computed tomography (CT) images. This paper presents a novel method for addressing this challenge that differs from previous approaches, which depend on tracking the position of the laparoscope. We take advantage of the fact that neighboring frames within a video sequence usually contain enough coherence to allow a 2-D-2-D registration, which is a much more tractable problem. The texturing process can be bootstrapped by an initial 2-D-3-D user-assisted registration of the first video frame followed by mostly-automatic texturing of subsequent frames. We perform experiments on phantom and real data, validate the algorithm against the ground truth, and compare it with the traditional tracking method by simulations. Experiments show that our method improves registration performance compared to the traditional tracking approach.
    IEEE transactions on medical imaging. 09/2009; 29(6):1213-23.
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    ABSTRACT: Surgeons and naval aviators are both trained to work in high-stakes environments. Any misadventure in either of their working worlds can lead to death. Yet the pathways to certification and implicit attitudes toward training are quite different in these 2 disciplines and provide an opportunity to compare and contrast the methodologies employed. At the 5th annual Innovations in the Surgical Environments Conference, senior and junior aviators and surgeons shared their experiences from the perspective of trainee and trainer and in the process presented an interesting study in parallels and contrasts. The US Navy follows a highly regimented training syllabus with graduated levels of responsibility designed to create the safest possible flying environment. Extensive preflight and postflight effort is required for each mission flown. Surgical training is also hierarchal in responsibility, but graduates demonstrate greater variability in their training experience. The surgical field can only fortify its emphasis on safety by seeking to provide the optimal training experiences necessary in the high-stakes environment of the operating theater. In doing so, surgeons may find reinvigorated commitment through study of the aviation industry's established methods of training and practice.
    Surgical Innovation 07/2009; 16(2):187-95. · 1.54 Impact Factor

Publication Stats

41 Citations
41.40 Total Impact Points


  • 2012–2014
    • University of Louisville
      • Department of Surgery
      Louisville, Kentucky, United States
    • Anne Arundel Medical Center
      Annapolis, Maryland, United States
  • 2011
    • University of Maryland Medical Center
      Baltimore, Maryland, United States
  • 2010–2011
    • University of Maryland, Baltimore
      • Department of Surgery
      Baltimore, MD, United States
    • Loyola University Maryland
      Baltimore, Maryland, United States
  • 2009
    • Cambridge Health Alliance
      • Department of Surgery
      Cambridge, MA, United States
    • University of Kentucky
      • Department of Computer Science
      Lexington, Kentucky, United States