title: Axial-spin technique of endoscopic intracorporeal knot tying: comparison with the conventional technique and objective assessment of knot security, learning curves, and performance efficiency across training levels.
abstract: BACKGROUND
  A major limitation of conventional laparoscopic surgery is the placement of an intracorporeal (IC) knot, which requires a significant amount of training and practice. An easier technique of IC knot tying using 90-degree grasper is compared with the conventional technique (CLT). The new axial-spin technique (AST) uses the spin of the instrument shaft to tie IC knots.
  
  
  METHODS
  Fourteen participants stratified into 3 training levels were instructed to tie 50 reef IC knots using each technique on trainers in 3 sessions. The final 5 knots tied using each technique were deemed to be representative of maximal performance efficiency (PE) and randomly subject to tensile strength measurements using a tensiometer at 50 mm/s distraction. Mean knot execution time (mKET) measured in seconds (s), normalized KE time (nET=group mean/mKET), knot holding capacity, relative knot security (RKS), and PE (PE=RKS/nET) of the knots tied were computed and analyzed using paired t and analysis of variance.
  
  
  RESULTS
  Variables included knot-tying session, technique and the training level. On completion of the study, junior residents (JR) averaged 51.72 seconds more, senior residents (SR) averaged 26.22 seconds more and attendings (ATT) averaged 19.17 seconds less to tie using CLT compared with the AST (F=40.52, P=0.0001). Across all levels, the CLT technique was taking 83.26 seconds on average to execute an IC knot compared with 59.08 seconds with AST method (t=2.784, P=0.015). Learning curves revealed that JR significantly improved mean KE times with the AST technique (first session vs. final session: 473.8 s vs. 55.9 s) compared with CLT (672.5 s vs. 107.6 s) across the sessions as compared with those in advanced levels of training. The RKS of knots executed by AST was significantly stronger (AST: 13.1 vs. 5.44 N, t=4.9, P=0.0001). The PE of knots executed using the CLT increased geometrically across training levels (JR: 1.35% SR: 5.58% ATT: 11.22%) whereas those of AST showed a linear trend (17.09%; 17.11%, and 13.95%).
  
  
  CONCLUSIONS
  The AST follows a linear pattern of learning across training levels compared with the steep exponential learning of the CLT. Inexperienced JRs were surprisingly 1.5 times more efficient with AST and 8 times less efficient with CLT compared with ATT using the CLT to execute the same knot. The AST is significantly easier to learn for JRs and could serve as a platform before acquiring more advanced knot-tying skills. Overall, with the AST, execution times are significantly shorter whereas the RKS and PE are significantly higher. JRs achieve a level of proficiency comparable with the senior level residents and ATT after participating in a reasonable training session consisting of at least 25 knots.
authors.affiliation: Department of Surgery, Easton Hospital, Easton PA and Drexel University College of Medicine, Philadelphia, PA, USA. gopaldas@bcm.tmc.edu
authors.forename: Raja R
authors.initials: RR
authors.lastname: Gopaldas
authors.forename: Chand
authors.initials: C
authors.lastname: Rohatgi
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D002983:Clinical Competence; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D013536:Suture Techniques / Q000193:education*; D014481:United States