title: Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload.
abstract: BACKGROUND
  Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room.
  
  
  METHODS
  Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastro-gastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da Vinci) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects' self-reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered significant.
  
  
  RESULTS
  Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595 +/- 22 s versus 459 +/- 137 s, respectively; p < 0.001), achieve higher overall scores (0 +/- 1 versus 95 +/- 128, respectively; p < 0.001), and commit fewer errors per knot (1.15 +/- 1.35 versus 0.05 +/- 0.26, respectively; p < 0.001). Subjects' overall score did not improve between the first and third attempt for laparoscopic suturing (0 +/- 0 versus 0 +/- 0; p = NS) but improved significantly for robotic suturing (49 +/- 100 versus 141 +/- 152; p < 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99 +/- 15 versus 57 +/- 23; p < 0.001).
  
  
  CONCLUSIONS
  Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed.
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, Carolinas Simulation Center, Charlotte, NC 28203, USA. dimitrios.stefanidis@carolinas.org
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Stefanidis
authors.forename: Fikre
authors.initials: F
authors.lastname: Wang
authors.forename: James R
authors.initials: JR
authors.lastname: Korndorffer
authors.forename: J Bruce
authors.initials: JB
authors.lastname: Dunne
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Scott
mesh_terms: D000328:Adult; D000818:Animals; D002983:Clinical Competence; D004521:Educational Measurement; D005260:Female; D018662:Fundoplication / Q000193:education / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011446:Prospective Studies; D012371:Robotics / Q000193:education; D013337:Students, Medical / Q000523:psychology*; D013536:Suture Techniques / Q000193:education / Q000295:instrumentation*; D013552:Swine; D018910:Video Games / Q000706:statistics & numerical data; D016526:Workload; D055815:Young Adult