title: A triangulating operating platform enhances bimanual performance and reduces surgical workload in single-incision laparoscopy.
abstract: BACKGROUND
  Single-site laparoscopy (SSL) attempts to further reduce the surgical impact of minimally invasive surgery. However, crossed instruments and the proximity of the endoscope to the operating instruments placed through one single site leads to inevitable instrument or trocar collision. We hypothesized that a novel, single-port, triangulating surgical platform (SPSP) might enhance performance by improving bimanual coordination and decreasing the surgeon's mental workload.
  
  
  METHODS
  Fourteen participants, proficient in basic laparoscopic skills, were tested on their ability to perform a validated intracorporeal suturing task by either an SSL approach with crossed articulated instruments or a novel SPSP, providing true-right and true-left manipulation. Standard laparoscopic (SL) access served as control. Sutures were evaluated using validated scoring methods and the National Aeronautics and Space Administration Task Load Index was used to rate mental workload.
  
  
  RESULTS
  All participants proficiently performed intracorporeal knots by SL (mean score 99.0; 95% CI 97.0 to 100.9). Performance decreased significantly (more than 50%, p < 0.001) with the SSL approach using 1 rigid and 1 articulating instrument in a cross-wise manner (mean score 39.2; 95% CI 28.3 to 50.1). The use of the SPSP significantly enhanced bimanual coordination (mean score 67.6; 95% CI 61.3 to 73.9; p < 0.001). Participants recorded lower mental workload when using true-right and true-left manipulation.
  
  
  CONCLUSIONS
  This study objectively assessed SSL performance and current attempts for instrumentation improvement in single-site access. While SSL significantly impairs basic laparoscopic skills, surgical platforms providing true-left and true-right maneuvering of instruments appear to be more intuitive and address some of the current challenges of SSL that may otherwise limit its widespread acceptance.
authors.affiliation: Minimally Invasive Surgery Program, Legacy Health, Portland, OR, USA. erwin.rieder@meduniwien.ac.at
authors.forename: Erwin
authors.initials: E
authors.lastname: Rieder
authors.forename: Danny V
authors.initials: DV
authors.lastname: Martinec
authors.forename: Maria A
authors.initials: MA
authors.lastname: Cassera
authors.forename: Trudie A
authors.initials: TA
authors.lastname: Goers
authors.forename: Christy M
authors.initials: CM
authors.lastname: Dunst
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanstrom
mesh_terms: D000328:Adult; D004867:Equipment Design; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000295:instrumentation* / Q000379:methods; D008297:Male; D008875:Middle Aged; D013536:Suture Techniques; D013647:Task Performance and Analysis; D016526:Workload