title: Force-Sensing Enhanced Simulation Environment (ForSense) for laparoscopic surgery training and assessment.
abstract: BACKGROUND
  Excessive or inappropriate tissue interaction force during laparoscopic surgery is a recognized contributor to surgical error, especially for robotic surgery. Measurement of force at the tool-tissue interface is, therefore, a clinically relevant skill assessment variable that may improve effectiveness of surgical simulation. Popular box trainer simulators lack the necessary technology to measure force. The aim of this study was to develop a force sensing unit that may be integrated easily with existing box trainer simulators and to (1) validate multiple force variables as objective measurements of laparoscopic skill, and (2) determine concurrent validity of a revised scoring metric.
  
  
  METHODS
  A base plate unit sensitized to a force transducer was retrofitted to a box trainer. Participants of 3 different levels of operative experience performed 5 repetitions of a peg transfer and suture task. Multiple outcome variables of force were assessed as well as a revised scoring metric that incorporated a penalty for force error.
  
  
  RESULTS
  Mean, maximum, and overall magnitudes of force were significantly different among the 3 levels of experience, as well as force error. Experts were found to exert the least force and fastest task completion times, and vice versa for novices. Overall magnitude of force was the variable most correlated with experience level and task completion time. The revised scoring metric had similar predictive strength for experience level compared with the standard scoring metric.
  
  
  CONCLUSIONS
  Current box trainer simulators can be adapted for enhanced objective measurements of skill involving force sensing. These outcomes are significantly influenced by level of expertise and are relevant to operative safety in laparoscopic surgery. Conventional proficiency standards that focus predominantly on task completion time may be integrated with force-based outcomes to be more accurately reflective of skill quality.
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom. Electronic address: t.cundy@imperial.ac.uk.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Cundy
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Thangaraj
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom.
authors.forename: Hedyeh
authors.initials: H
authors.lastname: Rafii-Tari
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Payne
authors.affiliation: Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Georges
authors.initials: G
authors.lastname: Azzie
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
authors.forename: Mikael H
authors.initials: MH
authors.lastname: Sodergren
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom.
authors.forename: Guang-Zhong
authors.initials: GZ
authors.lastname: Yang
authors.affiliation: The Hamlyn Centre, Institute of Global Health Innovation, Imperial College London, London, United Kingdom; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003198:Computer Simulation; D006801:Humans; D010535:Laparoscopy / Q000193:education*; D008131:London; D008297:Male; D055595:Mechanical Phenomena; D017145:Models, Educational; D009864:Ontario; D015203:Reproducibility of Results; D012371:Robotics; D012984:Software; D013647:Task Performance and Analysis; D014584:User-Computer Interface; D014741:Video Recording