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Objective: The objective of this study is to compare the use of three-dimensional (3D) vision systems with traditional two-dimensional systems in laparoscopic urological surgery, analyzing the benefits, limitations, and impact of introducing this medical technology with regard to surgical performance and the surgeon's ergonomics. Methods: A systematic review with a structured bibliographic search was conducted in the electronic libraries (PubMed and EMBASE) until August 2019 and with no language restrictions. Studies on 3D visualization technology in laparoscopic urologic surgery, randomized controlled trials, and observational comparative studies were included. Relevant data were extracted and analyzed. Results: A total of 25 articles were obtained, of which 4 were clinical studies with patients, 2 studies were carried out in experimental animal models, and the remaining 19 were conducted in simulated environments. Regarding the European training program in basic laparoscopic urological skills, the results showed no significant differences in execution time using either imaging system. Three-dimensional vision led to a significant reduction in surgery time in pyeloplasty and radical nephrectomy. In addition, there was a reported decrease in blood loss in adrenalectomy, nephron-sparing nephrectomy, radical nephrectomy, simple nephrectomy, and pyeloplasty using 3D vision. Regarding ergonomics, the studies generally described no differences in side effects (headache, nausea, eye strain) when comparing the two types of visualization systems. Surgeons reported reduced workloads and stress with 3D vision than with traditional laparoscopy. Conclusions: Three-dimensional laparoscopic systems essentially advance surgical performance in less-experienced laparoscopic surgeons. Three-dimensional laparoscopy leads to improvements in surgery time, which is important for specific surgical procedures involving intracorporeal ligatures and sutures. The results achieved on the surgeons' ergonomics showed better depth perception and decreased stress and workloads during 3D vision with no differences in potential side effects.

Wearable technology is an emerging field that has the potential to revolutionize healthcare. Advances in sensors, augmented reality devices, the internet of things, and artificial intelligence offer clinically relevant and promising functionalities in the field of surgery. Apart from its well-known benefits for the patient, minimally invasive surgery (MIS) is a technically demanding surgical discipline for the surgeon. In this regard, wearable technology has been used in various fields of application in MIS such as the assessment of the surgeon’s ergonomic conditions, interaction with the patient or the quality of surgical performance, as well as in providing tools for surgical planning and assistance during surgery. The aim of this chapter is to provide an overview based on the scientific literature and our experience regarding the use of wearable technology in MIS, both in experimental and clinical settings.

To test the feasibility of a new device for gasless laparoscopy in providing working space for diaphragmatic hernia repair in an ex vivo canine model as a pre-clinical study.Technical feasibility study.Eight beagles and two greyhound cadavers (not client-owned).The new device was used for abdominal traction in gasless laparoscopic reconstruction of diaphragmatic hernias produced in dog cadavers. It consists of three main parts (vertical and horizontal rods, a three-piece structure, and a 3D-printed unit that incorporates slots for haemostatic forceps). Composite hernias (two incisions of about 4 cm) were closed by an intra-corporeal suture [suture group (GS), n = 5] or by a central suture and a polypropylene mesh [mesh group (GM), n = 5]. Surgical steps were T1 (primary port access up to third port placement), T2 (defect development), and T3 (diaphragmatic reconstruction). Total surgical time (TT) was also recorded.The defect was successfully developed and reconstructed in all cadavers. To close the defect, 7.0 ± 0.7 crossed mattress sutures were required in the GS, and 15.2 ± 1.9 hernia staples and one intra-corporal suture were used in the GM. T3 was longer (p = 0.0076) in GS (50.00 ± 16.46 min) than in GM (23.24 ± 5.25 min). TT was 87.22 ± 19.23 min in GS and 66.45 ± 6.38 min in GM (p = 0.0547).Gasless laparoscopic diaphragmatic hernia repair using the developed device is feasible in the canine cadaver model. Both suture and mesh graft techniques for experimental diaphragmatic herniorrhaphy can be performed using this new device in this pre-clinical model.This new device for gasless laparoscopy allows diaphragmatic herniorrhaphy by intra-corporeal suture or mesh implantation in ex vivo canine model. The device demonstrates potential for future use in clinical cases.

Modern surgical education is focused on making use of the available technologies in order to train and assess surgical skill acquisition. Innovative technologies for the automatic, objective assessment of nontechnical skills are currently under research. The main aim of this study is to determine whether personal resourcefulness can be assessed by monitoring parameters that are related to stress and visual attention and whether there is a relation between these and psychomotor skills in surgical education. For this purpose, we implemented an application in order to monitor the electrocardiogram (ECG), galvanic skin response (GSR), gaze and performance of surgeons-in-training while performing a laparoscopic box-trainer task so as to obtain technical and personal resourcefulness’ metrics. Eight surgeons (6 nonexperts and 2 experts) completed the experiment. A total of 22 metrics were calculated (7 technical and 15 related to personal resourcefulness) per subject. The average values of these metrics in the presence of stressors were compared with those in their absence and depending on the participants’ expertise. The results show that both the mean normalized GSR signal and average surgical instrument’s acceleration change significantly when stressors are present. Additionally, the GSR and acceleration were found to be correlated, which indicates that there is a relation between psychomotor skills and personal resourcefulness.

During ultrasound-guided percutaneous interventions, needle localization can be a challenge. To increase needle visibility, enhancements of both the imaging methods and the needle surface properties have been investigated. However, a methodical approach to compare potential solutions is currently unavailable. The work described here involves automated image acquisition, analysis and reporting techniques to collect large amounts of data efficiently, delineate relevant factors and communicate effects. Data processing included filtering, line fitting and image intensity analysis steps. Foreground and background image samples were used to compute a contrast-to-noise ratio or a signal ratio. The approach was evaluated in a comparative study of commercially available and custom-made needles. Varied parameters included needle material, diameter and surface roughness. The shafts with kerfed patterns and the trocar and chiba tips performed best. The approach enabled an intuitive polar depiction of needle visibility in ultrasound images for a large range of insertion angles.

INTRODUCTION The adoption of surgical planning systems could greatly simplify the performance of video-assisted thoracoscopic surgery and improve its safety. MATERIAL AND METHODS A new application for surgical planning in video-assisted thoracoscopic surgery was developed, making use of the HoloLens (v1) mixed reality device. The information was displayed in the form of interactive holograms, by means of gestural, visual or voice control. The application was validated during a video-assisted right upper lobectomy surgery, including systematic lymphadenectomy for squamous cell carcinoma in the right upper lobe. RESULTS No complications were shown during surgery. Prior to surgery, the system allowed the surgeon to access in real time the patient's medical history, review the computed tomography study, and visualize and manipulate a 3D model of the lung with its respective vascular and bronchial elements, as well as the tumor to be removed. The surgeon’s vision using the device was easily shared with the rest of the surgical team. The surgeon placed the holographic models with the surgical planning information behind the field of view of the operating table for possible reference during the procedure. The weight and heat generated by the device were considered ergonomic aspects to be improved. CONCLUSIONS The system provides real-time access to important patient information for surgical planning during video-assisted lobectomy surgery, without losing the sterility of the surgical act. The surgeon's view can be shared for communication and learning purposes, as well as recorded for later review of surgical complications.

INTRODUCTION This study presents the first steps and results towards the development of a system for predicting the quality of surgical performance and workload in laparoscopic training. MATERIAL AND METHODS Surgeons wore a smartwatch which recorded their heart rate and hand motion during each laparoscopic procedure. Data was then correlated with both the Surgery Task Load Index (SURG-TLX) subjective questionnaire and the Global Operational Assessment of Laparoscopic Skills (GOALS) objective evaluation tool. Statistical analysis was conducted in order to study the relationship between parameters and to compare the results according to the surgeons’ level of experience. RESULTS Nine laparoscopic surgeons participated in this study, five gynecologists and four digestive surgeons. Gynecological surgeons showed a positive correlation between their level of experience, heart rate, hand motion, and GOALS score, except for bimanual dexterity. The reduction in the variability of hand accelerations led to improved tissue handling. Digestive surgeons showed a negative correlation between their level of experience and the reported temporal demand and complexity of the procedure. Novice digestive surgeons reported increased workload during surgery, mainly in mental, physical, and temporal workload. In both surgical specialties, it was observed that reduction in surgical workload was associated with improved GOALS score. CONCLUSIONS Preliminary results showed that bimanual dexterity is independent of the experience of gynecological surgeons. During laparoscopic surgical procedures, reduced variability in hand accelerations leads to better tissue manipulation. In addition, in gynecological and upper gastrointestinal procedures, reduced surgical workload is associated with improved surgical performance.

Background The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community. Methods Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018. Results 9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I-2 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I-2 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I-2 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D. Conclusion We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

Purpose. New laparoscopic devices are being continuously developed to overcome some of the technical and ergonomic limitations of laparoendoscopic single-site (LESS) surgery. This study aims to assess the surgeon’s surgical performance and ergonomics during the use of a handheld, robotic-driven, articulating laparoscopic instrument during LESS surgery. Methods. Seven right-handed experienced surgeons took part in this study. A set of basic suturing tasks and digestive and urological procedures in a porcine model were performed. Surgeons used both a conventional laparoscopic needle holder and a robotic device. The learning curve, execution time, and precision using the surgical needle were assessed. The surgeon’s posture was analyzed using a motion tracking system and a data glove. Results. After the training period, execution time on the intracorporeal suturing was significantly shorter using the conventional needle holder. The precision was higher using the conventional instrument in the horizontal plane, but the number of attempts to position the needle was lower using the robotic device (1.625 ± 0.250 vs 1.188 ± 0.375 attempts). The extension of the elbow (134.681 ± 14.35° vs 120.631 ± 13.134°) and the flexion of the shoulder (26.122 ± 7.411° vs 18.475 ± 14.166°) were significantly lower using the robotic instrument. The wrist posture using the robotic device was ergonomically acceptable during both surgical procedures. Conclusions. Results show a positive learning curve in ergonomics and surgical performance using the robotic instrument during LESS surgery. This instrument improves the surgeon’s body posture and the needle positioning errors. The use of the robotic instrument is feasible and safe during LESS partial nephrectomy and sigmoidectomy procedures.

Background Telemedicine holds promise for improving access to care. Telementoring—defined as mentoring by means of telecommunication and computer networks—can be used for remote education of healthcare professionals. Furthermore, it is rapidly establishing itself as a valuable asset in medicine and education. This paper aims to establish a financially and practically feasible, stable telementoring network using wearables for sterile and hands-free remote control, to be used during surgical procedures. Methods Two stand-alone computer systems, located at an academic hospital in the Netherlands and at a surgical research facility in Spain, were connected using TeamViewer software allowing for remote, hands-free controlling of radiological images using Myo gesture control armband. The operating surgeon consulted the remote surgeon through an audio, video and desktop sharing system during a live surgical procedure on a single porcine model. The system was analysed for feasibility and connection quality. Results The sensors used were commercially available and relatively cheap, with the integrating computer system being responsible for the majority of costs. A successful connection was established without any downtime and with only a minor time lag, not interfering with the telementoring procedures. The operating surgeon effectively consulted with and was mentored by the remote surgeon, through video, audio and the desktop sharing system, using the wearable sensors. Conclusions This proof of principle shows the feasibility of using an internet-based remote desktop sharing system in combination with wearable sensors and TedCube technology for telementoring purposes during surgical procedures.

We present the first steps toward building an intelligent system to measure the workload and surgical performance of minimally invasive surgeons. This pilot study was conducted during two training courses in minimally invasive suturing, one in microsurgery and one in laparoscopic surgery. During each training activity, surgeons wore a smartwatch with the Happimeter application running on it. This system recorded a set of physiological and motion parameters during the surgical execution. We found that monitoring the surgeon’s maneuvers and physiological parameters during surgical activity has the potential to play an important role in predicting the workload and surgical performance, especially regarding physical and mental demand and the level of distraction during surgery.

Objective To evaluate the feasibility of laparoscopic fluorescence lymphography (LFL) using indocyanine green (ICG) via intradermal (ID) or intrapopliteal (IPP) administration in an ex vivo canine model. Methods Six thawed adult male dog carcasses were placed in the Trendelenburg position after placing three surgical ports in triangulation. ICG (0.5 mg/ml; 0.05 mg/kg) was administered to five of the carcasses (one carcass was a pilot) via ID in the left torso and IPP (right position, by surgical access) to stain the lymphatic pathway and medial iliac lymph node (MILN). Fluorescence quality, staining time, structures stained, and lymph node histopathology were assessed. Thoracic duct staining was also evaluated. Results ID administration showed staining of parts of the lymphatic pathway of the iliosacral lymph center in all cases using a single dose of ICG, with left MILN visualization in four carcasses. IPP administration showed staining of the right MILN in all cases, using a single dose in four carcasses. ICG reached the thoracic duct in one case. The two administration routes showed similar results in terms of required ICG volume, staining time, and visualization quality, although IPP was more effective in staining the MILN. Conclusions This study confirms the feasibility of staining the iliosacral lymph center (mainly the MILNs) by LFL in thawed dog carcasses via ID or IPP administration of ICG. However, the IPP route showed greater effectiveness in staining the MILN.

The objective of this study was to evaluate the effect of 3D imaging on laparoscopic suturing performance using a box trainer and during laparoscopic partial nephrectomy. Besides, the safety and usefulness of this technology in clinical practice were also subjectively evaluated. For the study in the training environment participated 30 surgeons and 13 surgeons in the study with the experimental animal model. Participants were organized in a random way into two groups, starting the trials with the 2D imaging system or with the 3D system. Three-dimensional imaging seemed to facilitate the performance of intracorporeal sutures in the box trainer setting. However, these improvements were not as clear during the partial nephrectomy. Surgeons stated that the 3D vision system helps improve depth perception during surgery and facilitates needle handling during intracorporeal suturing. However, they also indicated that its use can lead to the onset of visual discomfort or fatigue. Most of them would use again this vision system in surgical practice. Further studies are needed to more clearly determine the benefits of 3D over standard 2D imaging systems in laparoscopic practice.

BACKGROUND Surgical environments require special aseptic conditions for direct interaction with the preoperative images. We aim to test the feasibility of using a set of gesture control sensors combined with voice control to interact in a sterile manner with preoperative information and an integrated operating room (OR) during laparoscopic surgery. MATERIAL AND METHODS Two hepatectomies and two partial nephrectomies were performed by three experienced surgeons in a porcine model. The Kinect, Leap Motion, and MYO armband in combination with voice control were used as natural user interfaces (NUIs). After surgery, surgeons completed a questionnaire about their experience. RESULTS Surgeons required

Background: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. Methods: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. Results: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. Conclusions: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits., SCOPUS: ar.j, info:eu-repo/semantics/published

OBJECTIVE To evaluate muscle activity and hand motion in veterinarians performing a standard set of laparoscopic training tasks. SAMPLE 12 veterinarians with experience performing laparoscopic procedures. PROCEDURES Participants were asked to perform peg transfer, coordination, precision cutting, and suturing tasks in a laparoscopic box trainer. Activity of the right biceps brachii, triceps brachii, forearm flexor, forearm extensor, and trapezius muscles was analyzed by means of surface electromyography. Right hand movements and wrist angle data were registered through the use of a data glove, and risk levels for the wrist joint were determined by use of a modified rapid upper limb assessment (RULA) method. One-way repeated-measures ANOVA with a Bonferroni post hoc test was performed to compare values between tasks. RESULTS Activity in the biceps muscle did not differ significantly among the 4 tasks. Activity in the triceps, forearm flexor, and forearm extensor muscles was significantly higher during precision cutting than during the coordination task. Activity in the trapezius muscle was highest during the suturing task and did not differ significantly among the other 3 tasks. The RULA score was unacceptable (score, 3) for the coordination, peg transfer, and precision cutting tasks but was acceptable (score, 2) for the suturing task. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the ergonomics of laparoscopic training depended on the tasks performed and the design of the instruments used. Precision cutting and suturing tasks were associated with the highest muscle activity. Acceptable wrist position, as determined with the RULA method, was found with the suturing task, which was performed with an axial-handled instrument. (Am J Vet Res 2016;77:186–193)

Background Motion analysis parameters (MAPs) have been extensively validated for assessment of minimally invasive surgical skills. However, there are discrepancies on how specific MAPs, tasks, and skills match with each other, reflecting that motion analysis cannot be generalized independently of the learning outcomes of a task. Additionally, there is a lack of knowledge on the meaning of motion analysis in terms of surgical skills, making difficult the provision of meaningful, didactic feedback. In this study, new higher significance MAPs (HSMAPs) are proposed, validated, and discussed for the assessment of technical skills in box trainers, based on principal component analysis (PCA). Methods Motion analysis data were collected from 25 volunteers performing three box trainer tasks (peg grasping/PG, pattern cutting/PC, knot suturing/KS) using the EVA tracking system. PCA was applied on 10 MAPs for each task and hand. Principal components were trimmed to those accounting for an explained variance >80% to define the HSMAPs. Individual contributions of MAPs to HSMAPs were obtained by loading analysis and varimax rotation. Construct validity of the new HSMAPs was carried out at two levels of experience based on number of surgeries. Results Three new HSMAPs per hand were defined for PG and PC tasks, and two per hand for KS task. PG presented validity for HSMAPs related to insecurity and economy of space. PC showed validity for HSMAPs related to cutting efficacy, peripheral unawareness, and confidence. Finally, KS presented validity for HSMAPs related with economy of space and knotting security. Conclusions PCA-defined HSMAPs can be used for technical skills’ assessment. Construct validation and expert knowledge can be combined to infer how competences are acquired in box trainer tasks. These findings can be exploited to provide residents with meaningful feedback on performance. Future works will compare the new HSMAPs with valid scoring systems such as GOALS.

Apart from the ergonomic inconveniences, LESS surgery presents some specific technical difficulties such as the loss of instruments triangulation, and closer proximity of instruments, leading to clashing and crossing of the instruments both inside and outside the patient. In this case, the surgeons need to adopt a posture particularly appropriate for this task. However, it is not clear whether the movements of the upper-limb joints are able to destabilize other body segments, like it is the head segment. The UCM framework allowed the quantification of the overall upper-limb joint variability into a task-relevant and task-irrelevant component. It was supposed that LESS surgery needs more flexibility by the surgeon than conventional laparoscopy, and that could compromise joint coordination. The results of the UCM analysis showed a positive degrees of freedom synergy index indicating that the co-variation of the upper-limb joint angles stabilizes the head posture of the surgeons in the anterior-posterior direction. There was not a statistically significant difference in the synergy index between the LAP and LESS approach for the UCMs of both the left (t(7)=1.76,p = 0.12) and right side joint spaces (t(7)=1.127,p = 0.902). However, important differences can be appreciated individually. The results showed that the underlying framework was able to quantify surgeons’ motor variability, providing inspiration for new human-machine interaction designs, as well as more targeted ergonomics assessments.

Purpose The objective of this study was to develop a multimodal, permanent liver phantom displaying functional vasculature and common pathologies, for teaching, training and equipment development in laparoscopic ultrasound and navigation. Methods Molten wax was injected simultaneously into the portal and hepatic veins of a human liver. Upon solidification of the wax, the surrounding liver tissue was dissolved, leaving a cast of the vessels. A connection was established between the two vascular trees by manually manipulating the wax. The cast was placed, along with different multimodal tumor models, in a liver shaped mold, which was subsequently filled with a polymer. After curing, the wax was melted and flushed out of the model, thereby establishing a system of interconnected channels, replicating the major vasculature of the original liver. Thus, a liquid can be circulated through the model in a way that closely mimics the natural blood flow. Results Both the tumor models, i.e., the metastatic tumors, hepatocellular carcinoma and benign cyst, and the vessels inside the liver model, were clearly visualized by all the three imaging modalities: CT, MR and ultrasound. Doppler ultrasound images of the vessels proved the blood flow functionality of the phantom. Conclusion By a two-step casting procedure, we produced a multimodal liver phantom, with open vascular channels, and tumor models, that is the next best thing to practicing imaging and guidance procedures in animals or humans. The technique is in principle applicable to any organ of the body. © The Author(s) 2017. This article is an open access publication.This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Introduction The objective of this study is to assess the usefulness of an evaluation system of surgical skills based on motion analysis of laparoscopic instruments. Method This system consists of a physical laparoscopic simulator and a tracking and assessment system of technical skills in laparoscopy. Six surgeons with intermediate experience (between 1 and 50 laparoscopic surgeries) and 5 experienced surgeons (more than 50 laparoscopic surgeries) took part in this study. All participants were right-handed. The subjects performed 3 repetitions of a cutting task on synthetic tissue with the right hand, dissection of a gastric serous layer, and a suturing task in the dissection previously done. Objective metrics such as time, path length, speed of movements, acceleration and motion smoothness were analyzed for the instruments of each hand. Results In the cutting task, experienced surgeons show less acceleration (P=.014) and a smoother motion (P=.023) using the scissors. Regarding the dissection activity, experienced surgeons need less time (P=.006) and less length with both instruments (P=.006 for dissector and P=.01 for scissors). In the suturing task, experienced surgeons require less time (P=.037) and distance traveled (P=.041) by the dissector. Conclusions This study shows the usefulness of the evaluation system for the cutting, dissecting, and suturing tasks. It represents a significant step in the development of advanced systems for training and assessment of surgical skills in laparoscopic surgery.

Adding to the ergonomic inconveniences already presented by traditional laparoscopy (LAP), laparoendoscopic single-site (LESS) surgery has been found to entail other more specific problems, including greater reduction in movement freedom, in-line vision with loss of triangulation, and greater proximity of instruments. The objective of this study was to evaluate surgeons' ergonomy during LESS surgery, through the study of muscular activity, wrist angle, and hand movements, and compare it with conventional laparoscopy.The study group was composed by 14 experienced laparoscopic surgeons, all right-handed. Each one performed dissection tasks on a physical simulator through LAP and LESS approaches. For LAP, straight laparoscopic scissors and dissector were used, whilst for LESS articulating tip scissors and dissector were chosen. During both tasks, muscular activity of biceps brachii, triceps brachii, forearm flexors and extensors, and trapezius muscles was registered through surface electromyography. Simultaneously right-hand movements and wrist angles were obtained through a motion capture data glove (CyberGlove(®)), which allowed for the use of a modified RULA test applied to the recorded angles with subsequent establishment of risk levels for the wrist joint.Muscular activity for trapezius (LAP 6.94 ± 4.12 vs. LESS 11.32 ± 4.68; p ≤ 0.05) and forearm extensor muscles (LAP 9.2 ± 2.45 vs. LESS 37.07 ≤ 16.05; p ≤ 0.001) was significantly lower in conventional laparoscopy compared with LESS approach. No statistical significance was obtained between the different sensors, except in 3 of the 11 analyzed CyberGlove(®) sensors. The modified RULA test showed a score of 3 for laparoscopy (unacceptable), whereas for LESS a score of 2 was obtained (acceptable), with statistically significant differences between them (p ≤ 0.05).The LESS approach entails greater level of muscular activity in the trapezius and forearm extensor muscles, but we have found evidences of a better wrist position during LESS compared with traditional laparoscopy.

Background. Laparoendoscopic single-site surgery has been presented in the past few years as an innovative minimally invasive approach, one which despite its advantages is also challenging and requires specific training. We propose to analyze the performance of attendants in a specific LESS training course. Methods. Following the LESSCAR 2010 guidelines, we focused on level 1 hands-on simulator tasks and level 2 hands-on training on animal model for skills acquisition during a LESS-specific training course. Each attendant completed coordination and cut tasks on simulator, followed by a cholecystectomy on an ex vivo porcine liver. Hands-on animal model each trainee performed 1 cholecystectomy and at least 2 nephrectomies (N1, N2). Performance was analyzed through video recording and reviewed by 3 independent observers. Each result was registered according to a modified objective structured assessment of technical skills. Total task or procedure completion time was also determined. Results. Regarding coordination and cut tasks, attendants improved on their performance from first to third attempts with an accompanying decrease in completion time. Surgeons completed the cholecystectomy on animal model significantly faster than on simulator, although with lower performance quality. Regarding N1 and N2, attendants showed improvement both in quality and total completion time. Conclusions. A gradual and positive evolution of attendants was observed throughout the training course. Thus, we believe a structured program for the acquisition of basic skills in new minimally invasive surgical approaches should be recommended. Considering that this is a small study, it would be advisable to increase the number of study subjects on future opportunities.