Impact of hand dominance, gender, and experience with computer games on performance in virtual reality laparoscopy
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- Grantcharov, T., Bardram, L., Funch-Jensen, P. et al. Surg Endosc (2003) 17: 1082. doi:10.1007/s00464-002-9176-0
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Background: The impact of gender and hand dominance on operative performance may be a subject of prejudice among surgeons, reportedly leading to discrimination and lack of professional promotion. However, very little objective evidence is available yet on the matter. This study was conducted to identify factors that influence surgeons’ performance, as measured by a virtual reality computer simulator for laparoscopic surgery. Methods: This study included 25 surgical residents who had limited experience with laparoscopic surgery, having performed fewer than 10 laparoscopic cholecystectomies. The participants were registered according to their gender, hand dominance, and experience with computer games. All of the participants performed 10 repetitions of the six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR) within 1 month. Assessment of laparoscopic skills was based on three parameters measured by the simulator: time, errors, and economy of hand movement. Results: Differences in performance existed between the compared groups. Men completed the tasks in less time than women (p = 0.01, Mann–Whitney test), but there was no statistical difference between the genders in the number of errors and unnecessary movements. Individuals with right hand dominance performed fewer unnecessary movements (p = 0.045, Mann–Whitney test), and there was a trend toward better results in terms of time and errors among the residence with right hand dominance than among those with left dominance. Users of computer games made fewer errors than nonusers (p = 0.035, Mann–Whitney test). Conclusions: The study provides objective evidence of a difference in laparoscopic skills between surgeons differing gender, hand dominance, and computer experience. These results may influence the future development of training program for laparoscopic surgery. They also pose a challenge to individuals responsible for the selection and training of the residents.
KeywordsSurgical trainingAssessmentGenderHand dominanceVirtual realityMinimally invasive surgery
The effect of gender and hand dominance on operative psychomotor performance may be a subject of prejudice among members of the surgical profession, potentially leading to discrimination and lack of professional promotion . However, objective evidence on the matter is limited. Furthermore, it is a general belief that younger surgeons may have better skills in laparoscopy than their elder colleagues, probably because they have been exposed to computer games at a young age. The aim of the current study was to investigate the impact of gender, hand dominance, and computer games experience on psychomotor skills demonstrated with a virtual reality laparoscopy simulator.
Materials and methods
The study was conducted in a department of abdominal surgery at a teaching hospital. The study participants were 25 surgeons in training. Seven of the participants were women, and five were left-handed. Ten had previous computer games experience. Their median age was 35 years (range, 27–43 years), and there had been a median of 7 years since their graduation (range, 1–12 years). They all had similar, limited experience in laparoscopic surgery (median cholecystectomies, 0; range, 0–10).
All the participants performed 10 repetitions of all six tasks of the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR; Mentice Medical Simulation, Gothenburg, Sweden). The MIST-VR and the nature of the tasks have been described previously . Objective measurement of surgical skill was based on three parameters (time, errors, and number of unnecessary movements), as calculated and registered by the computer system. The scoring system of the MIST-VR, validated in a number of studies, is considered to provide an objective and reliable assessment of surgical laparoscopic skill . For the analysis, we used data from task 6, which includes elements from most of the other tasks, is of the highest complexity and requires the highest levels of concentration and coordination. Previous studies have found that this task correlates best with surgical performance in vivo .
The Mann–Whitney’s test was used to examine differences in performance scores (men vs women, right-handers vs left-handers, and computer-games users vs. nonusers). After the normal distribution of the data had been tested and confirmed, multiple regression analysis was performed to investigate the effects of gender, handedness, and experience with computer games on time, error, and economy of movement scores. All p of 0.05 or less were considered statistically significant.
The results from this study are illustrated in Figs. 1, 2, and 3. Men performed task 6 significantly faster than women (p = 0.001, Mann–Whitney test). However, after adjustment for handedness and experience with computer games, the time difference between male and female surgeons became nonsignificant (p = 0.175, multiple regression analysis). No statistically significant difference existed between male and female residents in terms of error (p = 0.45) or economy of motion (p = 0.07) scores.
Right-handed individuals performed fewer unnecessary movements than their left-handed colleagues (p = 0.045, Mann–Whitney test). The difference remained significant after adjustment for gender and experience with computer games (p = 0.031, multiple regression analysis). No statistically significant difference existed between right- and left-handed surgeons in terms of time (p = 0.2) and error (p = 0.8) scores. However, right-handed subjects showed less intersubject variability than left-handed subjects (Fig. 2), indicating that they all were performing well.
Surgeons with computer games experience made significantly fewer errors than those without such experience (p = 0.035, Mann–Whitney test). This difference remained statistically significant after adjustment for gender and handedness (p = 0.05, multiple regression analysis).
The current study provides objective and quantitative evidence of a difference in laparoscopic psychomotor performance between right-handed and left-handed surgical residents. In this aspect, our results are consistent with the findings of Hanna et al. . Furthermore, our study showed that subjects who had experience with computer games performed better than their colleagues who had never performed personal computer games. This indicates that computer games may contribute to the development of skills that could be relevant for the performance of laparoscopic surgery, and that we should expect further developments in minimally invasive surgery when “the Nintendo generation” joins our profession.
Our results showed no difference in performance between male and female residents, and are therefore not consistent with the findings reported in previous studies of open surgery .
There is no doubt that each junior doctor entering a surgical training program should be evaluated as an individual, and not as a member of a certain group. However, differences in performance between left- and right-handed individuals should be considered by those responsible for the training activities in a surgical department. Although trocar positioning, and instrumentation in a standard laparoscopic cholecystectomy are based primarily on a right-handed approach, the MIST-VR system is testing skills for both the right and left hands. Our finding of impaired performance in left-handed individuals is therefore not the result of technical factors in the MIST-VR, but is rather a sign of “true” psychomotor differences between the two groups.
Future, larger studies should be performed to confirm our findings. Furthermore, future research should determine the neuropsychologic explanations for the observed differences, and evaluate whether left-handed individuals can reach the performance level of their right-handed colleagues with intensified training.
This work was supported by Sygekassernes Helsefond, Copenhagen, Denmark.