Surgical Endoscopy

, Volume 27, Issue 3, pp 854–863

A study of psychomotor skills in minimally invasive surgery: what differentiates expert and nonexpert performance

  • Erlend Fagertun Hofstad
  • Cecilie Våpenstad
  • Magdalena Karolina Chmarra
  • Thomas Langø
  • Esther Kuhry
  • Ronald Mårvik



A high level of psychomotor skills is required to perform minimally invasive surgery (MIS) safely. To assure high quality of skills, it is important to be able to measure and assess these skills. For that, it is necessary to determine aspects that indicate the difference between performances at various levels of proficiency. Measurement and assessment of skills in MIS are best done in an automatic and objective way. The goal of this study was to investigate a set of nine motion-related metrics for their relevance to assess psychomotor skills in MIS during the performance of a labyrinth task.


Thirty-two surgeons and medical students were divided into three groups according to their level of experience in MIS; experts (>500 MIS procedures), intermediates (31–500 MIS), and novices (no experience in MIS). The participants performed the labyrinth task in the D-box Basic simulator (D-Box Medical, Lier, Norway). The task required bimanual maneuvering and threading a needle through a labyrinth of 10 holes. Nine motion-related metrics were used to assess the MIS skills of each participant.


Experts (n = 7) and intermediates (n = 14) performed significantly better than the novices (n = 11) in terms of time and parameters measuring the amount of instrument movement. The experts had significantly better bimanual dexterity, which indicated that they made more simultaneous movements of the two instruments compared to the intermediates and novices. The experts also performed the task with a shorter instrument path length with the nondominant hand than the intermediates.


The surgeon’s performance in MIS can be distinguished from a novice by metrics such as time and path length. An experienced surgeon in MIS can be differentiated from a less experienced one by the higher ability to control the instrument in the nondominant hand and the higher degree of simultaneous (coordinated) movements of the two instruments.


Assessment Box trainer Minimally invasive surgery Motion analysis Psychomotor skills Training 


  1. 1.
    Hallam DM, Anwar MA, Khan IM, Memon MA, Steele K, Lidor A (2008) Access to the abdomen. In: Scott-Conner CEH (ed) The SAGES manual of strategic decision making. Springer, New York, pp 1–9CrossRefGoogle Scholar
  2. 2.
    Feldman LS, Sherman V, Fried GM (2004) Using simulators to assess laparoscopic competence: ready for widespread use? Surgery 135(1):28–42PubMedCrossRefGoogle Scholar
  3. 3.
    Subramonian K, DeSylva S, Bishai P, Thompson P, Muir G (2004) Acquiring surgical skills: a comparative study of open versus laparoscopic surgery. Eur Urol 45(3):346–351PubMedCrossRefGoogle Scholar
  4. 4.
    Gurusamy KS, Aggarwal R, Palanivelu L, Davidson BR (2009) Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev (1):CD006575Google Scholar
  5. 5.
    Basdogan C, Sedef M, Harders M, Wesarg S (2007) VR-based simulators for training in minimally invasive surgery. IEEE Comput Graph Appl 27(2):54–66PubMedCrossRefGoogle Scholar
  6. 6.
    Carter FJ, Schijven MP, Aggarwal R, Grantcharov T, Francis NK, Hanna GB, Jakimowicz JJ (2005) Consensus guidelines for validation of virtual reality surgical simulators. Surg Endosc 19(12):1523–1532PubMedCrossRefGoogle Scholar
  7. 7.
    Gallagher AG, Ritter EM, Satava RM (2003) Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training. Surg Endosc 17(10):1525–1529PubMedCrossRefGoogle Scholar
  8. 8.
    Vassiliou MC, Feldman LS, Andrew CG, Bergman S, Leffondre K, Stanbridge D, Fried GM (2005) A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg 190(1):107–113PubMedCrossRefGoogle Scholar
  9. 9.
    Oropesa I, Sanchez-Gonzalez P, Lamata P, Chmarra MK, Pagador JB, Sanchez-Margallo JA, Sanchez-Margallo FM, Gomez EJ (2011) Methods and tools for objective assessment of psychomotor skills in laparoscopic surgery. J Surg Res 171(1):e81–e95PubMedCrossRefGoogle Scholar
  10. 10.
    Narazaki K, Oleynikov D, Stergiou N (2006) Robotic surgery training and performance: identifying objective variables for quantifying the extent of proficiency. Surg Endosc 20(1):96–103PubMedCrossRefGoogle Scholar
  11. 11.
    Judkins TN, Oleynikov D, Stergiou N (2009) Objective evaluation of expert and novice performance during robotic surgical training tasks. Surg Endosc 23(3):590–597PubMedCrossRefGoogle Scholar
  12. 12.
    Satava RM (2008) Historical review of surgical simulation—a personal perspective. World J Surg 32(2):141–148PubMedCrossRefGoogle Scholar
  13. 13.
    Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L (2006) Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 296(9):1094–1102PubMedCrossRefGoogle Scholar
  14. 14.
    Schout BM, Hendrikx AJ, Scheele F, Bemelmans BL, Scherpbier AJ (2010) Validation and implementation of surgical simulators: a critical review of present, past, and future. Surg Endosc 24(3):536–546PubMedCrossRefGoogle Scholar
  15. 15.
    Chmarra KM, Klein S, de Winter F, Jansen JC, Dankelman FW et al (2010) Objective classification of residents based on their psychomotor laparoscopic skills. Volume 24. Springer, HeidelbergGoogle Scholar
  16. 16.
    Pellen MG, Horgan LF, Barton JR, Attwood SE (2009) Construct validity of the ProMIS laparoscopic simulator. Surg Endosc 23(1):130–139PubMedCrossRefGoogle Scholar
  17. 17.
    Woodrum DT, Andreatta PB, Yellamanchilli RK, Feryus L, Gauger PG, Minter RM (2006) Construct validity of the LapSim laparoscopic surgical simulator. Am J Surg 191(1):28–32PubMedCrossRefGoogle Scholar
  18. 18.
    Thijssen AS, Schijven MP (2010) Contemporary virtual reality laparoscopy simulators: quicksand or solid grounds for assessing surgical trainees? Am J Surg 199(4):529–541PubMedCrossRefGoogle Scholar
  19. 19.
    Chmarra MK, Kolkman W, Jansen FW, Grimbergen CA, Dankelman J (2007) The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system. Surg Endosc 21(11):2069–2075PubMedCrossRefGoogle Scholar
  20. 20.
    Maithel SK, Villegas L, Stylopoulos N, Dawson S, Jones DB (2005) Simulated laparoscopy using a head-mounted display vs traditional video monitor: an assessment of performance and muscle fatigue. Surg Endosc 19(3):406–411PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Erlend Fagertun Hofstad
    • 1
  • Cecilie Våpenstad
    • 1
  • Magdalena Karolina Chmarra
    • 2
  • Thomas Langø
    • 1
  • Esther Kuhry
    • 3
    • 4
    • 5
  • Ronald Mårvik
    • 3
    • 4
    • 5
  1. 1.Department of Medical TechnologySINTEF Technology and SocietyTrondheimNorway
  2. 2.Department of Circulation and Medical ImagingFaculty of Medicine, Norwegian University of Science and Technology (NTNU)TrondheimNorway
  3. 3.Department of Cancer Research and Molecular MedicineFaculty of Medicine, Norwegian University of Science and Technology (NTNU)TrondheimNorway
  4. 4.Department of SurgerySt. Olav’s Hospital, Trondheim University HospitalTrondheimNorway
  5. 5.National Center for Advanced Laparoscopic SurgerySt. Olav’s Hospital, Trondheim University HospitalTrondheimNorway

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