Surgical Endoscopy

, Volume 34, Issue 2, pp 787–795 | Cite as

The impact of guided instrument insertion during laparoscopy: a randomized study with novices in an optical box trainer

  • Wolfgang Kunert
  • Carolin Land
  • Manuel Braun
  • Johannes Reichold
  • Andreas KirschniakEmail author
  • Claudius Falch



During laparoscopic operations, the trocars are often out of the viewing field of the laparoscope. Blind insertion of laparoscopic instruments is potentially dangerous especially when they are pointed or hot. A guidance of the instrument to the target point has the potential to improve the safety of instrument insertion.


In this study, the effect of a mechanical and an optical tool for guided instrument insertion into the abdominal cave was evaluated. The controlled prospective randomized study measured safety and efficiency of instrument insertion by 60 novices in an inanimate standardized box trainer. A post-test questionnaire based on the NASA Task Load Index prompted for the subjective impressions of the subjects.


Instrument insertion with optical guidance showed a shorter (p = 0.002) insertion time (median 87.5 s for nine insertions) compared with blind insertion (median 112.0 s for nine insertions). The error number with optical guidance (median 0.5) was lower (p = 0.064) compared with blind insertion (median 1.0). The mechanical guidance showed a shorter (p = 0.001) insertion time (median 89.0 s for nine insertions) and less (p = 0.044) touch errors (median 0) compared with blind insertion. The results of the two guidance tools (mechanical vs. optical guidance) showed no significant difference. In the questionnaire, 89% of the novices subjectively judged the mechanical guidance tool better than blind insertion. The assessments of optical compared to mechanical guidance turned out quite similar.


In the experimental setup, instrument insertion with a guidance tool performed faster and safer compared with blind insertion. The subjective assessments confirmed the benefit of instrument guidance.


Laparoscopic surgery Laser guide Trocar with laser Instrument insertion Randomized controlled trial Experimental setup 



We gratefully acknowledge the implementation of two line laser modules to achieve laser cross-functionality by Patrick Haas and the suggestion of a “mechanical” guidance tool by PhD Sebastian Halder (TWT). We are also very thankful for the statistical support of the Institute for Clinical Epidemiology and Applied Biometry (Tübingen University).


The Panorama-Camera project is funded by the German Federal Ministry of Economics and Technology. Grant Number: KF2171006LW3

Compliance with ethical standards


W. Kunert, C. Land, M. Braun, J. Reichold, A. Kirschniak and C. Falch had and have no conflicts of interest or financial ties to disclose.


  1. 1.
    Martin KE, Moore CM, Tucker R, Fuchshuber P, Robinson T (2016) Quantifying inadvertent thermal bowel injury from the monopolar instrument. Surg Endosc 30:4776–4784CrossRefGoogle Scholar
  2. 2.
    Kaplan JR, Lee Z, Eun DD, Reese AC (2016) Complications of minimally invasive surgery and their management. Curr Urol Rep 17:47CrossRefGoogle Scholar
  3. 3.
    Cornette B, Berrevoet F (2016) Trocar Injuries in Laparoscopy: techniques, tools, and means for prevention. A systematic review of the literature. World J Surg 40:2331–2341CrossRefGoogle Scholar
  4. 4.
    van der Voort M, Heijnsdijk EAM, Gouma DJ (2004) Bowel injury as a complication of laparoscopy. Brit J Surg 91:1253–1258CrossRefGoogle Scholar
  5. 5.
    Levy B, Mobasheri M (2017) Principles of safe laparoscopic surgery. Surgery (Oxford) 35:216–219CrossRefGoogle Scholar
  6. 6.
    Rajab TK (2013) Modified trocar with laser diode for instrument guidance. Surg Innov 20:604–606CrossRefGoogle Scholar
  7. 7.
    Schulz KF, Altman DG, Moher D, Grp C (2010) CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Bmj-Brit Med J 340:c332CrossRefGoogle Scholar
  8. 8.
    Hart SG, Staveland LE (1988) Development of NASA-TLX (task load index): results of empirical and theoretical research. In: Peter AH, Najmedin M (eds) Advances in psychology. Elsevier, North-Holland, pp 139–183Google Scholar
  9. 9.
    Khoiy KA, Mirbagheri A, Farahmand F (2016) Automatic tracking of laparoscopic instruments for autonomous control of a cameraman robot. Minim Invasive Ther Allied Technol 25:121–128CrossRefGoogle Scholar
  10. 10.
    Franz AM, Haidegger T, Birkfellner W, Cleary K, Peters TM, Maier-Hein L (2014) Electromagnetic tracking in medicine-a review of technology, validation, and applications. IEEE T Med Imaging 33:1702–1725CrossRefGoogle Scholar
  11. 11.
    Lahanas V, Loukas C, Georgiou E (2016) A simple sensor calibration technique for estimating the 3D pose of endoscopic instruments. Surg Endosc 30:1198–1204CrossRefGoogle Scholar
  12. 12.
    Lahanas V, Loukas C, Smailis N, Georgiou E (2015) A novel augmented reality simulator for skills assessment in minimal invasive surgery. Surg Endosc 29:2224–2234CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.University Department of General, Visceral and Transplant Surgery, Workgroup Surgical Technology and TrainingUniversity Hospital TübingenTübingenGermany
  2. 2.TWT GmbH, Science & InnovationStuttgartGermany

Personalised recommendations