Surgical Endoscopy

, Volume 34, Issue 2, pp 869–879 | Cite as

Self-directed training with e-learning using the first-person perspective for laparoscopic suturing and knot tying: a randomised controlled trial

Learning from the surgeon’s real perspective
  • Mona W. Schmidt
  • Karl-Friedrich Kowalewski
  • Sarah M. Trent
  • Laura Benner
  • Beat P. Müller-Stich
  • Felix NickelEmail author



Laparoscopic suturing and knot tying is essential for advanced laparoscopic procedures and requires training outside of the operating room. However, personal instruction by experienced surgeons is limitedly available. To address this, the concept of combining e-learning with practical training has become of interest. This study aims to investigate the influence of the first-person perspective in instructional videos, as well as the feasibility of a completely self-directed training curriculum for laparoscopic suturing and knot tying.

Materials and methods

Ninety-one laparoscopically naïve medical students were randomised into two groups training with e-learning videos in either the first-person perspective (combining endoscopic view and view of hands/instruments/forearm motion) or the endoscopic view only. Both groups trained laparoscopic suturing and knot tying in teams of two until reaching predefined proficiency levels. Blinded, trained raters regularly assessed the participants’ performance by using validated checklists. After training, participants filled out questionnaires regarding training experience and personal characteristics.


Average training time to reach proficiency did not differ between groups [first-person perspective (min): 112 ± 44; endoscopic view only (min): 109 ± 47; p = 0.746]. However, participants from both groups perceived the first-person perspective as useful for learning new laparoscopic skills. Both groups showed similar baseline performances and improved significantly after training [Objective Structured Assessment of Technical Skills (OSATS) (max. 37 points): first-person perspective: 30.3 ± 2.3; endoscopic view only: 30.8 ± 2.3]. All participants managed to reach proficiency, needing 8–43 attempts without differences between groups. Visuospatial abilities (mental rotation) seemed to enhance the learning curve.


Modifying instructional videos to the first-person perspective did not translate into a better performance in this setting but was welcomed by participants. Completely self-directed training with the use of e-learning can be a feasible training approach to achieve technical proficiency in laparoscopic suturing and knot tying in a training setting.


Minimally invasive surgery Training First-person perspective Laparoscopic suturing and knot tying e-Learning 



Minimally invasive surgery


Virtual reality


Mental rotation test


Revised purdue spatial visualisation test



This work is part of Ms. Mona W. Schmidt’s doctoral thesis at Heidelberg University. We thank the European Social Fund of the State Baden-Wuerttemberg, from whom we received a total amount of 448.200 € for the laparoscopy training centre at the Department of Surgery at Heidelberg University to conduct laparoscopy training courses and the associated research.

Compliance with ethical standards


Mona. W. Schmidt, Karl-Friedrich Kowalewski, Sarah Trent, Laura Benner and Beat-Peter Müller-Stich have no conflict of interest or financial ties to disclose. F. Nickel reports receiving travel support for conference participation as well as equipment provided for laparoscopic surgery courses by KARL STORZ, Johnson & Johnson, Intuitive and Medtronic.


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Copyright information

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

Authors and Affiliations

  1. 1.Department of General, Visceral, and Transplantation SurgeryUniversity Hospital of HeidelbergHeidelbergGermany
  2. 2.Institute of Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany

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