Procedural surgical skill assessment in laparoscopic training environments

  • Munenori UemuraEmail author
  • Pierre Jannin
  • Makoto Yamashita
  • Morimasa Tomikawa
  • Tomohiko Akahoshi
  • Satoshi Obata
  • Ryota Souzaki
  • Satoshi Ieiri
  • Makoto Hashizume
Original Article



This study aimed to identify detailed differences in laparoscopic surgical processes between expert and novice surgeons in a training environment and demonstrate that surgical process modeling can be used for such detailed analysis.


Eleven expert surgeons each of whom had performed \({>}500\) laparoscopic procedures were compared with 10 young surgeons each of whom had performed \({<}15\) laparoscopic procedures, and five medical students. Each examinee performed a specific skill assessment task. During tasks, instrument motion was monitored using a video capture system. From the video, the corresponding workflow was recorded by labeling the surgeons’ activities according to a predefined terminology. Activities represented manual work steps performed during the task, described by a combination of a verb (representing the action), a tool, and the involved structure. The results were described as the number of occurrences (times), average duration (seconds), total duration (seconds), minimal duration (seconds), maximal duration (seconds), and occupancy percentage (%).


The terminology for describing the processes of this task included 10 actions, six tools, four structures, and three events for each hand. There were 63 combinations of different possible activities; significant differences in 12 activities were observed between the expert and novice groups (young surgeons and medical students). The expert group performed the task with fewer occurrences and shorter duration than did the novice group in the left hand.


We identified differences in surgical process between experts and novices in laparoscopic surgical simulation. Our proposed method would be useful for education and training in laparoscopic surgery.


Surgical skills Laparoscopic surgery Surgical training Surgical process model 



This work was supported by The Ministry of Education, Culture, Sports, Science, and Technology and Japan Society for the Promotion of Science KAKENHI Grant Nos. 26108010, 26870428, Joint Research Projects of Bilateral Programs with JSPS’s Counterpart Institutions and by French Ministry of Foreign and European Affairs and the Ministry of education and research and EGIDE/Sakura grant.

Compliance with ethical standards

Conflict of interest

Drs. Uemura, Jannin, Yamashita, Tomikawa, Akahoshi, Obata, Souzaki, Ieiri, and Hashizume declare that they have no conflicts of interest.


  1. 1.
    Yule S, Flin R, Paterson-Brown S, Maran N (2006) Non-technical skills for surgeons in the operating room: a review of the literature. Surgery 139:140–149CrossRefPubMedGoogle Scholar
  2. 2.
    Patey R, Flin R, Cuthbertson BH, MacDonald L, Mearns K, Cleland J, Williams D (2007) Patient safety: helping medical students understand error in healthcare. Qual Saf Health Care 16:256–259CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Tsuda S, Scott D, Doyle J, Jones DB (2009) Surgical skills training and simulation. Curr Probl Surg 46:271–370CrossRefPubMedGoogle Scholar
  4. 4.
    Zevin B, Levy JS, Satava RM, Grantcharov TP (2012) A consensus-based framework for design, validation, and implementation of simulation-based training curricula in surgery. J Am Coll Surg 215:580–586.e3CrossRefPubMedGoogle Scholar
  5. 5.
    Madan AK, Harper JL, Taddeucci RJ, Tichansky DS (2008) Goal-directed laparoscopic training leads to better laparoscopic skill acquisition. Surgery 144:345–350CrossRefPubMedGoogle Scholar
  6. 6.
    Uemura M, Tomikawa M, Nagao Y, Yamashita N, Kumashiro R, Tsutsumi N, Ohuchida K, Ieiri S, Ohdaira T, Hashizume M (2014) Significance of metacognitive skills in laparoscopic surgery assessed by essential task simulation. Minim Invasive Ther Allied Technol 23:165–172CrossRefPubMedGoogle Scholar
  7. 7.
    Patel VL, Arocha JF, Kaufman DR (2001) A primer on aspects of cognition for medical informatics. J Am Med Inf Assoc 8:324–343CrossRefGoogle Scholar
  8. 8.
    Uemura M, Tomikawa M, Kumashiro R, Miao T, Souzaki R, Ieiri S, Ohuchida K, Lefor AT, Hashizume M (2014) Analysis of hand motion differentiates expert and novice surgeons. J Surg Res 188: 8–13CrossRefPubMedGoogle Scholar
  9. 9.
    Lalys F, Jannin P (2014) Surgical process modelling: a review. Int J Comput Assist Radiol Surg 9:495–511CrossRefPubMedGoogle Scholar
  10. 10.
    Rosen J, Solazzo M, Hannaford B, Sinanan M (2001) Objective laparoscopic skills assessments of surgical residents using Hidden Markov Models based on haptic information and tool/tissue interactions. Stud Health Technol Inf 81:417–423Google Scholar
  11. 11.
    Yurtkuran A, Tok M, Emel E (2013) A clinical decision support system for femoral peripheral arterial disease treatment. Comput Math Methods Med 2013:898041CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Weinger MB, Herndon OW, Zornow MH, Paulus MP, Gaba DM, Dallen LT (1994) An objective methodology for task analysis and workload assessment in anesthesia providers. Anesthesiology 80:77–92CrossRefPubMedGoogle Scholar
  13. 13.
    Tanoue K, Ieiri S, Konishi K, Yasunaga T, Okazaki K, Yamaguchi S, Yoshida D, Kakeji Y, Hashizume M (2008) Effectiveness of endoscopic surgery training for medical students using a virtual reality simulator versus a box trainer: a randomized controlled trial. Surg Endosc 22:985–990CrossRefPubMedGoogle Scholar
  14. 14.
    Ieiri S, Nakatsuji T, Higashi M, Akiyoshi J, Uemura M, Konishi K, Onimaru M, Ohuchida K, Hong J, Tomikawa M, Tanoue K, Hashizume M, Taguchi T (2010) Effectiveness of basic endoscopic surgical skill training for pediatric surgeons. Pediatr Surg Int 26:947–954CrossRefPubMedGoogle Scholar
  15. 15.
    Yamaguchi S, Yoshida D, Kenmotsu H, Yasunaga T, Konishi K, Ieiri S, Nakashima H, Tanoue K, Hashizume M (2011) Objective assessment of laparoscopic suturing skills using a motion-tracking system. Surg Endosc 25:771–775CrossRefPubMedGoogle Scholar
  16. 16.
    Ieiri S, Ishii H, Souzaki R, Uemura M, Tomikawa M, Matsuoka N, Takanishi A, Hashizume M, Taguchi T (2013) Development of an objective endoscopic surgical skill assessment system for pediatric surgeons: suture ligature model of the crura of the diaphragm in infant fundoplication. Pediatr Surg Int 29:501–504CrossRefPubMedGoogle Scholar
  17. 17.
    Okada S, Shimada J, Ito K, Kato D (2014) A touch panel surgical navigation system with automatic depth perception. Int J Comput Assist Radiol Surg. doi: 10.1007/s11548-014-1080-2 PubMedGoogle Scholar
  18. 18.
    Fraser SA, Klassen DR, Feldman LS, Ghitulescu GA, Stanbridge D, Fried GM (2003) Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc 17: 964–967CrossRefPubMedGoogle Scholar
  19. 19.
    Wilson MR, Vine SJ, Bright E, Masters RSW, Defriend D, McGrath JS (2011) Gaze training enhances laparoscopic technical skill acquisition and multi-tasking performance: a randomized, controlled study. Surg Endosc 25:3731–3739CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Votanopoulos K, Brunicardi FC, Thornby J, Bellows CF (2008) Impact of three-dimensional vision in laparoscopic training. World J Surg 32:110–118CrossRefPubMedGoogle Scholar
  21. 21.
    Diesen DL, Erhunmwunsee L, Bennett KM, Ben-David K, Yurcisin B, Ceppa EP, Omotosho PA, Perez A, Pryor A (2011) Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices. J Surg Educ 68:282–289CrossRefPubMedGoogle Scholar
  22. 22.
    Neumuth T, Jannin P, Strauss G, Meixensberger J, Burgert O (2009) Validation of knowledge acquisition for surgical process models. J Am Med Inform Assoc 16:72–80CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Aggarwal R, Grantcharov TP, Eriksen JR, Blirup D, Kristiansen VB, Funch-Jensen P, Darzi A (2006) An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg 244:310–314CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Wilson M, McGrath J, Vine S, Brewer J, Defriend D, Masters R (2010) Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts. Surg Endosc 24:2458–2464CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Bell AK, Zhou M, Schwaitzberg SD, Cao CG (2009) Using a dynamic training environment to acquire laparoscopic surgery skill. Surg Endosc 23:2356–2363CrossRefPubMedGoogle Scholar
  26. 26.
    Aggarwal R, Grantcharov T, Moorthy K, Hance J, Darzi A (2006) A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 191:128–133CrossRefPubMedGoogle Scholar
  27. 27.
    McNatt SS, Smith CD (2001) A computer-based laparoscopic skills assessment device differentiates experienced from novice laparoscopic surgeons. Surg Endosc 15:1085–1089CrossRefPubMedGoogle Scholar
  28. 28.
    Egi H, Okajima M, Kawahara T, Yoshimitsu M, Sumitani D, Tokunaga M, Takeda H, Itamoto T, Ohdan H (2010) Scientific assessment of endoscopic surgical skills. Minim Invasive Ther Allied Technol 19:30–34CrossRefPubMedGoogle Scholar
  29. 29.
    Woodrum DT, Andreatta PB, Yellamanchilli RK, Feryus L, Gauger PG, Minter RM (2006) Construct validity of the LapSim laparoscopic surgical simulator. Am J Surg 191:28–32CrossRefPubMedGoogle Scholar
  30. 30.
    Sakai Y, Kitano S (2015) Practice guidelines on endoscopic surgery for qualified surgeons by the endoscopic surgical skill qualification system. Asian J Endosc Surg 8:103–113CrossRefPubMedGoogle Scholar

Copyright information

© CARS 2015

Authors and Affiliations

  • Munenori Uemura
    • 1
    Email author
  • Pierre Jannin
    • 2
    • 3
  • Makoto Yamashita
    • 1
  • Morimasa Tomikawa
    • 4
  • Tomohiko Akahoshi
    • 1
  • Satoshi Obata
    • 4
  • Ryota Souzaki
    • 4
  • Satoshi Ieiri
    • 4
  • Makoto Hashizume
    • 1
    • 4
  1. 1.Department of Advanced Medical Initiatives, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
  2. 2.INSERM, U1099RennesFrance
  3. 3.LTSIUniversité de Rennes 1RennesFrance
  4. 4.Department of Advanced Medicine and Innovative TechnologyKyushu University HospitalFukuokaJapan

Personalised recommendations