Surgical Endoscopy

, Volume 32, Issue 4, pp 1656–1667 | Cite as

Skills in minimally invasive and open surgery show limited transferability to robotic surgery: results from a prospective study

  • Karl-Friedrich Kowalewski
  • Mona W. Schmidt
  • Tanja Proctor
  • Moritz Pohl
  • Erica Wennberg
  • Emir Karadza
  • Philipp Romero
  • Hannes G. Kenngott
  • Beat P. Müller-Stich
  • Felix Nickel



There is limited evidence on the transferability of conventional laparoscopic and open surgical skills to robotic-assisted surgery. The primary aim of this study was to evaluate the transferability of expertise in conventional laparoscopy and open surgery to robotic-assisted surgery using the da Vinci Skills Simulator (dVSS). Secondary aims included evaluating the influence of individual participants’ characteristics.


Participants performed four tasks on the dVSS: Peg Board 1 (PB), Pick and Place (PP), Thread the Rings (TR), and Suture Sponge 1 (SS). Participants were classified into three groups (Novice, Intermediate, Experts) according to experience in laparoscopic and open surgery. All tasks were performed twice except for SS. Performance was assessed using the built-in scoring system.


37 medical students and 25 surgeons participated. Experts did not perform significantly better than less experienced participants on the dVSS. Specifically, with regard to laparoscopic experience, total simulator scores were: Novices 68.2 ± 28.8; Intermediates 65.1 ± 31.2; Experts 65.1 ± 30.0; p = 0.611. Regarding open surgical experience, scores were: Novices 68.6 ± 28.7; Intermediates 68.2 ± 30.8; Experts 63.2 ± 30.3; p = 0.305. Although there were some significant differences among groups for single parameters in specific tasks, there was no constant superiority of one group. Laparoscopic and open surgical Novices improved significantly in overall score and time for all three tasks (p < 0.05). Laparoscopic intermediates improved only in PP time (4.64 ± 3.42; p = 0.006), open Intermediates in PB score (11.98 ± 13.01; p = 0.025), and open Experts in PP score (6.69 ± 11.48; p = 0.048). Laparoscopic experts showed no improvement. Participants with gaming experience had better overall scores than non-gamers when comparing all second attempts (Gamer 83.62 ± 7.57; Non-Gamer 76.31 ± 12.78; p = 0.008) as well as first and second attempts together (Gamer 72.08 ± 8.86; Non-Gamer 65.45 ± 11.68; p = 0.039). Musical and sports experience showed no correlation with robotic performance.


Robotic-assisted surgery requires skills distinct from conventional laparoscopy or open surgery. Basic robotic skills training prior to patient contact should be required.


Minimally invasive surgery DaVinci Robotics Skill transfer Laparoscopy Training 



The authors would like to thank Mr. Tilman Schlick from Intuitive Surgical Inc. for access to the dVSS which made the conduction of the study possible.

Author contributions

Study conception and design: Kowalewski, Nickel, Müller-Stich, Kenngott. Acquisition of data: Schmidt, Karadza, Romero, Kowalewski. Statistical analysis: Proctor, Pohl, Wennberg. Analysis and interpretation of data: Kowalewski, Schmidt, Wennberg, Proctor, Pohl. Drafting of manuscript: Schmidt, Wennberg, Kowalewski, Karadza, Nickel. Critical revision: Müller-Stich, Kenngott, Nickel, Romero.


The current study was supported by the Heidelberg Surgery Foundation and by the Ministry of Science and Arts of the State Baden Wurttemberg.

Compliance with ethical standards


Felix Nickel reports receiving travel support for conference participation as well as equipment provided for laparoscopic surgery courses by KARL STORZ, Johnson & Johnson, and Medtronic. Karl-Friedrich Kowalewski, Mona W. Schmidt, Tanja Proctor, Philipp Romero, Erica Wennberg, Emir Karadza Hannes Kenngott, and Beat Müller-Stich have no conflicts of interest or financial ties to disclose.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Karl-Friedrich Kowalewski
    • 1
  • Mona W. Schmidt
    • 1
  • Tanja Proctor
    • 2
  • Moritz Pohl
    • 2
  • Erica Wennberg
    • 1
  • Emir Karadza
    • 1
  • Philipp Romero
    • 3
  • Hannes G. Kenngott
    • 1
  • Beat P. Müller-Stich
    • 1
  • Felix Nickel
    • 1
  1. 1.Department of General, Visceral, and Transplantation Surgery, University Hospital of HeidelbergUniversity of HeidelbergHeidelbergGermany
  2. 2.Institute of Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany
  3. 3.Division of Pediatric Surgery, Department of General, Visceral, and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany

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