Intraoperative monitoring of laparoscopic skill development based on quantitative measures

Methods for evaluating standard skills in the operating room typically are based on direct observation and checklists, but such evaluations are time consuming and can be subject to bias. It often is possible to acquire more objective measurements using surgical simulators. However, motor performance in simulators can differ significantly from that in the operating room. Intraoperative assessment is particularly challenging because of the significant variability between procedures related to differences in the patients, the surgical setup, and the team. This study aimed to evaluate the feasibility of using a new framework for interpreting quantitative measures acquired in the operating room to distinguish between levels of laparoscopic skill development.

Two levels of surgical skill development were observed, namely, those of three fourth-year residents and three attending surgeons performing three laparoscopic cholecystectomies each. Electromagnetic position sensors were attached by the surgeons to a 5-mm curved dissector and a 5-mm atraumatic grasper. From the tools' position histories and video recordings, time, kinematics, and movement transition measures were extracted. Various measures such as the Kolmogorov-Smirnov statistic and the Jensen-Shanon Divergence were used to provide intuitive dimensionless difference measures ranging from 0 to 1. These scores were used to compare residents and expert surgeons executing two surgical tasks: exposure of Calot's triangle and dissection of the cystic duct and artery.

The two groups could be clearly differentiated in both tasks during monitoring for the dominant hand (analysis of variance [ANOVA] and Mann-Whitney; p < 0.05) but not for the nondominant hand.

It is practical to acquire time, kinematic, and movement transition measures intraoperatively using video and electromagnetic position-sensing technologies. Principal component analysis proved to be a useful technique for presenting differences between skill levels based on those measures. The authors conclude that objective assessment of intraoperative surgical motor behavior is feasible and likely practical.