Analysis of the tractive force pattern on a knot by force measurement during laparoscopic knot tying

Quantifying surgical skills assists novice surgeons when learning operative techniques. We measured the interaction force at a ligation point and clarified the features of the force pattern among surgeons with different skill levels during laparoscopic knot tying.

Forty-four surgeons were divided into three groups based on experience: 13 novice (0-5 years), 16 intermediate (6-15 years), and 15 expert (16-30 years). To assess the tractive force direction and volume during knot tying, we used a sensor that measures six force-torque values (x-axis: Fx, y-axis: Fy, z-axis: Fz, and xy-axis: Fxy) attached to a slit Penrose drain. All participants completed one double knot and five single knot sequences. We recorded completion time, force volume (FV), maximum force (MF), time over 1.5 N, duration of non-zero force, and percentage time when vertical force exceeded horizontal force (PTz).

There was a significant difference between groups for completion time (p = 0.007); FV (total: p = 0.002; Fx: p = 0.004, Fy: p = 0.007, Fxy: p = 0.004, Fz: p < 0.001, Fxy/Fz: p = 0.003), MF (total: p = 0.004; Fx: p = 0.015, Fy: p = 0.035, Fxy: p = 0.009, Fz: p = 0.001, Fxy/Fz: p = 0.041); time over 1.5 N (p = 0.002); duration of non-zero force (p = 0.029); and PTz (p < 0.001). PTz showed the only significant difference comparing intermediates with experts (intermediates: 13.7 ± 9.0, experts: 4.9 ± 3.2; p < 0.001).

We clarified the characteristics of the force pattern at the ligation point during suturing by surgeons with three levels of experience using a force measurement system. We revealed that both force volume and force direction differed depending on surgeons' skill level during knot tying.