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Surg Endosc. 2010 Sep;24(9):2145-55. doi: 10.1007/s00464-010-0913-5. Epub 2010 Feb 21.

A comparison of early learning curves for complex bimanual coordination with open, laparoscopic, and flexible endoscopic instrumentation.

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Minimally Invasive Surgery Program, Legacy Health System, Portland, OR 97210, USA.



This study takes an initial step towards understanding the learning process of flexible endoscopic surgery. Bimanual coordination learning curves were contrasted between three different surgical paradigms. We hypothesized that use of an open or laparoscopic paradigm would result in better performance and a shorter learning process (reaching a learning plateau earlier) than an endoscopic paradigm.


Our model required seven subjects to perform identical bimanual coordination tasks with three different tools (a dual-channel endoscope with graspers, laparoscopic Maryland graspers, and straight hemostats for open surgery). The task required subjects to coordinate two instruments in order to perform a series of standardized maneuvers. Performance was measured by movement speed and accuracy. The learning process was broken down into three distinct phases: the practice phase, the short-term retention phase, and the long-term retention phase. The learning curves of four surgical novices for 33 tasks with each device were compared with the performance of three surgeons.


Overall performance speed was significantly faster using open or laparoscopic tools than endoscopy for all groups (open 13 ± 1 s; lap 28 ± 3 s; endo 202 ± 82 s; P < 0.001). The difference between open and laparoscopy was not significant (P = 0.149). There was no significant difference (P = 0.434) in accuracy (number of ring drops) between any of the devices. Novices performed significantly slower than the expert in the endoscopy task (P = 0.010). Their performance improved with practice (P = 0.005) but they failed to reach the level of the expert after the practice phase (novices: 202.3 ± 23.4 s versus expert: 89.0 ± 34 s, P = 0.009).


Bimanual coordination tasks have shortest performance time and are easiest to learn using an open surgery paradigm. Performance times and the learning process take longer for the laparoscopic paradigm and significantly longer for the endoscopic paradigm.

[Indexed for MEDLINE]

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