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J Surg Educ. 2013 Mar-Apr;70(2):172-9. doi: 10.1016/j.jsurg.2012.10.001. Epub 2012 Nov 3.

A comparison of skill acquisition and transfer in single incision and multi-port laparoscopic surgery.

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Department of Biosurgery and Surgical Technology, Imperial College London, London W2 1NY, United Kingdom.



Single incision laparoscopic surgery (SILS) offers a scar-less approach to cholecystectomy. We conducted a cadaveric randomized crossover study to compare the novice learning curves for multiport laparoscopic cholecystectomy (LC) and single incision laparoscopic cholecystectomy (SILC), and to investigate the acquisition of transferable skills.


Twenty medical students were randomized into SILS or LC groups.


After baseline assessment and cognitive learning modules, groups completed 5 cadaveric porcine cholecystectomies in their designated modality, followed by one using the other approach. Performance was assessed using a validated surgical assessment device (ICSAD) and by expert video analysis with generic and procedure-specific rating scales [modified global rating scale (mGRS) and procedure-specific rating scales (PSRS)].


Analysis of the first case revealed significant differences between LC and SILS groups for time-taken (median 46.00 vs 68.19 min, p = 0.019), and path length (216 vs 348 m, p = 0.034). Intergroup analysis of the remaining group cases showed no difference for any of the performance metrics. Outlying performance of the 4th case in the LC group rendered learning curve comparison unviable. At crossover, performance of the SILS group on their LC compared with the 5th LC performed by the LC group showed no significant difference. However, comparing the LC group's SILC to the 5th SILC performed by the SILS group showed significant difference for all performance metrics (p < 0.05).


This study suggests that the difference between novice performance for SILC and LC becomes negligible after the first procedure. Furthermore, dedicated SILC training appears to develop competencies for both SILC and LC, therefore its addition to the early surgical curriculum is likely to extend the access of SILC to patients without reducing multiport laparoscopic skill acquisition.

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