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J Minim Access Surg. 2019 Nov 26. doi: 10.4103/jmas.JMAS_143_19. [Epub ahead of print]

Higher quality camera navigation improves the surgeon's performance: Evidence from a pre-clinical study.

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Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.



To objectively assess the quality of laparoscopic camera navigation (LCN), the structured assessment of LCN skills (SALAS) score was developed and validated for laparoscopic cholecystectomy. The aim of this pre-clinical study was to investigate the influence of LCN on surgical performance during virtual cholecystectomy (vCHE) using this score.


A total of 84 medical students were included in this prospective study. Individual characteristics were assessed with questionnaires. Participants completed a structured 2-day training course on a validated virtual reality laparoscopic simulator. At the end of the course, all students took over LCN during vCHE, all performed by the same surgeon. The numbers of errors regarding centering, horizon adjustment and instrument visualisation as well as manual and verbal corrections by the surgeon were recorded to calculate the SALAS score (range 5-25) to investigate the influence of LCN on surgical performance. The study population was divided by the recorded SALAS score into low and medium performers (Group A; 1st-3rd quartile; n = 60) and high performers (Group B, 4th quartile, n = 21).


The SALAS score of the camera assistant correlates positively with the surgeon's overall performance in vCHE (P < 0.001), and the surgeon's virtual laparoscopic performance was significantly better in Group B (P < 0.001). Moreover, a significantly shorter operation time during vCHE was shown for Group B (Median (IQR); Group A: 508 s [429 s; 601 s]; Group B: 422 s [365 s; 493 s]; P = 0.001). Frequent gaming and a higher self-confidence to assist during a basic laparoscopic procedure were associated with a higher SALAS score (P = 0.013).


In this pre-clinical setting, the surgeon's virtual performance is significantly influenced by the LCN quality. LCN by high performers resulted in a shorter operation time and a lower error rate.


Camera navigation; laparoscopic simulation; minimal invasive surgery; surgical education; virtual surgery

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