Abstract
There is an unresolved question about whether realigned visual feedback is beneficial or costly to laparoscopic task performance. We provide evidence that camera realignment imposes a reliable cost on performance across both naive controls and experienced surgeons. This finding clarifies an important ongoing discussion in the literature about the effects of camera realignment, which could inform the strategies that laparoscopic surgeons use in the operating room.
Similar content being viewed by others
Introduction
A fundamental challenge routinely faced by laparoscopic surgeons is that, since an assistant can only direct the camera through a non-aligned port, the viewpoints of the surgeon and the laparoscopic camera are often considerably misaligned. This causes instrument movements in the workspace to produce counter-intuitive movements on the video display. One obvious coping strategy in such scenarios is to reposition the camera to precisely counteract the misalignment (henceforth called realignment). However, while this successfully realigns camera and surgeon viewpoints, it also introduces discrepancies between how instrument movements are visually depicted on the screen and the surgeon’s actual movements in the workspace. There is a tension in the literature with respect to the impact of camera realignment, with some research reporting that it is helpful1,2,3,4,5, and other research indicating that it is harmful6,7,8,9,10. A similar tension exists when viewing this issue from the perspective of motor learning neuroscience. Here, the dominant empirical observation is that visuomotor misalignments (or perturbations) are generally harmful to performance11,12,13,14. Yet it is currently unclear to what extent these findings—which relate to simple unimanual reaching and pointing—should be expected to apply to a laparoscopic context.
In the current study, we investigated the effects of realigned visual feedback on motor performance in a laparoscopic task for both naive controls and experienced surgeons. We observed that realignment imposed a reliable cost on task performance across both groups.
Methods
10 expert surgeons and 10 naive controls participated in the study. All were right-hand dominant (LQ > 70) assessed using the ten-item version of the Edinburgh Handedness Inventory15, with normal or corrected to normal vision and no reported motor impairments. All surgeons (age 47 ± 14 years; 9 males, 1 female) were from Macquarie University Hospital, and had completed > 100 laparoscopic procedures according to self-report. Of those, 3 reported completing > 1000 MIS procedures. Controls (23 ± 3 years; 4 males, 6 females) were Macquarie University undergraduates with no prior surgical experience or training. The study was performed in compliance with the Declaration of Helsinki and was approved by the Macquarie University Human Research Ethics Committee (#5201800444). All participants provided informed written consent before taking part in the study.
Participants completed a unimanual version of the peg transfer task16,17,18,19,20 using a laparoscopic dissector (Ethicon Inc.) in a custom-built box trainer (Fig. 1A). Instrument ports were positioned at 45° increments around a centrally positioned camera that provided an overhead view of the workspace (Fig. 1B), similar to a number of previous studies of laparoscopic performance under camera rotation9,10,21. The camera was attached to a custom adjustable mount with interlocking teeth on both the camera and base that permitted 360° rotation in precise, highly reproducible 15° increments. The peg transfer apparatus consisted of 8 cylindrical pegs (1 cm × 0.5 cm) positioned equidistant from the center (5 cm radius) at 45° increments, and secured to a circular base (Fig. 1C). This configuration, which is invariant over angular rotations, was chosen to ensure that no overt visual cues about the experimental condition (i.e., camera rotation) were available to the participants during the experiment. A shallow high contrast white recess on the top of each peg provided a secure, easily visible target site for placement of a small orange foam ball (0.5 cm).
During the task, participants were instructed to transfer the ball as quickly and directly as possible back and forth between two opposing pegs. Visual feedback was displayed on a monitor mounted vertically and positioned directly in front of the participant. Instrument position was tracked using an infrared 3D motion tracking system (Polaris Vicra, Northern Digital Inc.) mounted above the box trainer, which recorded the positions of the infrared sensors of an NDI rigid body secured to the top of the tool handle at 20 Hz. Instrument tip position was extrapolated via the “pivot” function in the NDI ToolBox tracking software. Position data was exported as a csv file prior to analysis.
The overall experiment involved 2 groups (expert, control) × 2 conditions (canonical, realigned) × 9 ports (0°, 45°, 90°, 135°, 180°) × 10 trials as factors. Every factor except group was within-subject. In 5 canonical visual feedback conditions, transfers were completed from 5 different port locations (0°, 45°, 90°, 135°, 180°) with the camera rotated 0°. In 4 realigned visual feedback conditions (45°, 90°, 135°, 180°), the camera was rotated by an amount equal and opposite to the active port location. Different pegs were used for each condition such that start and end targets were always either at the rightmost (90°) or leftmost (270°) positions in visual space. This resulted in visual feedback about instrument and target position matched to the 0° (canonical) port irrespective of the instrument’s real position and orientation in the workspace, which was the same in every condition. Trials were blocked by port location, and port order was randomised and counterbalanced across participants. The canonical condition was always completed first at each port location. Kinematic measures including movement time(s), velocity (mm/s) and movement smoothness estimated by dimensionless total squared jerk (tsj)22 (a.u.) were calculated for all reaches. We performed mixed-design ANOVAs treating either movement time or movement smoothness as a dependent variable, group as a between-subject factor, and condition as a within-subject factor. We performed post-hoc t-tests to ascertain the direction of significant omnibus results. All analyses were performed using Pingouin 0.3.1118.
Results
Camera realignment increased movement time for both groups to similar degrees as evidenced by a significant main effect of condition [F(1,18) = 32.95, p < 0.001, η2 = 0.65], and a non-significant group × condition interaction [F(1,18) = 0.57, p = 0.46, η2 = 0.03]. Post hoc t-tests support the direction of this effect [t(19.0) = − 5.81, p < 0.01, d = − 0.77]. Overall, experts moved more quickly than controls as evidenced by a main effect of group [F(1,18) = 9.62, p = 0.01, η2 = 0.35], and further supported by a post hoc t-test [t(18.0) = 3.1, p = 0.01, d = 1.39].
Experts moved more smoothly than controls overall as evidenced by a significant main effect of group [F(1,18) = 9.09, p = 0.01, η2 = 0.34], and supported by a post hoc t-test [t(18.0) = 3.02, p < 0.01, d = 1.35]. Realignment decreased movement smoothness for both groups as evidenced by a significant main effect of condition [F(1,18) = 12.12, p < 0.001, η2 = 0.4], and supported by a post hoc t-test [t(19.0) = − 3.05, p < 0.01, d = − 0.9]. However, movement smoothness was more severely degraded for controls than for experts as evidenced by a significant group × condition interaction [F(1,18) = 6.79, p < 0.05, η2 = 0.27], and supported by a post hoc t-test comparing groups under realignment [rot × group: t(18.0) = 2.84, p < 0.05, d = 1.27]. See Fig. 2 for a visualization of these effects.
Discussion
In this study, we showed that camera realignment leads to greater movement times to similar degrees for both experts and controls, and decreased movement smoothness for both groups, but significantly more for controls than for experts. Why might some previous studies indicate that camera realignment is helpful1,2,3,4,5, while others suggest that it is harmful6,7,8,9,10?
One possible explanation emerges from another challenge routinely faced by laparoscopic surgeons. Namely, since laparoscopic instruments are inserted through ports in the skin that serve as pivot points, instrument tip motion is reversed relative to hand motion—a complication referred to as the “fulcrum effect”1. Camera realignment may help as it causes instrument tip movements to appear to match hand movements. This suggests that it is primarily those that are not well-practised in dealing with the fulcrum effect that may benefit from realignment. In line with this, laparoscopic surgeons already acclimated to the fulcrum effect, do not appear to show similar improvements from camera realignment as naive controls23. (But see Johnston et al.2 for possible exceptions).
The broader literature on tool use reinforces this interpretation. In tool-based contexts similar to MIS, which transform hand movements into inverted movements of the tool tip, performance is improved when visual feedback is manipulated so there is a spatial correspondence between the location of the stimulus and the direction of tool tip motion, independent of the movement direction of the hand6,24,25. Importantly, the participants in these studies were all naive.
Misalignment between the viewpoint of the surgeon and the camera is an inherent challenge in laparoscopic surgery. Although simple camera realignment may be helpful under certain conditions and in some populations, the overall literature in combination with our current results, show that it is not a reliable intervention to improve performance—a finding that could usefully inform the strategies that laparoscopic surgeons use in the operating room. Instead, experienced laparoscopic surgeons seem capable of learning to cope with challenging misalignment without relying on camera counter-rotation. One possibility suggested by the broader literature on motor learning is that humans are capable of using cognitive strategies to respond rapidly and flexibly to changes in visuomotor mappings26. It is therefore possible that expert surgeons have discovered appropriate strategies for contending with camera misalignments and consequently do not require physical realignment of the camera to maintain stable performance. We suggest that a productive and still largely unexplored research direction is to understand what confers these surgeons with such remarkable adaptability including whether they successfully exploit high-level cognitive strategies or heuristics27,28.
References
Gallagher, A., McClure, N., McGuigan, J., Ritchie, K. & Sheehy, N. An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills. Endoscopy 30, 617–620 (1998).
Johnston, W. K., Low, R. K. & Das, S. Image converter eliminates mirror imaging during laparoscopy. J. Endourol. 17(5), 327–331. https://doi.org/10.1089/089277903322145521 (2003).
Abodeely, A. A., Cheah, Y.-L., Ryder, B. A., Aidlen, J. T. & Luks, F. I. Eliminating the effects of paradoxic imaging during laparoscopic surgery. J. Laparoendosc. Adv. Surg. Tech. 20(1), 31–34. https://doi.org/10.1089/lap.2009.0227 (2010).
Gill, R. S. et al. Image inversion and digital mirror-image technology aid laparoscopic surgery task performance in the paradoxical view: A randomized controlled trial. Surg. Endosc. 25(11), 3535–3539. https://doi.org/10.1007/s00464-011-1754-6 (2011).
Miura, S. et al. Optimal monitor positioning and camera rotation angle for mirror image: Overcoming reverse alignment during laparoscopic colorectal surgery. Sci. Rep. 9(1), 8371. https://doi.org/10.1038/s41598-019-44939-0 (2019).
Cresswell, A. B., Macmillan, A. I. M., Hanna, G. B. & Cuschieri, A. Methods for improving performance under reverse alignment conditions during endoscopic surgery. Surg. Endosc. 13(6), 591–594. https://doi.org/10.1007/s004649901048 (1999).
Ames, C., Frisella, A. J., Yan, Y., Shulam, P. & Landman, J. Evaluation of laparoscopic performance with alteration in angle of vision. J. Endourol. 20(4), 281–283. https://doi.org/10.1089/end.2006.20.281 (2006).
Gallagher, A. G., Al-Akash, M., Seymour, N. E. & Satava, R. M. An ergonomic analysis of the effects of camera rotation on laparoscopic performance. Surg. Endosc. 23(12), 2684–2691. https://doi.org/10.1007/s00464-008-0261-x (2009).
Zhang, L. & Cao, C. G. Effect of automatic image realignment on visuomotor coordination in simulated laparoscopic surgery. Appl. Ergon. 43(6), 993–1001. https://doi.org/10.1016/j.apergo.2012.02.001 (2012).
Klein, M. I., Wheeler, N. J. & Craig, C. Sideways camera rotations of 90° and 135° result in poorer performance of laparoscopic tasks for novices. Hum. Factors J. Hum. Factors Ergon. Soc. 57(2), 246–261. https://doi.org/10.1177/0018720814553027 (2015).
Cunningham, H. A. Aiming error under transformed spatial mappings suggests a structure for visual-motor maps. J. Exp. Psychol. Hum. Percept. Perform. 15(3), 493 (1989).
Krakauer, J. W., Pine, Z. M., Ghilardi, M.-F. & Ghez, C. Learning of visuomotor transformations for vectorial planning of reaching trajectories. J. Neurosci. 20(23), 8916–8924 (2000).
Krakauer, J., Hadjiosif, A., Xu, J., Wong, A. & Haith, A. Motor Learning. Compr. Physiol. 9(2), 613–663. https://doi.org/10.1002/cphy (2019).
Krakauer, J. W. Motor learning and consolidation: The case of visuomotor rotation. In Progress in Motor Control (ed. Sternad, D.) 405–421 (Springer US, 2009). https://doi.org/10.1007/978-0-387-77064-2_21.
Oldfield, R. The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychologia 9(1), 97–113. https://doi.org/10.1016/0028-3932(71)90067-4 (1971).
Vassiliou, M. C. et al. The MISTELS program to measure technical skill in laparoscopic surgery. Surg. Endosc. 20(5), 744–747 (2006).
Ritter, E. M. & Daniel, J. S. Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg. Innov. 14(2), 107–112 (2007).
Sroka, G. et al. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am. J. Surg. 199(1), 115–120 (2010).
Bilgic, E. et al. Trends in the fundamentals of laparoscopic surgery® (FLS) certification exam over the past 9 years. Surg. Endosc. 32(4), 2101–2105 (2018).
Hanna, G. B. & Cuschieri, A. Influence of the optical axis-to-target view angle on endoscopic task performance. Surg. Endosc. 13(4), 371–375 (1999).
Hogan, N. & Sternad, D. Sensitivity of smoothness measures to movement duration, amplitude, and arrests. J. Mot. Behav. 41(6), 529–534. https://doi.org/10.3200/35-09-004-RC (2009).
Vallat, R. Pingouin: Statistics in Python. J. Open Source Softw. 3(31), 1026. https://doi.org/10.21105/joss.01026 (2018).
Crothers, I., Gallagher, A., McClure, N., James, D. & McGuigan, J. Experienced laparoscopic surgeons are automated to the “fulcrum effect”: An ergonomic demonstration. Endoscopy 31(05), 365–369 (1999).
Kunde, W., Müsseler, J. & Heuer, H. Spatial compatibility effects with tool use. Hum. Factors J. Hum. Factors Ergon. Soc. 49(4), 661–670. https://doi.org/10.1518/001872007X215737 (2007).
Müsseler, J., Kunde, W., Gausepohl, D. & Heuer, H. Does a tool eliminate spatial compatibility effects?. Eur. J. Cogn. Psychol. 20(2), 211–231. https://doi.org/10.1080/09541440701275815 (2008).
McDougle, S. D., Ivry, R. B. & Taylor, J. A. Taking aim at the cognitive side of learning in sensorimotor adaptation tasks. Trends Cogn. Sci. 20(7), 535–544 (2016).
Crossley, M., Hewitson, C., Cartmill, J. & Kaplan, D. Motor adaptation: An underappreciated aspect of technical surgical skill. ANZ J. Surg. 91, 489–490 (2020).
Dunnican, W. J. et al. Reverse alignment “mirror image” visualization as a laparoscopic training tool improves task performance. Surg. Innov. 17(2), 108–113. https://doi.org/10.1177/1553350610365346 (2010).
Author information
Authors and Affiliations
Contributions
C.L.H., J.C., D.M.K., and S.T.S. conceived and designed the experiment. C.L.H. collected the data. C.L.H. and M.J.C. analyzed the data. C.L.H., M.J.C., and D.M.K. interpreted the data and wrote the manuscript. J.C. and S.T.S. reviewed the manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Hewitson, C.L., Shukur, S.T., Cartmill, J. et al. Camera realignment imposes a cost on laparoscopic performance. Sci Rep 11, 17634 (2021). https://doi.org/10.1038/s41598-021-96965-6
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41598-021-96965-6
Comments
By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.