Reverse-alignment surgical skills assessment

Background: During the course of certain laparoscopic procedures, a surgeon may encounter circumstances where the camera and working instruments are not aligned along the same axis. When the alignment is off by 180 degrees, the laparoscope is pointed directly at the surgeon and a mirror image of the operative field is created. Under reverse alignment conditions, surgeons often become disoriented and task performance may be degraded. The aim of this study is to measure the degree to which reverse alignment conditions impair the performance of operators of varying laparoscopic surgical skill and experience. Methods: Nineteen general surgery residents and 3 attending surgeons were tested in a video trainer. A task designed to simulate tack placement during laparoscopic ventral hernia repair was created. Time required to successfully complete this task in both forward and reverse alignment conditions was measured for all participants. For this study, the impact of visual-spatial discordances of angles other than 180 degrees on task performance was not assessed. Data regarding prior laparoscopic case volume and MISTELS scores were collected for each resident. Results: Significant and strong correlations were observed between resident experience and individual MISTELS scores. No significant correlation was found between reverse image times and any other surrogate measure of experience or skill for the residents. All study participants required a significantly longer period of time to complete the simulated tack task in reverse alignment compared to forward alignment conditions. Attendings required 65% more time and resident times increased by 470%. Attendings completed the task significantly faster than residents in reverse alignment conditions. Conclusions: Reverse-alignment surgical skills can be improved with experience, but may require a volume of cases exceeding that encountered in residency training. Reverse image skills are not derivative from surgical skills developed in a video trainer with forward orientation.