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Background: Eye-hand coordination problems occur during laparoscopy. This study aimed to investigate the difference in instrument movements between the surgeon him-or herself holding the camera and an assistant holding the camera during performance of a laparoscopic task and to check whether experience of the surgeon plays a role in this issue. Methods: The participants were divided into three groups: experts, residents, and novices. Each participant performed positioning tasks using the right (R) and left (L) hands. During these tasks, the camera was manipulated either by the participant (C self ) or by an assistant (C assistant ). Movements of instruments were recorded with the authorsÕ new TrEndo tracking system. The performance was analyzed using five kinematic parameters: time, path length, three-dimensional (3D) motion smoothness, 1D motion smoothness (along the axis), and depth perception. Results: A total of 46 participants contributed. Three tests were performed: test 1-LC self , test 2-LC assistant , and test 3-RC assistant . In all the tests, the experts performed better than the residents and novices in terms of time, path length, and depth perception. The novices performed better in tests 1-LC self and 2-LC assistant than in test 3-RC assistant in terms of path length, 3D motion smoothness, and depth perception. Conclusions: Laparoscopic experience and the cameraholding factor influenced the performance of laparoscopic tasks on the simulator. Time, path length, and depth perception clearly discriminate between different levels of experience in laparoscopy, whereas 3D and 1D motion smoothness play a limited role. Novices experienced more difficulties when an assistant held the camera. Therefore, self-manipulation of the camera seems to improve novicesÕ eye-hand coordination.Key words: Endoscope -Eye-hand coordination: motion analysis -Laparoscopy: training Minimally invasive surgery (MIS, e.g., laparoscopy) currently is widely used for therapeutic purposes. It is well known that laparoscopy has many advantages for the patient such as reduced morbidity, shorter hospitalization, better cosmetic results, and earlier return to normal activity [6]. Laparoscopic surgery, however, requires expertise in psychomotor skills different from those needed to perform open surgical procedures and results in longer learning curves [8]. These skills include a shift from a three-dimensional (3D) operating field to a 2D monitor display, judgment of altered depth perception and spatial relationships, distorted eye-hand coordination, adaptation to the fulcrum effect, manipulation of long surgical instruments while adjusting for amplified tremor, diminished tactile feedback, and fewer degrees of freedom [12]. To guarantee safe performance of laparoscopy, surgeons must be properly trained, and the procedures must be assessed thoroughly [1] (e.g., as in flight simulators for pilots) [13].Most laparoscopic procedures require the use of an operating team that includes not only a surgeon, but also at least one operating...

Our aim was to test our laparoscopic simulator for construct validity and for establishing performance standards. The skills of laparoscopic novices (n=18) and advanced gynaecologists (experts, n=5) were tested on our inanimate simulator by their performance of five tasks. The sum score was the sum of scores of all five tasks. We calculated the scores by adding completion time and penalty points. After baseline evaluation, the novices were assigned to five weekly training sessions (n=8, training group) or no training (n=10, control group). Both groups were retested. The experts were tested once, and their performance was compared with the baseline scores of all novices to establish construct validity. The training group improved significantly in all tasks. The final scores of the trained group were significantly better than those of the control group. The training group reached a plateau within seven trials, except for intra-corporeal knot tying. During final testing, the trained group reached the experts' level of skills on the simulator. We concluded that our simulation model has construct validity. Novices can reach the experts' basic laparoscopic skills level on the simulator after a short and intense simulator training course. Experts' basic skills level on the simulator is an achievable performance standard during residency training.

Incorporation of basic laparoscopic procedures into residency training has been successful; however, advanced procedures are not. Simulator training is still in its infancy in The Netherlands, is not frequently used voluntarily, and should be mandatory during residency. Acquired laparoscopic skills on a simulator and in the operating room should be objectively assessed, and above all, training of trainers is imperative.