Laparoscopic Warm-up Exercises Improve Performance of Senior-Level Trainees During Laparoscopic Renal Surgery

Abstract

Background and Purpose: Surgery is a high-stakes ''performance.'' Yet, unlike athletes or musicians, surgeons do not engage in routine ''warm-up'' exercises before ''performing'' in the operating room. We study the impact of a preoperative warm-up exercise routine (POWER) on surgeon performance during laparoscopic surgery. Materials and Methods: Serving as their own controls, each subject performed two pairs of laparoscopic cases, each pair consisting of one case with POWER ( + POWER) and one without (-POWER). Subjects were randomly assigned to + POWER or -POWER for the initial case of each pairing, and all cases were performed ‡ 1 week apart. POWER consisted of completing an electrocautery skill task on a virtual reality simulator and 15 minutes of laparoscopic suturing and knot tying in a pelvic box trainer. For each case, cognitive, psychomotor, and technical performance data were collected during two different tasks: mobilization of the colon (MC) and intracorporeal suturing and knot tying (iSKT). Statistical analysis was performed using SYSTAT v11.0. Results: A total of 28 study cases (14 + POWER, 14 -POWER) were performed by seven different subjects. Cognitive and psychomotor performance (attention, distraction, workload, spatial reasoning, movement smoothness, posture stability) were found to be significantly better in the + POWER group (P £ 0.05) and technical performance, as scored by two blinded laparoscopic experts, was found to be better in the + POWER group for MC (P = 0.04) but not iSKT (P = 0.92). Technical scores demonstrated excellent reliability using our assessment tool (Cronbach f = 0.88). Subject performance during POWER was also found to correlate with intraoperative performance scores. Conclusions: Urologic trainees who perform a POWER approximately 1 hour before laparoscopic renal surgery demonstrate improved cognitive, psychomotor, and technical performance.

A systematic examination of preoperative surgery warm-up routines

“…Two cross-over trials [27,29] reported ambiguous findings for the effect of preoperative simulation on surgical performance; the first study [27] reported a significant effect as measured by one global rating scale, but no effect according to another also-reported scale. The second study [28] found a significant improvement in one assessed task, but not another. One RCT [22] and one cross-over trial [30] found that preoperative simulation had no effect on subsequent performance, as judged by a global rating scale.…”

“…The authors reported undertaking structured mental practice significantly improved participants' mental imagery of a procedure. Finally, in one cross-over study [28] it was found that preoperative simulation improved attention, reduced distraction / drowsiness and reduced mental workload in comparison to no warm-up.…”

“…In a majority of studies, validated global rating assessments were used. In three studies [22,28,30] a modification of a previously published global rating scale was employed.…”

“…The authors of four studies [24,25,28,33] reported outcome metrics generated by the laparoscopic simulator used during their experiments. Hand and tool movement smoothness and instrument path length were reported, but there was no concordance across the studies; some reported significant results in certain outcome metrics while others did not.…”

“…In four studies [24,25,28,33] the effect of preoperative simulation on the number of errors made during a procedure (determined by a simulator or expert assessor) was reported. The authors of one RCT [24] and one case study [33] found that preoperative simulation significantly reduced the number of errors that occurred during simulated laparoscopic performance.…”