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Tarek A. Emam, MB, BCh, MCh; George B. Hanna, MB, BCh, FRCS(Edin), PhD; Chris Kimber, FRACS, MBBS, FRACS; Peta Dunkley, MB, BCh, FRCS; Alfred Cuschieri, MD, ChM, FRCS(Edin), FRSE

Arch Surg. 2000;135:62-65.

Hypothesis  Better endoscopic task performance and more ergonomic movements of a surgeon's dominant upper limb can be achieved within a certain range of intracorporeal-extracorporeal instrument length ratio.

Design  Investigating the effect of 3 intracorporeal-extracorporeal instrument length ratios (240:120 mm, level 1; 180:180 mm, level 2; and 120:240 mm, level 3) on efficiency and quality of a standardized endoscopic task (intracorporeal surgeon's knot). Ten surgeons tied 360 knots inside a trainer in a random sequence. Task efficiency was measured by the execution time, which was recorded for each knot. Task quality was measured by the knot quality score, derived from the force-extension curves obtained by distraction of each knot in a tensiometer. Motion analysis parameters were obtained at the elbow and shoulder joints using a 3-dimensional motion analysis system (Kinemetrix Model 5.0-3D/3MBM; Medical Research Ltd, Leeds, England). The Kruskal-Wallis and Mann-Whitney tests were used for analysis.

Results  The level 3 ratio had the lowest knot quality score (P = .07) and longest execution time (P<.05). The range of movement at the elbow was significantly greater with the level 3 ratio than with the level 1 ratio (P<.05). The level 3 ratio also resulted in the widest range of movement at the shoulder (P<.05 for level 2 vs 3; P = .06 for level 1 vs 3). The median angular velocity was 329.5°/s, 360°/s, and 530°/s for levels 1, 2, and 3, respectively (P = .10).

Conclusions  Intracorporeal-extracorporeal instrument length ratio below 1.0 degrades task performance and is associated with a wider range of movement at the elbow and shoulder and a higher angular velocity at the shoulder.

From the Department of Surgery and Surgical Skills Unit, Ninewells Hospital and Medical School, Dundee, Scotland.

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