Discussion
INTRAOPERATIVE COMPLICATIONS, COMPLICATION, COMPLICATIONS
Efficient training is still a challenge in the field of MIS. Several studies showed that telestration with AR showed great potential for improving surgical performance at the beginning of MIS training [There are several telestration devices with AR that have been developed to assist with surgical training and performance [In this randomized controlled study, the visual guidance with the iSurgeon contributed to significantly better performance and fewer complications in 10 repetitively performed LCs, regardless of the difficulty of the LCs, compared to the control group that had only verbal guidance. Assessment of the task-specific and global GOALS and OSATS scores showed significantly higher scores in the iSurgeon group for all LCs performed, proving that the use of the iSurgeon system with expert guidance improves MIS skills such as tissue and instrument handling, preparation, dissection as well as the flow of operation. Interestingly, this was already shown after the first LC was performed with the assistance of the iSurgeon. There are several studies that have reported a positive influence of telestration on performance [The transfer of this kind of MIS training to the OR is accompanied by potential risks of complications, especially during the learning phase of the exercising surgeon [Interestingly, trainees in the iSurgeon group performed their baseline LC significantly faster than those in the control group. Nonetheless, this was only observed in the baseline LC. The two groups had no statistically significant difference in total operating time in the following 10 LCs.Concerning safe execution of the procedures, the iSurgeon group showed more successful completion of LCs within 90 min compared to the control group. No major damage was induced on the liver, gallbladder, cystic duct, or artery, which could lead to potentially severe complications in a real-life scenario. These aspects of safe conduct during a surgical procedure correspond with findings that misunderstandings and lack of efficient communication can lead to intraoperative complications [Additionally, according to the VAS, the iSurgeon group had a significantly lower complication rate than the control group despite more challenging LCs. This demonstrates how additional iSurgeon visual guidance potentially assists trainees to perform the LCs safely. It is comprehensible that the use of the iSurgeon with visual expert guidance assisted the trainees in developing a better understanding of the anatomical structures and procedure itself, leading to a more effortless flow from one procedural move to the next independently and being able to perform the procedure more often within the given time limit.Furthermore, visual guidance helped the trainees in the iSurgeon group achieve the CVS more often, which is one of the crucial steps in LC and essential in preventing damage to the surrounding structures [Finally, the iSurgeon group had more difficult gallbladders to work with, assessed using the VAS before each training. Considering the lower rate of complications and a higher percentage of successfully performed LCs, the iSurgeon group benefitted from visual guidance even in difficult cases, making the iSurgeon a potentially valuable tool in preclinical and clinical scenarios. Telestration devices with AR, like the iSurgeon, could have an additional effect on the learning curves of surgical trainees and patients' safety. Also, the iSurgeon could show potential in training young aspiring surgeons when used in specialized training centers or upon transfer to the OR with proctoring by a senior surgeon.However, despite promising opportunities that iSurgeon offers in MIS training, its routine application in everyday MIS training is still not accessible to all institutions due to its ongoing development. To implement the iSurgeon in training centers or the OR, it is necessary to have the corresponding material and software, which could potentially make it difficult to implement such technology without the required financial support. Nevertheless, the benefit of such assistance systems in MIS training should encourage institutions to invest in further research to make such technology accessible to improve surgical performance and quality and, through that, hopefully, patient outcomes.