however , laparoscopic techniques also have limitations , including an unstable camera platform , the limited motion of straight laparoscopic instruments , two - dimensional ( 2d ) vision , and poor ergonomics for the surgeon .
the da vinci surgical system ( intuitive surgical , sunnyvale , ca , usa ) was specifically designed to overcome the limitations of current laparoscopic technology .
the skills required for robotic surgery are , therefore , different from those required for laparoscopic surgery .
the surgeon sits at the console and views a three - dimensional ( 3d ) image of the procedure through two viewing holes , while maneuvering the arms with two foot pedals and two hand controllers .
specifically , the endo - wrist instruments allow maneuvering of the robotic arms in a manner that simulates fine human movements .
these characteristics enable robotic surgery to overcome the technical limitations of laparoscopy by restoring vision and manual control of open surgery in a minimally invasive environment .
we hypothesized that the laparoscopic experience does not affect robotic dexterity , because the techniques necessary for laparoscopic surgery and robotic surgery are different from each other .
a dry lab using the da vinci surgical system is optimal for comparing robotic dexterity , but this is limited because the expensive robot can only be used for this study , when surgery is not being performed .
the dv - trainer ( mimic technologies , seattle , wa , usa ) is a compact virtual reality platform that closely reproduces the experience of the da vinci surgical console .
it is the only robotic simulator demonstrated to have face ( degree of resemblance with the actual robot ) , content ( usefulness as a training tool as viewed by experts ) , construct ( degree to which the results on the simulator reflect the actual skill of the subject ) , and concurrent ( equivalence between assessment on the simulator and assessment on an actual da vinci surgical system ) validity in multiple studies .
virtual reality simulations can be performed at any time , and they can provide a real - time , objective assessment of users performance . accordingly , surgical fellows experienced in laparoscopic surgery were compared with medical students using the well - validated dv - trainer .
in february 2011 , surgical fellows and medical students were invited to participate in this prospective study .
all surgical fellows had > 3 years of experience as a surgeon or an assistant in laparoscopic surgery including laparoscopic appendectomy , cholecystectomy , gastrectomy , and colectomy , with no experience with the da vinci surgical system .
all subjects in both groups had not previously used the dv - trainer . after a standardized introduction and 10 min of practice ,
each subject completed three virtual endo - wrist modules (  pick and place , 
 peg board ,  and  match board  ) in sequence [ figure 1 ] .
pick and place consists of placing red , blue , or yellow objects in the corresponding colored boxes .
peg board consists of grasping rings on a vertical stand with the left hand and then passing these to the right hand before placing them on a peg .
match board consists of placing nine numbers and letters in specific squares on the board .
three virtual endo - wrist modules : ( a ) pick and place , ( b ) peg board , ( c ) match board performance was recorded using a computerized built - in scoring algorithm created by the manufacturer .
the measured variables included the time to complete the exercise ( seconds ) , economy of motion ( cm ) , number of instrument collisions , excessive instrument force ( seconds ) , instruments out of view ( cm ) , master workspace range ( cm ) , and number of drops .
a percentage score derived from a proprietary algorithm that combined a selection of these variables was also reported .
after completion of all tests , the data were statistically evaluated using ibm spss version 20.0 ( ibm , armonk , ny , usa ) .
direct comparisons of surgical fellows and medical students were performed using an independent - sample t - test or the mann - whitney u - test depending on the data distribution . differences of p < 0.05 were considered as statistically significant .
there was no significant difference between the groups in terms of the sex of the participants ( male : female = 10:4 vs. 8:3 , p = 1.000 ) , but surgical fellows were significantly older than the students ( age : 25.57  2.14 years vs. 35.63  2.25 years , p < 0.001 ) . in the pick and place module ,
surgical fellows scored significantly a better in the number of instrument collisions ( 4.11  2.98 vs. 1.18  1.60 , p = 0.016 ) , and the number of drops ( 2.67  1.80 vs. 1.00  1.01 , p = 0.028 ) , but the percentage score was not significantly different in the peg board module ( 41.56  16.31 vs. 51.36  18.27 , p = 0.239 ) [ table 2 ] .
no significant differences were found between surgical fellows and medical students in the match board module [ table 3 ] . when the scores for all three modules were tallied , the mean score was 53.21  20.12 for the medical students and 54.61  19.58 for the surgical fellows ( p = 0.764 ) .
the intensive training needed for laparoscopic surgery , and the demand for high technical standards may discourage surgeons , who perform open surgery from performing minimally invasive surgery .
however , the advent of robotics has increased the interest in minimally invasive surgery among laparoscopically nave surgeons .
nevertheless , the surgeons may be reluctant to perform robotic surgery , assuming that learning robotic skills will be difficult without laparoscopic experience . in a previous study , that evaluated the impact of laparoscopic experience on performance with the da vinci surgical system , the authors concluded that the laparoscopic experience was the strongest predictor of performance .
they assessed robotic dexterity using three tasks performed with the da vinci surgical system : two of the three tasks involved creating a double knot and needle driving .
however , these two tasks require an understanding of tying knots , and handling a round needle , skills that may have been lacking among the medical students participating in the previous study .
we , therefore , assessed robotic dexterity using three endo - wrist modules of the dv - trainer , as these are not related to surgical skills and knowledge .
construct validity is regarded as one of the most important aspects of simulator evaluation , because it determines whether a device can discriminate between experienced and inexperienced surgeons .
perrenot et al . performed a large study of the validity of the dv - trainer and found that the pick and place and peg board modules offered good construct validity .
conversely , the match board module has been associated with good construct validity in other studies .
the current study used these three virtual endo - wrist modules , as they have been proven useful for comparing robotic skills .
our results indicated that the laparoscopic experience is not strongly correlated with robotic dexterity when using the dv - trainer .
for example , with the da vinci surgical system , a hand movement to the right outside the body causes the instrument inside a patient to be moved to the right .
by contrast , during laparoscopy , the instrument tip moves in the opposite direction of the surgeon 's hand , and surgeons have to adjust their hand - eye coordination to translate their hand movements in this  reverse  environment .
moreover , endo - wrist instruments are unique in that they allow seven - degrees of freedom of motion , which replicates the full range of motion of the surgeon 's hand . in addition , our results can also be affected by the fact that learning robotic skills is relatively easy .
compared the efficacy of the da vinci surgical system using both the 3d and 2d view options with traditional manually assisted laparoscopic techniques for performing standardized exercises .
the inexperienced students performed the tasks significantly quicker and with fewer errors , when assisted by the robot in the 3d and 2d view modes compared with traditional laparoscopic surgery .
reported the initial experience of a surgeon without laparoscopic experience with robot - assisted radical prostatectomy .
they concluded that a laparoscopically nave yet , experienced open surgeon could successfully apply open surgical skills to the minimally invasive environment in 8 - 12 cases using the da vinci surgical system .
however , laparoscopic experience is clearly beneficial for some aspects of robotic surgery . in particular , laparoscopic experience is useful for access , not only for placement of ports but also for laparoscopically treatable adhesions that prevent the placement of the ports .
in addition , when multi - quadrant abdominal access is needed , laparoscopic skills can be used to reduce docking time .
for example , in rectal cancer surgery , colonic mobilization is laparoscopically performed by some surgeons before bringing the robot to the bedside for rectal dissection .
the dv - trainer is a well - validated simulator of the da vinci system that can discriminate between expert and novice robotic surgeons .
however , the instrument can not simulate the da vinci system completely , which results in instrument bias .
surgical fellows outperformed medical students in some variables of the peg board module , but the percentage score was not significantly different between the groups .
if the number of participants was larger , then the percentage score in the peg board module may have been significantly , different between the groups .
our study found that scores of three virtual endo - wrist modules were not significantly affected by the operator 's laparoscopic experience .
these results greatly suggest that the laparoscopic experience is not an important factor for learning robotic performance , although laparoscopic experience is beneficial for some aspects of robotic surgery so far .
 background : different skills are required for robotic surgery and laparoscopic surgery . we hypothesized that the laparoscopic experience would not affect the performance with the da vinci system . a virtual robotic simulator was used to estimate the operator 's robotic dexterity.materials and methods : the performance of 11 surgical fellows with laparoscopic experience and 14 medical students were compared using the dv - trainer. each subject completed three virtual endo - wrist modules (  pick and place ,   peg board ,  and  match board  ) . 
 performance was recorded using a built - in scoring algorithm.results:in the peg board module , the performance of surgical fellows was better in terms of the number of instrument collisions and number of drops ( p < 0.05 ) . 
 however , no significant differences were found in the percentage scores of the three endo - wrist modules between the groups.conclusion:robotic dexterity was not significantly affected by laparoscopic experience in this study . 
 laparoscopic experience is not an important factor for learning robotic skills . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION