over the last 2 decades , advances in surgical technology combined with a growing consumer demand have created a shift towards gynecologic minimally invasive surgery ( mis ) .
the safety and efficacy of mis have been thoroughly documented in the literature and include decreased blood loss , a shorter hospital stay , faster recovery time , fewer wound - related complications , and superior cosmetic results [ 1 , 2 ] .
the da vinci surgical system ( intuitive surgical , sunnyvale , ca , usa ) for use during gynecologic procedures has quickly become the minimally invasive alternative to conventional laparoscopy by providing surgeons with greater dexterity and improved visualization of the surgical field .
this shift towards mis in gynecology has required that academic institutions train their residents and fellows in new technology while simultaneously teaching the fundamentals of open surgery .
however , these expectations are becoming increasingly difficult in an environment of limited resident work hours and increased financial concerns where respecting patient safety and satisfaction is essential . as a result , a push has been made to discover the most effective way to train residents and fellows in both laparoscopic and robotic surgery .
becoming competent in mis requires adequate preparation time to acquire this unique set of skills .
the importance of preparation via mis simulation labs prior to entry into the operating theater is well documented . however ,
whether or not the skills gained from laparoscopy translate into improved robotic surgery skills for physicians in training is yet to be explored .
previous studies by surgeons investigating their personal experiences in learning robotic - assisted gynecologic surgery partly attributed their short learning curves to their extensive experience with advanced laparoscopic procedures prior to using robotic assistance [ 58 ] .
while these previous studies suggest that surgeons with more laparoscopic experience learn robotic surgery more quickly , it is not yet known if that data can be extrapolated to resident physicians .
current data is limited on the impact of previous laparoscopic exposure on learning robotic surgery skills for physicians in training .
laparoscopic suturing is arguably the hardest task while learning laparoscopic surgery because it requires a mastery of a complex set of maneuvers and skills .
although the increased dexterity provided by the robot has decreased the difficulty of suturing , it still represents one the fundamental skills that must be learned by trainees in robotic surgery .
the aim of the study was to evaluate if previous experience with laparoscopic surgery among gynecology residents could influence  and perhaps shorten  the learning curve for robotic suturing .
  this study was approved by the institutional review board at the university of texas medical branch , galveston tx , usa . a total of 13 residents were recruited for participation in this study : 4 third - year residents ( pgy3 ) and 9 fourth - year residents ( pgy4 ) .
none of the residents who participated in this study had any previous robotic surgery experience .
third - year residents had an additional dry laboratory with hands - on training in suturing prior to their initial experience in the operating room .
all but 2 of the pgy4s already had exposure to mis suturing during their previous experience in the operating room , so they received no additional dry - lab teaching . the 2 pgy4s with
group 1 consisted of all pgy3s and the 2 pgy4s considered to be mis - naive residents .
the more mis - experienced pgy4s , all of whom had at least 3 previous mis experiences , made up group 2 .  
both groups of residents were evaluated using 2 different techniques : robotic suturing with intracorporeal knot tying and laparoscopic suturing using extracorporeal knot tying . in both the laparoscopic and robotic approaches ,
the vaginal cuff was closed using a 0 polyglactin ( vicryl , ethicon ) on a ct-1 needle in an interrupted suture closure .
the suture time was defined as the elapsed time for loading the needle , placing 4 square knots , and cutting the suture .   a t - test compared mean suturing times by surgery modality and stratified by groups of clinicians .
the satterthwaite correction was applied when the test for heterogeneity of variances between groups was significant .
  the mean suturing times of the pgy3 and pgy4 residents are shown in table 1 .
table 1 demonstrates that pgy3s had a shorter suturing time than their pgy4 counterparts in both robotic and laparoscopic suturing . for the pgy3 group , no statistically significant difference ( p = 0.5 ) was found between the mean suturing time in robotic suturing ( 235  337 seconds ) versus laparoscopic suturing ( 158  457 ) ( table 1 , figure 1 ) .
the pgy4 group 's mean suture time was 337  235 seconds for robotic suturing and 457  158 seconds for laparoscopic suturing , a statistically significant difference  ( p = 0.02 ) ( table 1 , figure 1 ) .
for all residents , it took on average 382  159 seconds for laparoscopic suturing and 326  196 seconds for robotic suturing , which was not found to be statistically significant ( p = 0.12 ) ( figure 2 ) .  
the mean suturing times between pgy3 and pgy4 for combined robotic and laparoscopic suturing , was also compared ( table 2 ) . the difference between the mean suture times in the pgy3 ( 310  95.8 seconds ) versus pgy4 ( 393  210.6 seconds ) groups
was found to be statistically significant ( p = 0.01 ) ( table 2 ) .  
the surgical experience of the residents was also taken into account ( table 3 ) .
residents in group 1 ( n = 6 ) had 2 or fewer previous laparoscopic surgery experiences , and those in group 2 ( n = 7 ) had 3 or more cases ( average = 4.4 ) prior to enrollment in the study .
the residents in group 1 had a significantly lower mean suture time than those residents in group 2 for laparoscopic suturing ( p = 0.009 ) .
the residents in group 2 had a lower mean suture time on the robot compared to group 1 ; however , this difference did not achieve significance ( p = 0.5 ) .
  in the literature , a variety of publications report about surgical education using robotic systems [ 911 ] and the learning curve for robotic - assisted surgery [ 1214 ] .
however , our study is the first to examine the effect that gynecology residents ' previous laparoscopic experiences have on their initial experiences with robotically assisted suturing in the operating room .
the results from our study demonstrate that previous laparoscopy experience improves the learning curve for robotic surgery . as shown in table 1 , a statistically significant difference between the means of the laparoscopic suturing time and the robotic suturing time occurred in the pgy4 group , which had more overall laparoscopic experience .
the less - experienced pgy3s did well laparoscopically but did not show the same type of time reduction for robotic suturing .
however , our findings also indicated the importance of structured teaching in dry labs prior to beginning in the operating room .
described the robot as an  enabling technology  because it may allow those with less - advanced laparoscopic skills to perform minimal access procedures they would otherwise do via an open approach .
our results support the idea that physicians in training must first learn the basics in a well - established dry - lab environment prior to relying on robot technology .  
the primary limitation of our study is that of sample size , as both study groups were composed of a small number of residents , likely affecting the power of the statistical analysis .
we stopped enrolling participants in the study when the gynecology mis department implemented the use of a braided suture for vaginal cuff closure .
a second limitation of our study involves selection bias with regard to surgical case difficulty assigned to the different resident groups .
trials with larger number of trainees and using braided sutures to reflect the trend in closure are needed before coming to a definitive conclusion .  
in conclusion , introducing the robotically assisted suturing technique to our residents resulted in a steep learning curve regardless of their previous experience in laparoscopy .
however , our data suggest that residents with previous laparoscopic - suturing experience will gain more from a robotic - surgery experience than those residents with minimal or no previous laparoscopic - surgery experience .
furthermore , initial introduction in a dry - lab setting decreases the learning curve for residency training . as suturing and knot tying are
the bases of minimal access surgery , the need for specific training for all surgeons who aim to become competent with the techniques is paramount . in an era of increasing financial concerns and decreasing resident work hours ,
the need to effectively train residents in a time efficient manner , while keeping patients safe , is also a priority .
 
 objective . 
 to assess the impact of gynecology residents ' previous laparoscopic experience on the learning curve of robotic suturing techniques and the value of initial structured teaching in dry lab prior to surgery . 
 
 methods . 
 thirteen gynecology residents with no previous robotic surgery experience were divided into group 1 , consisting of residents with 2 or fewer laparoscopic experiences , and group 2 , consisting of residents with 3 or more laparoscopic experiences . 
 group 1 had a dry - laboratory training in suturing prior to their initial experience in the operating room . 
 
 results . for all residents , 
 it took on average 382  159 seconds for laparoscopic suturing and 326  196 seconds for robotic suturing ( p = 0.12 ) . 
 residents in group 1 had a lower mean suture time than residents in group 2 for laparoscopic suturing ( p = 0.009 ) . 
 the residents in group 2 , however , had a lower mean suture time on the robot compared to group 1 ( p = 0.5 ) . conclusion . residents with previous laparoscopic suturing experience may gain more from a robotic surgery experience than those with limited laparoscopic surgery experience . 
 in addition , dry lab training is more efficient than hands - on training in the initial phase of teaching for both laparoscopic and robotic suturing skills . 
 
1. Introduction
2. Methods
3. Results
4. Discussion