Surg Endosc (2017) 31:1999–2005
DOI 10.1007/s00464-016-5153-x
NEW TECHNOLOGY
Comparison of the performance of experienced and novice
surgeons: measurement of gripping force during laparoscopic
surgery performed on pigs using forceps with pressure sensors
Azumi Araki1 • Kazuhide Makiyama1 • Hiroyuki Yamanaka1 • Daiki Ueno1
Kimito Osaka1 • Manabu Nagasaka2 • Takahiro Yamada3 • Masahiro Yao1
Received: 22 March 2016 / Accepted: 25 July 2016 / Published online: 29 August 2016
Ó Springer Science+Business Media New York 2016
Abstract
Background Laparoscopic surgical techniques are difficult
to learn, and developing such skills involves a steep
learning curve. To ensure surgeons achieve a high skill
level, it is important to be able to measure and assess their
skills. Therefore, it is necessary to understand the perfor-
mance differences between experienced and novice sur-
geons, as such information could be used to help surgeons
learn laparoscopic skills. We examined the differences in
gripping and reaction force between experienced and
novice surgeons during laparoscopic surgery.
Methods We measured the gripping force generated during
laparoscopic surgery performed on pigs using forceps with
pressure sensors. Several sensors, including strain gauges,
accelerometers, and a potentiometer, were attached to the
forceps. This study included 4 experienced and 4 novice
surgeons. Each subject was asked to elevate the kidney in
order to approach the renal hilus using the forceps.
Throughout the experiment, we measured the gripping
force and reaction force generated during the movement of
the forceps in real time.
Results The experienced and novice surgeons exhibited
similar reaction force levels. Conversely, gripping force
differed significantly between the groups. The experienced
and novice surgeons exhibited mean gripping force levels
of 3.06 and 7.15 N, respectively. The gripping force
& Azumi Araki
koku15you@yahoo.co.jp
1
Department of Urology, Yokohama City University,
Yokohama 236-0004, Japan
2
Mitsubishi Precision Co., Ltd., Kamakura 247-8505, Japan
3
Graduate School of Environment and Information Sciences,
Yokohama National University, Yokohama 240-8501, Japan
and Other Interventional Techniques
•
standard deviation values for the experienced and novice
surgeons were 1.43 and 3.54 N, respectively. The mean
and standard deviation gripping force values of the expe-
rienced surgeons were significantly lower than those of the
novice surgeons (P = 0.015 and P = 0.011, respectively).
Conclusions This study indicated that experienced sur-
geons generate weaker but more stable gripping force than
novice surgeons during laparoscopic procedures.
Keywords Laparoscopy
Gripping force
Force
measurement system
Laparoscopic surgical techniques are difficult to learn, and
developing such skills involves a steep learning curve.
Surgeons must acquire laparoscopic skills before per-
forming laparoscopy in the operating room. Therefore, it is
essential that they are trained using practical methods and
equipment. Surgical simulators, including both virtual
reality-based and analog box-based trainers, play an
important role in surgical training. To ensure that such
training results in a high level of skill, it is necessary to be
able to measure and assess surgeons’ skills. Therefore, it is
important to understand the performance differences
between experienced and novice surgeons.
Ordinarily, experienced surgeons are distinguished from
novice surgeons using performance scores based on per-
formance time, the speed at which the instruments are
manipulated, and the number of errors made during an
operation. Some studies of surgical skill have examined
psychomotor skills and hand–eye coordination during
laparoscopic surgery, whereas in other studies kinematic
analyses of motion, involving parameters such as time,
path length, and speed, have been performed using elec-
tromagnetic position-tracking sensors [1, 2]. However,
123
2000
quantitative parameters such as the forceps reaction force,
gripping force, and the grabbing angle have rarely been
investigated.
Therefore, as a first step, we recorded the forces pro-
duced during laparoscopic surgery performed on pigs using
forceps with pressure sensors [3]. The forceps were
developed through collaboration among Yokohama City
University, Mitsubishi Precision, and Yokohama National
University. The forceps can be used to measure reaction
force, gripping force, the grabbing angle, and acceleration.
In this study, we examined the differences in gripping
and reaction force between experienced and novice sur-
geons during laparoscopic surgery using the above-men-
tioned forceps with pressure sensors.
Information about the differences in these forces between
experienced and novice surgeons could be used to give novice
surgeons feedback regarding their laparoscopic skills, thereby
increasing the effectiveness of their practice and shortening
the training period required to obtain proficiency.
Methods
Subjects
The study subjects were 8 surgeons. The subjects were
divided into two groups, i.e., 4 experienced and 4 novice
surgeons.
The experienced surgeons had performed 6, 20, [100,
and [1000 laparoscopic surgical procedures, respectively,
Fig. 1 External appearance of
the forceps with pressure
sensors. Force and acceleration
sensors (strain gauges,
accelerometers, and a
potentiometer) were attached to
the tips and handle of the
forceps. This made it possible to
measure X/Y/Z directional
forces as reaction forces
123
Surg Endosc (2017) 31:1999–2005
and had 5–20 years of experience as urologists. On the
other hand, the novice surgeons were urology residents
who had never performed laparoscopic surgery.
Measurement system
We developed a multimodal measurement device that has
minimal impact on surgeons’ movements. The system was
developed through collaboration among Yokohama City
University, Mitsubishi Precision, and Yokohama National
University (homepage: http://www-user.yokohama-cu.ac.
jp/*urology/kenkyu/surgicalsimulatorindex.html) [3].
The device is illustrated in Fig. 1. The sensor wires were
packed inside the device, and we used a special guide
when we inserted the forceps into the trocar. So, the
forceps were free from contact or damage, and we were
able to obtain accurate measurements. A block diagram is
presented in Fig. 2. Several sensors (strain gauges,
accelerometers, and a potentiometer) are attached to the
forceps and used to measure X/Y/Z directional forces,
blade force, gripping force, the grabbing angle, and
acceleration. All of these parameters were measured over
0.1 ms, and the data were stored on a hard disk drive for
later analysis. To synchronize the acquired physical
parameters, such as the reaction force, with the corre-
sponding surgical operations, we adopted a method in
which we overlaid a graph of the quantitative data on the
operation’s graphical representation (Fig. 3). The system
was calibrated, and then the controls of each sensor were
checked.
Surg Endosc (2017) 31:1999–2005
Fig. 2 A block diagram of the system
Fig. 3 A graphical representation of the experiment: elevating the
kidney to approach the renal hilus using the forceps with pressure
sensors. A line chart of each force applied to the forceps was
displayed on the computer screen in real time
Task
The measurements were obtained while the subjects per-
formed laparoscopic nephrectomy on a pig.
First, an incision was made in the peritoneum, and the
colon was displaced. Next, the ureter and the renal artery
and vein were exposed. Then, each subject was asked to
elevate the kidney using the forceps in order to approach
the renal hilus (Fig. 3).
The subjects elevated the kidney using two sets of for-
ceps alternately. They used the forceps with pressure sen-
sors in one hand and forceps without sensors in the other
2001
hand. Each subject performed the task twice and swapped
the forceps over between each task (i.e., from the right to
left hand and vice versa).
Throughout the experiment, the gripping and reaction
forces generated during the movement of the forceps were
measured in real time. The forceps used for the measure-
ments were fragile, so we used normal forceps or energy
devices when not taking measurements.
Statistical analysis
The statistical analyses were performed using the software
Statcel3. The Student’s t test was used to determine the
significance of inter-group differences, and a probability of
P \ 0.05 was considered statistically significant.
Results
The results regarding gripping and reaction force are
shown in Fig. 4. Both groups exhibited similar reaction
force values. The experienced and novice surgeons gen-
erated mean reaction forces of 1.15 and 1.51 N, respec-
tively, during the procedures. The difference between the
groups was not statistically significant (P = 0.34).
Conversely, gripping force differed between the expe-
rienced and novice surgeons. Specifically, the experienced
and novice surgeons produced mean gripping forces of
3.06 and 7.15 N, respectively, during the procedures. In
addition, gripping force standard deviation values of 1.43
123
2002 Surg Endosc (2017) 31:1999–2005

Fig. 4 Box plots of mean

gripping force. The experienced
surgeons exhibited a
significantly lower mean
gripping force than the novice
surgeons (P = 0.015). The
mean gripping force levels of
the right and left hands differed
significantly among the
experienced surgeons, but no
such differences were observed
among the novice surgeons
(P = 0.003 and P = 0.273,
respectively)

and 3.54 N were recorded in the experienced and novice
surgeons, respectively. The experienced surgeons exhibited
significantly lower mean and standard deviation gripping
force values than the novice surgeons (P = 0.015 and
P = 0.011, respectively). Figures 4 and 5 show box plots
of the mean and standard deviation gripping force values of
the two groups.
Furthermore, the gripping force generated by the right
hand (dominant hand) tended to be weaker and more
stable than the gripping force produced by the left hand.
The experienced surgeons’ right and left hands generated
mean gripping forces of 1.44 and 4.67 N, respectively,
whereas the novice surgeons’ right and left hands produced
mean gripping forces of 5.62 and 8.67 N, respectively.
Among the experienced surgeons, the mean gripping force
generated by the right hand was significantly lower than
that produced by the left hand, but no such differences
were observed among the novice surgeons (P = 0.003 and
P = 0.273, respectively).
The gripping force standard deviation values for the
experienced surgeons’ right and left hands were 0.52 and
2.56 N, respectively, and those for the novice surgeons’
right and left hands were 2.49 and 4.89 N, respectively.
Among the experienced surgeons, the gripping force stan-
dard deviation value for the right hand was significantly
lower than that for the left hand, but no such differences
were seen among the novice surgeons (P = 0.033 and
P = 0.089, respectively).

Fig. 5 Box plots of gripping

force standard deviation values.
The experienced surgeons
exhibited significantly lower
gripping force standard
deviation values than the novice
surgeons (P = 0.011). The
gripping force standard
deviation values for the right
and left hands differed
significantly among the
experienced surgeons, but no
such differences were observed
among the novice surgeons
(P = 0.033 and P = 0.089,
respectively)

123
Surg Endosc (2017) 31:1999–2005
Discussion
Our goal was to determine the performance differences
between experienced and novice surgeons using quantita-
tive parameters, such as the forceps reaction force. Some
previous studies have analyzed the motion of laparoscopic
instruments. Various technologies have been used to track
the movements of laparoscopic instruments, including
electromagnetic, mechanical, sensor-based, and video-
based tools [4]. In terms of the type of analysis performed,
kinematic analyses have been carried out using electro-
magnetic positional tracking sensors in several studies.
[1, 5–7].
Uemura et al. [1] monitored instrument motion using a
magnetic tracking system and analyzed the paths of the
centers of gravity of the tips of needle holders as well as
the relative paths of the tips using mathematical methods.
Hofstad et al. [5] assessed psychomotor skills during the
performance of a labyrinth task in a dry box using the
Aurora electromagnetic measurement system. In the latter
study, kinematic data such as the position and axis of
each instrument were assessed. The time, path length,
Fig. 6 Representative reaction force and gripping force results.
Representative reaction force and gripping force results for the novice
and experienced surgeons. A a right-handed novice surgeon, B a left-
2003
mean velocity, and bimanual dexterity were also evalu-
ated. In other studies, video-based tracking systems were
used [2, 8–13]. Some of these systems were based on
artificial markers that had been placed on the instru-
ments, such as colored markers placed on the distal ends
of the instruments [9–11]. Other researchers have ana-
lyzed the 3D position of an instrument’s tip based on its
projection in the image plane [2]. In these studies, the
positions and orientation of laparoscopic instruments
were investigated.
Mechanical tracking systems can also be employed in
such studies. Nasr et al. [14] used a mouse sensor and an
accelerometer in their study. They assessed motion in the
four degrees of freedom that are available during surgery
(pitch, yaw, roll, and surge) based on range, velocity, and
acceleration data.
On the other hand, few studies have measured the force
levels of laparoscopic instruments [15–17]. Hwang et al.
[15] assessed force/torque and derivatives of the position of
the tool tip (velocity, acceleration, and jerk) during
laparoscopic cholecystectomy. Yoshida et al. [16] quanti-
fied the force patterns generated during single-stroke
handed novice surgeon, C a right-handed experienced surgeon, D a
left-handed experienced surgeon
123
2004
laparoscopic dissection maneuvers by measuring the
magnitudes of the vertical and horizontal forces generated
at the instrument tip using a box trainer (ex vivo). Hanna
et al. [17] developed a force measurement system for use
with different instruments in clinical practice. The latter
system measured the gripping, dissecting, pulling, and
pushing forces using force and displacement sensors
mounted on the instrument’s handle and the access port.
Unfortunately, these studies did not obtain detailed
quantitative data about instrument force levels, such as the
forceps reaction force, gripping force, and the grabbing
angle, in a real surgical environment. We developed for-
ceps equipped with pressure sensors and used them to
obtain forceps force measurements. Furthermore, while
many of the tasks in previous studies were performed in a
dry box with a metal cylinder, our experiment was per-
formed in a real operative environment with real forceps
that were capable of measuring gripping force and reaction
force.
Prior to the study, we predicted that the novice surgeons
would move the forceps with greater force than the expe-
rienced surgeons. Contrary to our expectations, the expe-
rienced and novice surgeons exhibited similar mean
reaction force levels. However, the experienced surgeons
displayed significantly lower mean and standard deviation
gripping force values than the novice surgeons. Moreover,
the novices tended to display rapid changes in gripping
force and reaction force, whereas these parameters changed
more slowly in the experienced surgeons (the difference
was not statistically significant; see Fig. 6 for representa-
tive force values). These findings seem to indicate that the
gripping force of experienced surgeons is lower and more
stable than that of novice surgeons during laparoscopic
procedures. Furthermore, the gripping force generated by
the right hand (the dominant hand) tended to be lower and
more stable than that produced by the left hand. We sup-
pose that when surgeons are novices or using forceps with
their non-dominant hands, they are tense and put unnec-
essary strain on themselves. This tension might result in an
increase in gripping force and more rapid changes in
gripping and reaction force. Conversely, experienced sur-
geons and/or surgeons using their dominant hands might be
able to move forceps delicately and smoothly while grip-
ping them softly.
This study had some limitations. First, the number of
subjects was very small. Second, the task performed by the
subjects involved a very simple motion (elevating the
kidney), and we did not investigate complicated motions,
such as stitching and cutting, during a real operation. In our
next study, we will try to examine other motions using a
greater number of subjects.
By analyzing various forceps motions and quantifying
the force levels generated during each motion, we will be
123
Surg Endosc (2017) 31:1999–2005
able to estimate surgical skill objectively. In general,
experienced surgeons educate novice surgeons based on
their subjective knowledge. However, if we were able to
obtain quantitative data about ideal surgical techniques,
then it would be possible to educate surgeons based on
empirical evidence.
In a previous study, we developed a patient-specific
virtual reality-based simulator for laparoscopic surgery.
The haptic feedback force generated by this system is
based on surgeons’ subjective sensations. In future, we
want to apply the objective force data acquired from this
study to our simulator.
Compliance with ethical standards
Disclosures Azumi Araki, Kazuhide Makiyama, Hiroyuki Yama-
naka, Daiki Ueno, Kimito Osaka, Manabu Nagasaka, Takahiro
Yamada, Masahiro Yao have no conflicts of interest or financial ties
to disclose.
References
1. Uemura M, Tomikawa M, Kumashiro R, Miao T, Souzaki R, Ieiri
S, Ohuchida K, Lefor AT, Hashizume M (2014) Analysis of hand
motion differentiates expert and novice surgeons. J Surg Res
188:8–13. doi:10.1016/j.jss.2013.12.009
2. Oropesa I, Sánchez-González P, Chmarra MK, Lamata P, Fer-
nández Á, Sánchez-Margallo JA, Jansen FW, Dankelman J,
Sánchez-Margallo FM, Gómez EJ (2013) EVA: laparoscopic
instrument tracking based on endoscopic video analysis for psy-
chomotor skills assessment. Surg Endosc Other Interv Tech
27:1029–1039. doi:10.1007/s00464-012-2513-z
3. Yamanaka H, Makiyama K, Osaka K, Nagasaka M, Ogata M,
Yamada T, Kubota Y (2015) Measurement of the physical
properties during laparoscopic surgery performed on pigs by
using forceps with pressure sensors. Advances in Urology.
doi:10.1155/2015/495308
4. Sánchez-Margallo JA, Sánchez-Margallo FM, Oropesa I, Gómez
EJ (2014) Systems and technologies for objective evaluation of
technical skills in laparoscopic surgery. Minim Invasive Ther
Allied Technol 23:40–51. doi:10.3109/13645706.2013.827122
5. Hofstad EF, Våpenstad C, Chmarra MK, Langø T, Kuhry E,
Mårvik R (2013) A study of psychomotor skills in minimally
invasive surgery: what differentiates expert and nonexpert per-
formance. Surg Endosc Other Interv Tech 27:854–863. doi:10.
1007/s00464-012-2524-9
6. Pagador JB, Sánchez-Margallo FM, Sánchez-Peralta LF, Sán-
chez-Margallo JA, Moyano-Cuevas JL, Enciso-Sanz S, Usón-
Gargallo J, Moreno J (2012) Decomposition and analysis of
laparoscopic suturing task using tool-motion analysis (TMA):
improving the objective assessment. Int J Comput Assist Radiol
Surg 7:305–313. doi:10.1007/s11548-011-0650-9
7. Trudeau MO, Nasr A, Carrillo B, Gerstle JT, Azzie G (2014)
Construct validity and possible educational role for motion
analysis in a laparoscopic trainer. Surg Endosc Other Interv Tech
28:252. doi:10.1007/s00464-014-3474-1
8. Sánchez-Margallo JA, Sánchez-Margallo FM, Pagador JB,
Gómez EJ, Sánchez-González P, Usón J, Moreno J (2011) Video-
based assistance system for training in minimally invasive sur-
gery. Minim Invasive Ther Allied Technol 20:197–205. doi:10.
3109/13645706.2010.534243
Surg Endosc (2017) 31:1999–2005
9. Bouarfa L, Akman O, Schneider A, Jonker PP, Dankelman J
(2012) In-vivo real-time tracking of surgical instruments in
endoscopic video. Minim Invasive Ther Allied Technol
21:129–134. doi:10.3109/13645706.2011.580764
10. Tonet O, Thoranaghatte RU, Megali G, Dario P (2007) Tracking
endoscopic instruments without a localizer: a shape-analysis-
based approach. Comput Aided Surg 12:35–42. doi:10.3109/
10929080701210782
11. Escamirosa FP, Flores RMO, Garcı́a IO, Vidal CRZ, Martı́nez
AM (2014) Face, content, and construct validity of the EndoViS
training system for objective assessment of psychomotor skills of
laparoscopic surgeons. Surg Endosc 29(11):3392–3403. doi:10.
1007/s00464-014-4032-6
12. Uemura M, Jannin P, Yamashita M, Tomikawa M, Akahoshi T,
Obata S, Souzaki R, Ieiri S, Hashizume M (2015) Procedural
surgical skill assessment in laparoscopic training environments.
Int J Comput Assist Radiol Surg. doi:10.1007/s11548-015-1274-2
13. Smith MH, Flanagan CL, Kemppainen JM, Sack JA, Chung H,
Das S, Hollister SJ, Feinberg SE (2006) Computed tomography-
2005
based tissue-engineered scaffolds in craniomaxillofacial surgery.
Int J Med Robot 2:207–216. doi:10.1002/rcs
14. Nasr A, Carrillo B, Gerstle JT, Azzie G (2014) Motion analysis in
the pediatric laparoscopic surgery (PLS) simulator: validation and
potential use in teaching and assessing surgical skills. J Pediatr
Surg 49:791–794. doi:10.1016/j.jpedsurg.2014.02.063
15. Hwang H, Lim J, Kinnaird C, Nagy AG, Panton ONM, Hodgson
AJ, Qayumi KA (2006) Correlating motor performance with
surgical error in laparoscopic cholecystectomy. Surg Endosc
Other Interv Tech 20:651–655. doi:10.1007/s00464-005-0370-8
16. Yoshida K, Kinoshita H, Kuroda Y, Oshiro O, Matsuda T (2013)
Analysis of laparoscopic dissection skill by instrument tip force
measurement. Surg Endosc 27:2193–2200. doi:10.1007/s00464-
012-2739-9
17. Hanna GB, Drew T, Arnold G, Fakhry M, Cuschieri A (2008)
Development of force measurement system for clinical use in
minimal access surgery. Surg Endosc 22:467–471. doi:10.1007/
s00464-007-9489-0
123