Tag Archive for: surgical anastomosis


Editorial: Mental imagery: ‘you can observe a lot by watching!’

Urethrovesical anastomosis (UVA), like any other surgical anastomosis, is a key example of motor muscle memory, where aligning two hollow structures should result in a watertight anastomosis defining its success and help avoid complications. The authors [1] investigated the importance of cognitive training during UVA, which has been shown to be a promising supplement to skill‐based training. The authors utilised the Global Evaluative Assessment of Robotic Skills (GEARS), which has been validated for assessment of general robotic rather than procedure‐specific skills. As the authors chose UVA to evaluate training, they could have used the Robotic Anastomosis Competency Evaluation (RACE), which has been developed and validated for specific evaluation of UVA [2]. However, the study eloquently revealed higher scores, using the validated movement imagery questionnaire modified for robot‐assisted surgery whilst evaluating mental imagery.

Motor imagery utilises imagining action without its physical execution and this leads to eliciting activity in regions of brain normally activated during performance. Motor imagery has shown significant neural activity in important brain area involved in somatosensory perception, especially kinesthetic information from motor perception and muscle spindles. Such areas become active when a motor illusion is induced that ultimately share the same basis with areas active during executing movement. Mental imagery also yields more benefits if its sessions are interposed between periods of training [3]. Unfortunately, the ability to imagine more complex tasks is less accurate when utilising mental imagery [4]. In future, studies using procedure‐specific evaluation, such as RACE, may help us understand in depth the role of mental imagery during various steps of complex task, such as UVA. The hypothesis of improvement of skills whilst utilising supplemental cognitive training is reasonable; future studies will benefit from utilising an elaborate cognitive assessment. Metrics such as electroencephalograms (EEGs) and eye tracking, or even less sophisticated tools like the National Aeronautics and Space Administration Task Load Index (NASA‐TLX) self‐assessment questionnaires, have previously been used for assessment of cognitive load [5]. Objective feedback provided by a brain–computer interface (BCI) can increase the brain activation levels produced during motor imagery and thereby help in improving performance [6].

Motor imagery has been used as a popular input for BCI and in future could be used as a link to establishing instruction to semi‐autonomous robotic systems [6]. Meanwhile, a motor imagery BCI using EEG is utilising intention recognition through decoding brain activity, which ultimately could allow for intuitive control of devices like robotic systems.


  1. Raison N, Ahmed K, Abe T et al. Cognitive training for technical and non‐technical skills in robotic surgery: a randomised controlled trial. BJU Int 2018; 122: 1075–81
  2. Raza SJ, Field E, Jay C et al. Surgical competency for urethrovesical anastomosis during robot‐assisted radical prostatectomy: development and validation of the robotic anastomosis competency evaluation. Urology 2015; 85: 27–32
  3. Nicholson VP, Keogh JW, Low Choy NL. Can a single session of motor imagery promote motor learning of locomotion in older adults? A randomized controlled trial. Clin Interv Aging 2018; 13: 713–22
  4. Kalicinski M, Kempe M, Bock O. Motor imagery: effects of age, task complexity, and task setting. Exp Aging Res 2015; 41: 25–3
  5. Besharat Shafiei S, Hussein AA, Ahmed Y, Guru K. Can eye tracking help explain an expert surgeon’s brain performance during robot‐assisted surgery? J Urol 2018; 199 (Suppl.): e1–2
  6. Batula AM, Kim YE, Ayaz H. Virtual and actual humanoid robot control with four‐class motor‐imagery‐based optical brain‐computer interface. Biomed Res Int 2017; 2017: 1463512.


Article of the Week: An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison between robot-assisted, laparoscopic and open approaches

Oussama Elhage*, Ben Challacombe*, Adam Shortland‡ and Prokar Dasgupta*
§*The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, Medical Research Council (MRC) Centre for Transplantation, King’s College London, One Small Step Laboratory, and §MRC Centre for Transplantation & National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre, King’s College London, King’s Health Partners, Guy’s Hospital, London, UK


Read the full article

To evaluate, in a simulated suturing task, individual surgeons’ performance using three surgical approaches: open, laparoscopic and robot-assisted.


Six urological surgeons made an in vitro simulated vesico-urethral anastomosis. All surgeons performed the simulated suturing task using all three surgical approaches (open, laparoscopic and robot-assisted). The time taken to perform each task was recorded. Participants were evaluated for perceived discomfort using the self-reporting Borg scale. Errors made by surgeons were quantified by studying the video recording of the tasks. Anastomosis quality was quantified using scores for knot security, symmetry of suture, position of suture and apposition of anastomosis.


The time taken to complete the task by the laparoscopic approach was on average 221 s, compared with 55 s for the open approach and 116 s for the robot-assisted approach (anova, P < 0.005). The number of errors and the level of self-reported discomfort were highest for the laparoscopic approach (anova, P < 0.005). Limitations of the present study include the small sample size and variation in prior surgical experience of the participants.


In an in vitro model of anastomosis surgery, robot-assisted surgery combines the accuracy of open surgery while causing lesser surgeon discomfort than laparoscopy and maintaining minimal access.

Read more articles of the week

Editorial: Conventional laparoscopic surgery – more pain, no gain!

Advances in surgical technology have revolutionized the way surgery is performed today. Conventional laparoscopic surgery dominated the surgical paradigm for several decades, until robot-assisted surgery created the next giant leap. In the pressent article, Elhage et al. [1] compare and correlate physical stress and surgical performances among three modes of a standardized surgical step. Their study shows the obvious physical strain and technical limitations faced while performing conventional laparoscopic surgery, subsequently leading to compromised surgical outcomes. The physical impact of conventional laparoscopic surgery has been well documented through surgeon feedback as well as ergonomic assessment [2, 3]. Various studies have reported that higher physical stress, associated with ergonomic limitations, is experienced when performing conventional laparoscopy compared to the comfort and ease of robot-assisted surgery, as highlighted in the present study. Increased workload has also been associated with performance errors, with a steep learning curve needed to achieve surgical excellence during conventional laparoscopy [4].

Currently, the use of robot-assisted surgery is on the rise, as an alternative to both open and conventional laparoscopic surgery across the developed world, despite its obvious economic limitations. Better ergonomics during robot-assisted surgery will increase the comfort of the surgeon, but the future of surgery may easily be linked to the improvements experienced by all of us in the automobile industry. Developments, from manual gear-clutch control to automatic speed control and the luxury of adaptive cruise control today, make us safe drivers with minimal physical stress. The concept of adaptive cruise control, which adjusts the speed of a vehicle in relation to its surroundings, sounds similar to the leap from manual camera control during conventional laparoscopy to console-based control during camera navigation in robot-assisted surgery. With advances in the speed and size of computers, pneumatic-based joint mechanics and mindfulness meditation on the horizon, it will not be long before surgeons will sit back and watch the marvel of the machine. Surgeons just need to learn to hold on to their seats!

Read the full article
Syed J. Raza*, Khurshid A. Guru† anRobert P. Huben†
*Fellow, †Endowed Professor of Urologic Oncology, Department of Urology and A.T.L.A.S (Applied Technology Laboratory for Advanced Surgery) Program, Roswell Park Cancer Institute, Buffalo, NY, USA




2 Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic and robotic surgery.

J Robotic Surg 2012; 6: 65–723 Hubert N, Gilles M, Desbrosses K, Meyer JP, Felblinger J, Hubert J. Ergonomic assessment of the surgeon’s physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot 2013; 9:142–147

4 Yurko YY, Scerbo MW, Prabhu AS, Acker CE, Stefanidis D. Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool. Simul Healthc 2010; 5: 267–271


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