Page 26 - World Journal of Laparoscopic Surgery

Nava Navaneethan, Peter Hewett
and meta-analysis of 32 studies that investigated per-
formance after warm-up in various sports concluded
that performance was improved after a warm-up 79%
of the time. 4
Apart from the main limitation of the study of small
numbers, a logical question arises about the interpreta-
tion of the results to a clinical context. As the study is
entirely performed in a nonclinical set up performance
of the operator may be different to a situation, when
performed in a clinical scenario. nevertheless many
5,9
studies have shown the effectiveness of simulation
training in improving surgeon’s skill in operating room,
thereby it could be logically argued that results could be
generalized to a clinical context.
Graph 4: Interaction plot for working areas Van Heerzele et al (2008) observed that experienced
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compared with a group who had warm-up prior to the surgeons also benefit from simulator training. In their
designated task. As expected surgeons performed better study, expert endovascular surgeons received a simu-
in all aspects. lator training course, after which they showed shorter
The post warm-up did show some improvement in real surgery time and fewer errors, and also felt more
time effect (speed), acceleration, and working areas but competent to conduct the procedure. Also, group consis-
was not clinically significant. These results contrasts the tency was higher after the course; they all performed the
2
outcome of a previous large randomized control study task about as fast and as safe. Thus, there is evidence that
which found no significant effect on warming up. Com- skills acquired in a simulator are indeed transferable to
pared to the above study, in this study, the metrics are reality and lead to reduction of errors in the operation
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measured with a computer software, thereby observer theater and an improvement in overall performance. 6
error is avoided. nevertheless there are some studies The major difference of this study from the previous
1,3
which show positive effect of warming up. Due to studies of similar nature is analyzing the movement
the limited number in this study, power of the study is and speed using computerized metric assessment tools,
inadequate to prove the significance. The smaller number thereby not only avoiding the observer error but also
of surgeons participated would have widely varying analyzing other metrics such as acceleration, areas of
laparoscopic skills and it is possible that due to sampling tool employment. Handedness of the operator could
error, one arm could have had either very experienced or have been analyzed using the same software but was not
poor experienced, affecting the results. performed considering the small number of participants,
Warming-up is routine for athletes and stage per- which may not reflect accurate results.
formers and there are studies in favor of warming up In conclusion, this study did find a significant
to improve athletic performance. A systematic review effect of warm-up on laparoscopic tasks in most of the

Table 4: Analysis variable: working areas
Operator Warm-up Participants Mean Std dev Minimum Maximum
Medical student Control 9 1.70 1.26 0.07 3.85
Post warm-up 8 0.90 0.88 0.07 2.40
Surgeon Control 6 0.87 0.74 0.01 2.10
Post warm-up 6 0.71 0.37 0.29 1.29
Surgical trainee Control 8 2.56 1.51 1.50 6.10
Post warm-up 7 1.65 1.36 0.01 3.79

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Table 5: Formulas used to calculate metrics (Reproduced with permission from Rowland et al )
Metric Unit Formula/description
Time (t) Seconds
Average speed (as) mm/second average speed/time
2
6
5
Motion smoothness mm/second 3 √(( t /2) × td × as )
td = total distance
Working area mm Average distance between instrument tips
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