To what extent does monitor position influence performance during minimally invasive surgery

Background: In Minimally Invasive Surgery (MIS), the natural relationship between hand and eye is disrupted i.e. surgeons typically control tools inserted through the patient’s abdomen while viewing the workspace on a remote monitor, which can be located in a variety of positions. This separates the location of visual feedback from the area in which a motor action is executed. Previous studies suggest that the visual display should be placed directly ahead of the surgeon (i.e. to preserve visuomotor mapping). However, the extent of the impact of this rotation on surgical performance is unknown. Methods: Eighteen participants completed an aiming task on a tablet PC within a surgical box trainer using a laparoscopic tool in a controlled simulated environment. Visual feedback was presented on a remote monitor located at 0, +/-45 and +/-90, with order randomised using the ‘Latin Square’ method. Results: Movements were significantly slower when the monitor was 90 relative to midline, but spatial accuracy was unaffected by monitor position. Interestingly, the effect of reduced speed in the 90 was transient- decreasing over time, suggesting rapid adaptation to the rotation. Conclusions: We conclude that the angle of the visual display in the context of MIS may require a surgeon to adapt to a changed mapping between visual inputs and motor outputs. While this adaptation occurs relatively quickly, it may interfere with skilled actions (e.g. intracorporeal suturing) in complex surgical procedures.