# Integrating subjective perceptions and objective video analysis to identify challenges in laparoscopic suturing: a cross-sectional study to enhance surgical training

## TL;DR

This study combines surgeon self-reports and video analysis to identify laparoscopic suturing challenges and improve training methods.

## Contribution

The novel integration of subjective and objective assessments reveals consistent technical challenges in laparoscopic suturing across experience levels.

## Key findings

- Knot tying was perceived as the most challenging task by 42.4% of participants.
- Expert surgeons outperformed novices significantly in all GOALS metrics.
- Subjective and objective assessments together provide a comprehensive view of performance differences.

## Abstract

Laparoscopic suturing remains one of the most technically demanding skills in minimally invasive surgery. This study aimed to identify the key technical and cognitive challenges encountered during laparoscopic suturing through both subjective perceptions and objective performance analysis. It was also sought to inform the development of more effective, targeted training strategies to enhance laparoscopic suturing training proficiency. A cross-sectional study was conducted with 33 laparoscopic surgeons, 22 novices and 11 experts. A Delphi consensus among six expert surgeons identified four core subtasks which formed the basis of a structured survey. Participants performed standardized laparoscopic suturing on animal tissue using a box trainer before completing the questionnaire. Objective assessments using the Global Operative Assessment of Laparoscopic Skills (GOALS) evaluated time to completion, needle handling, knot tying quality, tissue manipulation, and tension maintenance through video analysis. Knot tying was reported as the most challenging task by 42.4% of participants, followed by needle handling at 27.3% and maintaining suture tension at 21.2%. No significant difference in perceived difficulty was observed between novice and expert surgeons. Objective GOALS-based analysis demonstrated that expert surgeons significantly outperformed novices across all metrics. Mean time to complete suturing was 5.7 ± 0.8 min for experts compared with 8.4 ± 1.2 min for novices (P < 0.001). Needle handling scores were 4.5 ± 0.3 versus 2.9 ± 0.5 (P < 0.001). Knot tying quality was 4.6 ± 0.4 versus 2.8 ± 0.6 (P < 0.001). Tissue manipulation scores were 4.4 ± 0.3 versus 3.0 ± 0.5 (P < 0.001). Tension maintenance scores were 4.5 ± 0.4 versus 2.7 ± 0.6 (P < 0.001). This study demonstrates that technical challenges in laparoscopic suturing persist across all experience levels. Integrating subjective perceptions with objective GOALS-based video analysis provides a comprehensive assessment of performance differences. Targeted simulation training focusing on knot tying, needle manipulation, hand positioning, and motion efficiency is essential to enhance suturing proficiency.