Training Laparoscopic Surgeons: Assessing Workload and Skill Using Nasa-Tlx

Abstract

Objective: Laparoscopic suturing stands as one of the most technically demanding competencies in minimally invasive surgery, requiring nuanced psychomotor coordination, refined spatial perception, and precise instrument handling. Despite the growing emphasis on simulation-based training, few studies have investigated the subjective workload associated with laparoscopic suturing and its correlation with objective performance metrics.

Design: This prospective study aimed to explore these dynamics by enrolling 68 general surgery residents in a standardized box-trainer-based suturing task. Participants' subjective workload was quantified using the NASA Task Load Index (NASA-TLX), which measures mental demand, physical demand, temporal demand, perceived performance, effort, and frustration. Objective suturing proficiency was evaluated using a newly developed Suture Point System, capturing parameters such as suture placement accuracy, tension control, and speed.

Setting: This study was conducted at Etlik City Hospital, General Surgery Clinic, a tertiary care academic medical center located in Ankara/Turkey. The study took place within the institution's surgical training program, utilizing a standardized laparoscopic simulation laboratory designed for resident education.

Results: The results revealed a pronounced learning curve: early-stage trainees (PGY-1 and PGY-2) exhibited higher overall workload scores and lower suturing proficiency compared to their senior counterparts. Specifically, PGY-1 residents reported the highest mean NASA-TLX scores (72.38), driven primarily by elevated mental demand and effort, and had the poorest performance in terms of correct suture placement and timing. By contrast, PGY-5 residents demonstrated significantly lower workload indices (23.33) coupled with superior suture quality, highlighting a steady reduction in cognitive strain and a progressive elevation of technical skills across residency levels. Analysis of laparoscopic case volume further corroborated these findings: residents with experience beyond established case thresholds consistently achieved higher composite suture scores and reported diminished mental and physical demands. Notably, sex-based comparisons did not yield statistically significant differences, suggesting that cumulative case exposure and training intensity are more influential than sex in determining laparoscopic proficiency and workload perception.

Conclusion: These observations underscore the importance of early and targeted exposure to laparoscopic suturing tasks within a structured, competency-based curriculum. Simulation-based approaches, particularly those employing standardized feedback and ergonomic instrument design, may accelerate skill acquisition and mitigate novice-level fatigue or frustration. From an educational standpoint, integrating real-time workload assessment tools such as NASA-TLX can facilitate the identification of trainees who might benefit from tailored interventions, thereby enhancing training efficiency and patient safety. In conclusion, this study provides robust evidence that both subjective workload and objective performance metrics improve significantly as surgical trainees progress in residency and accumulate procedural experience. These findings endorse a model of surgical education that emphasizes staged, repetitive practice in simulator settings, ultimately aiming to produce surgeons proficient in complex laparoscopic techniques with minimal cognitive and physical strain.

Keywords: Laparoscopy; Surgical education; Suturing; Task performance and analysis; Workload.