Background
Many technologies have been developed to aid in surgical instrument counting, but wide adoption is rare. A technology that has been widely adopted around 20 years ago is the weighing scale. Lessons can be extracted from its sustainment and fidelity, and applied to the development and implementation of new laboursaving technologies in healthcare.

Methods
We conducted semi-structured interviews with experienced staff in four hospitals that use weighing systems in their surgical instrument cycle, which we analysed according to the Matrixed Multiple Case Study (MMCS) methodology. Hospitals were designated a low, medium, or high sustainment and fidelity score, after which influencing factors were identified. These factors were categorised according to the i-PARIHS domains of Innovation, Recipient, Context, and Facilitation. Within-site analysis and cross-site analysis was performed to identify influencing factors associated with a high or low level of sustainment or fidelity.

Results
All hospitals showed a high sustainment. Two hospitals showed low fidelity, and two showed high fidelity. Twenty-one total influencing factors were identified, divided among all i-PARIHS domains. All hospitals experienced similar limitations of the technology, and all hospitals showed signs of facilitation efforts during the implementation phase. In low-fidelity hospitals, interdepartmental coordination and trust in technology were limited, in contrast to high-fidelity hospitals. A large and/or complex surgical instrument inventory hindered fidelity of the weighing system.

Conclusions
20 years after implementation, there is varying success concerning the fidelity of weighing systems for surgical instrument counting. All participating hospitals have adapted their workflow to the limitations of the technology in different ways. Given the relative straight-forwardness of weighing scales as a technology, our findings underline the complexity of implementation processes, regardless of the complexity of the innovation.

Background: Surgical instrument counting is a manual, attention-intensive task of the operating room (OR) nurse. Many labour-saving technologies have been proposed, but implementation remains challenging. Knowledge of current counting methods and staff preferences could guide future developments towards effective application. Approach: We observed OR nurses counting materials and instruments in 50 surgical procedures performed by various surgical specialties in a regional teaching hospital in Delft, The Netherlands. Additionally, we surveyed them on their preferences concerning the methods of counting. Key findings: Variations in approaches of surgical counting were observed, with OR nurses using multiple strategies and counting techniques to manage disruptions and limit workload. Interest in using supportive technology is limited to the preoperative and postoperative phase. Relevance: This research relates observational data to staff preferences. Our findings may guide future developments of labour-saving innovations regarding surgical counting towards developing more effective applications and to ensure successful implementation.

Background: As global use of surgical robotic systems is steadily increasing, surgical simulation can be an excellent way for robotic surgeons to acquire and retain their skills in a safe environment. To address the need for training in less wealthy parts of the world, an affordable surgical robot simulator (PoLaRS) was designed. Methods: The aim of this pilot study is to compare learning curve data of the PoLaRS prototype with those of Intuitive Surgical’s da Vinci Skills Simulator (dVSS) and to establish face- and construct validity. Medical students were divided into two groups; the test group (n = 18) performing tasks on PoLaRS and dVSS, and the control group (n = 20) only performing tasks on the dVSS. The performance parameters were Time, Path length, and the number of collisions. Afterwards, the test group participants filled in a questionnaire regarding both systems. Results: A total of 528 trials executed by 38 participants were measured and included for analyses. The test group significantly improved in Time, Path Length and Collisions during the PoLaRS test phase (P ≤ 0.028). No differences was found between the test group and the control group in the dVSS performances during the post-test phase. Learning curves showed similar shapes between both systems, and between both groups. Participants recognized the potential benefits of simulation training on the PoLaRS system. Conclusions: Robotic surgical skills improved during training with PoLaRS. This shows the potential of PoLaRS to become an affordable alternative to current surgical robot simulators. Validation with similar tasks and different expert levels is needed before implementing the training system into robotic training curricula.