Background: Performing an intestinal anastomosis is a challenging part of laparoscopic surgery, and ensuring adequate closure is essential to prevent anastomotic leakage. The aim of this study was to develop an objective method for quantitative assessment of laparoscopic intestinal anastomosis during simulation training. Methods: A modular intraluminal air leakage device, the LeakChecker, was designed and validated by comparing laparoscopic intestinal anastomoses performed by laparoscopic novices and experts. The MaxForce, MeanNon-zero force, PathLength and DepthPerception parameters from the Lapron box-trainer vs MaxPressure and PressureArea from the LeakChecker were used for comparison. Results: A functional prototype was built and the data of 10 laparoscopic novices and seven experts were included. Anastomoses made by the experts tolerated a higher MaxPressure (3,10(2,51-7,24)kPa vs 0,98(0,81-1,35)kPa; p=0.010) and showed a higher pressureArea (24,89(16,13-100,04)kPa*t vs 5,99(4,78-9,23)kPa*t; p=0.032). The Lapron box trainer data showed significant differences between the experts and novices for almost all including force and motion parameters. Conclusion: The LeakChecker can quantify anastomotic leakage during training as it objectively distinguishes between novices and experts. Implementing this kind of smart training task in a training program with objective skill assessment would inform participants of both their instrument handing skills and the quality of their execution.

Background: Human cadaver simulation is vital in medical training, offering realistic experience crucial for skill development, especially in laparoscopic surgery. Traditional cadaver types, like fresh frozen and embalmed, have limitations. Fix4Life (F4L), a novel embalming technique, aims to overcome these drawbacks by providing flexible, pliable tissue without discoloration. This study evaluates the realism and face validity of the F4L embalmed cadaver model for laparoscopic training, aiming to enhance surgical education and patient safety. Methods: Surgical residents and expert surgeons from Amsterdam UMC participated in a hands-on laparoscopy course, performing laparoscopic appendectomy, cholecystectomy, and totally extraperitoneal (TEP) hernia repair on Fix4Life cadavers. Prior to this, residents completed questionnaires immediately after training, while experts reviewed procedure videos and provided evaluations. Ethical approval was obtained, and written consent was acquired from participants. Procedures were supervised, recorded, and securely shared for assessment. Face validation forms were filled by both novices and experts, assessing realism and key aspects of laparoscopic surgery. Statistical analysis included non-parametric tests due to non-normal data distribution. Results: Both residents and experts rated the laparoscopic procedures positively, with the TEP receiving particularly high scores. Residents rated the laparoscopic appendectomy and cholecystectomy as “Good” for all assessment points, while the TEP was frequently rated as “Very Good”. The experts also rated the procedures in the majority of cases as “Good”. Furthermore, novices tended to rate the procedures more favorably than experts, particularly in terms of lifelike tissue manipulation (p < 0.001), tissue color (p = 0.014), and comparability to reality (p = 0.046). Conclusion: The Fix4Life embalming method provides a realistic training modality for laparoscopic appendectomy, laparoscopic cholecystectomy, and TEP.

Objective: Grasping force control is crucial for safe laparoscopic surgery. However, force feedback is limited as haptic information on grasping strength and tissue stiffness is mostly lost due to internal instrument backlash and friction. This increases tissue trauma risk as excessive grasping forces can lead to (postoperative) complications. This study aims to develop a grasping force feedback providing add-on for a laparoscopic grasper and to validate its impact on skills acquisition in basic laparoscopic skills training. Method: The ShaftFlex, a shaft-based grasping force measurement system providing feedback was designed as an add-on for standard reusable instruments. It consists of a compliant element deflecting proportionally to the applied grasping force, and a Hall sensor measuring that deflection. Influence on skills acquisition was evaluated in a comparative study where novices were divided into a Feedback and No feedback group, performing five training trials of a silicon torus transfer boxtrainer task. Afterwards, both groups performed a post-training task without feedback. Grasping force, time to completion and number of errors were measured. Results: There was a significant difference in mean grasping force between groups for all training trials and the post-training trial. In the Feedback group, there was no significant increase in grasping force when feedback was removed. Conclusions: The ShaftFlex working principle provided a feasible, sustainable method to measure grasping forces exerted by a laparoscopic grasper, enabling immediate haptic feedback. It potentially enhances objective skill assessment, providing feedback on training performance. In a clinical context, the ShaftFlex might be useful in surgery where delicate tissue is grasped.

With high global carbon offset and generation of waste, especially in high-income countries, the health sector paradoxically contributes to the greatest threat to worldwide human health and prosperity of this century. The growing demand for surgical care and worsening of planetary health call for responsible action by health care professionals, med tech companies, government and large health care accreditation, norms and standardization institutes. A large shift toward a circular practice with hereby reduction of greenhouse gas emissions is mandatory. Based on an analysis of the field and practical examples of instrument reuse and recycle initiatives, sustainable system developments and new sustainable training initiatives, we provide ideas on how robotic surgery, as an important surgical discipline, can be redirected to become more sustainable in the future.

Objective: To systematically evaluate the economic impact of disposable versus reusable instruments in minimally invasive surgery (MIS), and to summarize the limited available evidence on environmental impact. Background: The increasing use of disposable instruments in MIS has raised concerns regarding healthcare costs and environmental sustainability. While reusable instruments may reduce per-procedure costs and waste, their economic and environmental performance is influenced by procedure type, workflow, and reprocessing requirements. Evidence integrating these factors across surgical specialties remains limited. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Studies published since 2014 comparing disposable and reusable instruments in MIS were identified using predefined PICOS criteria. Data extraction focused on cost components, including instrument costs, sterilization, operating room time, and total procedural costs. Environmental outcomes were recorded when available. Results: Nine studies encompassing 4,724 procedures across multiple surgical specialties met inclusion criteria. In general surgery, reusable instruments were consistently associated with lower per-procedure costs, with reported savings ranging from $16 to $388. In selected subspecialties, including gynecology, thoracic surgery, and spinal surgery, disposable instruments were associated with reduced operative time, indirectly lowering total costs in specific settings. Only one included study directly assessed environmental impact, providing limited, low-level evidence that reusable instruments may confer environmental benefit primarily when used repeatedly. Conclusion: Reusable instruments appear to be associated with lower per-procedure costs in general surgery, while disposable instruments may offer context-specific economic advantages in selected subspecialties. Conclusions regarding environmental impact are limited by the scarcity of primary data. Future studies incorporating standardized cost definitions and robust environmental assessments, including life-cycle analyses, are needed to support evidence-based and sustainable instrument selection in MIS.

Background: The National Health System is responsible for 8–10% of total greenhouse gas emissions. Operating rooms are responsible for 60–70% of all hospital waste. Over the last 30 years abdominal surgery transcended from a laparoscopic approach toward a robot-assisted approach. The role of robot-assisted laparoscopic surgery is still debated in some procedures, such as colorectal surgery. The studies available in scientific literature comparing laparoscopic and robot-assisted left hemicolectomy are focused on clinical outcomes. The environmental sustainability of these procedures remains largely unexplored, representing a key area that our study seeks to investigate. Methods: In this pilot study consecutive patients scheduled for a minimally invasive left hemicolectomy for diverticular disease or cancer were recruited and randomly assigned 1:1 to the laparoscopic or robotic groups. The “Green Team” supported the operating room staff in separate waste collection during the surgical procedures. Primary end point was CO₂ consumption and secondary endpoints the specific mass of the most important waste stream. Results: Ten patients were enrolled. Robot-assisted left hemicolectomy required more CO₂ consumption in liters to maintain pneumoperitoneum (p = 0.03) compared with laparoscopic left hemicolectomy and required a longer operation time (p = 0.04). In total, the robot and laparoscopic approaches produced a total of 74.5 and 54 kg of plastic, non-woven fabric (TNT), unsorted waste bins, and biohazardous waste combined, which cost €92 and €71 to dispose of. Conclusion: Robot-assisted left hemicolectomy seems to have a greater environmental impact compared with laparoscopic left hemicolectomy in terms of both CO₂ emissions and waste production. Given the growing focus on operating room sustainability, further studies are needed to compare laparoscopic and robotic techniques to inform surgical decisions.

Objective: Central venous catheters (CVCs) provide direct access to the central circulatory system, commonly used in hemodialysis and intensive care units for drug administration. Although uncertified for the procedure, CVCs are sometimes used for power injection of contrast medium (CM) during CT scans to avoid peripheral intravenous catheter placement. Previous studies suggest this practice is safe, but incidents are reported. This study aims to measure intraluminal pressure during CM injection through CVCs and assess its impact on the luminal surface to guide responsible clinical use. Materials and methods: An experimental in vitro test setup was developed. Four samples each of three different types of unused CVCs were used. Strain gauges were applied to the exterior walls of either the inflow or outflow lumen of the CVC. These gauges measured material deformation due to intraluminal pressure during CM injections at rates of 4.5 and 8 mL/s, each performed five times. Strain data were calibrated against known pressures in a static system. Three CVCs of each type were then pressurized until bursting, and one was subjected to microscopic analysis of the luminal surfaces. Results: Intraluminal pressures measured (97–545 kPa or 14–79 PSI) were below the burst pressure (779–1248 kPa or 113–181 PSI) in all instances. Strain regression analysis shows a statistically significant (p < 0.01) trend over 10 injections in all CVCs tested except one, indicating material fatigue. Surface microscopy revealed surface micro-cracks from repeated injections, suggesting material damage. Conclusions: The intraluminal pressures from power injections of CM are sufficiently low to prevent CVC bursting. While incidental use for CM injection appears safe, repeated use may cause material damage.

Modern medical science stands at the crossroads of technology, precision and innovation. An enormous variety of technological marvels proliferate in modern medical practice, which many take for granted, such as ultrasound, CT and MRI imaging, portable sensors, implants of almost any part of the anatomy including skin, endoscopic contrivances of mind-blowing complexity, robotics, and an abundance of medication quite undreamt of just 50 years ago. [...]

Background: Totally extraperitoneal (TEP) inguinal hernia surgery is a commonly performed but technically challenging procedure with a long learning curve. As TEP can be executed using two different trocar placements: a midline or a triangular configuration, the question remains which one is technically easier to master. Methods: In a multicenter crossover-study, medical students were randomised into two groups and executed tasks on a box trainer that measured time, volume and force parameters. Additionally, the study assessed whether the SATA instrument, a steerable laparoscopic instrument that articulates the instrument’s tip, would reduce the difficulty of performing the tasks in the midline configuration. After training, all participants executed a first experiment using both trocar configurations, followed by a second experiment executed with steerable and non-steerable instruments in the midline configuration. Subjective and objective performances per condition and learning curves were assessed. Results: Participants were faster and showed lower peak forces in the triangulated configuration. Learning curve analysis showed a positive improvement in time and path length in the midline configuration. Although participants rated ergonomics and intuitiveness similarly between the instruments, they found the task easier with the SATA instruments, ranking the added value of the steering function as 5 out of 5. Objectively, time and path length showed no significant differences while exerted forces were lower when using conventional instruments. Conclusion: Although the midline configuration is preferred in terms of comfort and posture, the findings indicate that, for inexperienced practitioners, performing TEP surgery in midline configuration is both subjectively and objectively more challenging, highlighting the need for extensive training to overcome its difficulties and possibly shorten its learning curve. Although instruments with additional steering functions were preferred over conventional instruments in the more challenging midline configuration, additional steering complexity did not result in better parameter outcomes, showing the need for more extensive training.

Since the introduction of robot-assisted laparoscopic surgery, efforts have been made to incorporate force sensing technologies to monitor critical components and to provide force feedback. The advanced laparoscopic robotic system (AdLap RS) is a robotic platform that aims to make robot technology more sustainable through the use of the fully reusable shaft-actuated tip-articulating (SATA) instruments. The SATA instrument driver features electronics and sensors exposed to the sterile environment, which complicate the sterilisation process. The aim of this study was to develop and validate smart sensing in stepper motors using the back electromotive force in a newly developed Smart SATA Driver (SSD), eliminating the need for sensors in the sterile environment. Methods: The stepper drivers were equipped with TMC2209 ICs featuring StallGuard technology to measure back EMF. The tip was actuated up until a set StallGuard threshold value was reached, at which the resulting tip force was measured. This cycle was repeated ten times for a range of threshold levels. A regression analysis with a power series model was used to determine the quality of the fit. Results: The SSD is capable of exerting tip forces between 2.4 and 8.2 N. The back EMF force test demonstrated a strong correlation between obtained StallGuard values and measured tip forces. The regression analysis showed an R-squared of 0.95 and a root Mean squared error of 0.4 N. Discussion: The back EMF force test shows promise for force feedback, but its accuracy limits real-time use due to back EMF fluctuations. Future improvements in motor stability and refining the back EMF model are needed to enable real-time feedback. Conclusion: The strong correlation during the back EMF force test shows its potential as a low-budget method for detecting motor stalls and estimating tool–tissue forces without the need for sensors in laparoscopic instruments.

This guide is designed to assist surgeons in understanding the proper procedures for legitimately securing the outcomes of their original ideas and collaborations with industry partners as “intellectual property.” Our web-based survey conducted among EAES members in 2019 revealed that surgeons have traditionally shown limited interest in intellectual property. The findings suggested that even when surgeons generate and realize novel concepts, these innovations are often inadequately protected, leaving them vulnerable to misappropriation. Accordingly, this guide focuses on the patenting process for surgeons engaged in collaborative research with industry. It addresses common questions that arise during this process in a Q&A format. The guide also explains key aspects of communication with corporate partners and intellectual property specialists during patent application procedures. Furthermore, it outlines the transition from domestic to international patent protection, with particular emphasis on the Patent Cooperation Treaty (PCT) system. Although this article serves as a practical guide for surgeons seeking to protect their intellectual contributions, it may also be used as an educational resource for industry designers, engineers and business developers, highlighting the importance of respecting and safeguarding the intellectual property rights of medical professionals.

Background: Laparoscopic surgery requires a complex set of motor skills. Currently, basic laparoscopic skills training is performed in a static environment, while intraoperatively, abdominal tissue is often moving. The aim of this study was to develop a dynamic training platform and evaluate its impact on laparoscopic skills acquisition in a box trainer. Methods: The Dynamic Laparoscopic Platform (DyLaP) includes a moving base which has been intergrated with the Lapron box trainer and the ForceSense objective measurement system. Dynamic training was evaluated in a comparative study where novices were divided into a static and dynamic training group, performing six training trials of a peg transfer task with the DyLaP. Afterwards, both groups performed a dynamic exam task. Task manipulation (force) and instrument efficiency (path length and time) were measured. Results: Participants (n = 12) exhibited a significant difference (p < 0.05) in time, path length, and maximum force between the static and dynamic groups in the first trial. Learning curves were most prevalent in the dynamic group. Conclusions: The DyLaP can be used to provide a challenging and realistic training environment. From the comparative peg transfer study, it can be concluded that dynamic training significantly affects laparoscopic skill acquisition. More research is needed to evaluate dynamic training effects in force-based training tasks.

This book offers a comprehensive roadmap toward a circular and sustainable healthcare system, structured into three distinct parts.

Part I describes circular principles and policy tactics. Chapter 1 outlines the essentials of sustainable healthcare and designates the paradox in daily practice of sustainability and the circular economy. In Chapter 2 the impact of leadership on policy together with best practices is discussed. The legislation and infrastructural web, in which many stakeholders and circular economy initiatives are strangled, is described. Despite the fact that politicians and policymakers are motivated to encourage sustainability, the infrastructure is designed to discourage circular economy projects. This chapter shows examples of setting-up intrinsic motivated teams of hospital staff, green teams, industry leaders and scientific motivated research teams. Swimming against the current is about the legislation paradox. In chapter 3 described as how legislation should be redesigned to accomplish the goals as set out in the green deal and the climate law.

Part II serves as a practical guide to implementing circular strategies. In chapter 4 the reader is guided through the fundamentals of circular strategies by visualizing the circular economy. Chapter 5 reveals successful design strategies for products and processes which contribute to a zero-waste society. Using recycled materials by using waste as input for new products is described in chapter 6. In chapter 6 we will explore (surgical) waste as input for new products. Recycled should and could be used more. This is a fundamental concept within circular design principles but hardly used until this moment.

Part III explores circular economy design principles on basis of successful examples. This part dives into real-world applications and measurable outcomes. It showcases successful circular design concepts and business models that have reshaped the market. Chapter 7: Is about leading by design. Success stories of circular concepts which have effectively changed the market with circular products and services are designated. Also entrepreneurial success stories of circular economy business models are presented. Chapter 8 investigates how to measuring effectiveness and impact of circular economy products and processes. In particular how reliable some facts are which are used by many to sell products or introduce new policies or legislation. How trustworthy is data from life cycle assessments (LCA’s)? What are the pitfalls? Is it possible to manipulate these data? Why should we characterize one-sided data from an LCA as greenwashing? Circular Economy principles, sustainability and, in broader sense, the climate discussion seem to trigger emotions. Using fundamental and reliable data is essential in order to be able to judge whether a product or process indeed reduces CO2 emissions is essential in decision-making. Chapter 9 focusses on how universities can contribute to sustainable solutions by presenting different cases which resulted in actual results which were implemented or are ready for upscaling. The role of universities as innovation hubs is highlighted through case studies with proven impact. The final chapter offers a reflective and forward-looking analysis on how circular strategies in healthcare can shape future societal developments.

The authors reflect on the content in chapter 10. A final part in which a critical analysis is presented and the impact it could have on future developments and the society.

Background: To validate whether the SATA-LRS, a novel reusable articulating laparoscopic instrument, fits surgical practice, a pre-clinical study was performed. Methods: Thirteen medical doctors used the instrument in a laparoscopic endoscopic inguinal hernia repair (TEP)-like task inside a cadaver. A set of sensors on the instrument handle detected motion and articulation of the instrument tip. Data from the sensors and video recordings were used to assess the amount and type of movement of the instrument and the time spent on tasks. questionnaire was used to gain insight into the participants’ perception of the contextual factors. Results: There was no difference between task time and instrument tip velocities when using articulation (or not) and all participants used articulation at least half of the task time. Instrument-handle movement, indicating the user’s hand and arm movement, was significantly reduced when using articulation. The questionnaire indicated strong acceptance of the instrument and the experimental setup, and a desire to use the instrument in surgery by most participants. Conclusions: The added articulation feature of the SATA-LRS instrument was deemed beneficial by the participants, showed no increased handling complexity or time spent on the task and was used frequently when enabled, indicating intuitiveness.

The Neptune 3 drainage system is developed as an alternative to canister systems for collecting surgical fluids in the operating room. This study investigates the difference in the environmental impact between Neptune 3 and canister systems, evaluating all individual stages of the product life cycle of the Neptune and canisters. Using the RECIPE model, 17 impact categories (midpoints) were defined and results were aggregated into three endpoint categories (human health, ecosystems, resources). The volume of waste was varied in a setup in a hospital in the Netherlands and included different fluid volume collection scenarios performed over seven years: high-volume (2.0–24 L waste) and low-volume (0.1–0.5 L waste). In both high and low volume procedures, Neptune 3 has a lower environmental impact compared to canisters for global warming (15–89% reduction), ozone formation terrestrial ecosystems & human health (24–91% reduction), fossil resource scarcity (36–92% reduction) and water consumption (44–106% reduction). In high volume scenarios (5 + Liters) Neptune also has a lower impact in stratospheric ozone depletion, fine particulate matter formation, terrestrial acidification for the high volume scenarios (5 L or more). In the case of ionizing radiation, freshwater eutrophication, and human carcinogenic toxicity the Neptune has a lower impact only in the very large volume procedures (10 + Liter). By aggregating the mid-point results to end-point results, it is observed that the Neptune system is beneficial for resources in each scenario, and for human health and ecosystems for procedures with larger volumes. Results from this LCA demonstrate that the Neptune 3 system is environmentally beneficial compared to canisters. This study provides valuable information for policymakers and hospital decisionmakers to treat their surgical waste in an environmentally friendly way.

Background: Technological innovations have significantly enhanced the objective assessment of technical skills in minimally invasive surgery, offering substantial potential for proficiency-based training. However, the integration of these innovative tools into surgical education curricula remains limited. This study aims to evaluate the adoption and implementation of data-driven assessment tools within laparoscopic simulation training. Methods: A systematic search of PubMed and Embase was conducted following PRISMA guidelines, identifying studies that employed objective assessments of technical skills in surgical training curricula. Eligible studies utilized data-driven assessment methods as part of structured training programs for surgical residents. A descriptive analysis was performed on the included studies. Results: From 2814 identified articles, 718 were eligible for full-text screening, and 35 studies met the inclusion criteria. These studies described the implementation of 14 different data-driven tools in laparoscopic skills training. Most tools focused on assessing instrument handling, measuring parameters such as motion speed, path length, and accuracy. Only three studies evaluated tissue handling skills using metrics like knot quality, tissue handling forces, and anastomotic integrity. Conclusions: The adoption of data-driven tools in laparoscopic simulation training is progressing slowly and exhibits considerable variability. Most technologies emphasize instrument handling, while tools for assessing tissue manipulation and force application are limited. To improve training outcomes, a combination of motion- and force-based assessment tools should be considered, enabling a more comprehensive evaluation of technical skills in minimally invasive surgery.

Background: The Veress Needle (VN) is commonly used in establishing pneumoperitoneum in laparoscopic surgery. However, severe vascular and/or visceral complications can occur due to overshoot at the insertion of the VN in the abdominal cavity. In order to investigate whether the new VeressPLUS needle (VN+) could improve safety, the learning curve of this needle was compared to that of a conventional VN, under standardized conditions. Methods: In total, 26 residents and med students, without prior Veress needle experience, were recruited and randomly assigned to VN or the VN+ group. A learning curve plateau phase recognition model was developed and used to determine the learning curve of the participants who used either the VN or the VN+ needle on two Thiel-embalmed human cadavers. Insertion of the needles was done in a systematic way in the upper abdomen and insertion depth was measured under direct laparoscopic vision. At the end of the learning curve, the number of participants that reached a safe insertion depth between 5 and 15 mm was compared. Results: On average, it took the VN group 8 trials to reach and establish the plateau phase of the learning curve. The VN+ group showed no learning curve at all. At the 8th trial, a significant difference (p < 0.002) in average insertion depth was found in favor of the VN+ (mean: 5.4 mm SD 1.4) compared to the VN (mean: 12.7 mm SD 6). In the VN group and VN+ group, 46% versus 8% exceeded the safe insertion depth of 10 mm at the end of the learning curve. Conclusion: This study indicates that for novices, there is no learning curve for the VN+, when compared to VN. Moreover, in all cases, the insertion depths were significantly reduced (with more than 50%) while using the VN+ when compared to the VN.

Introduction: Most robotic instruments and their drives still risk residual contamination due to cleaning complexities, rendering them limited reusable, and tend to have larger instruments than the 5mm laparoscopic standard. The novel steerable laparoscopic SATA-LRS uses modularity for cleanability and exchangeability. The SATA-Drive: a robotic driver designed for the actuation of a 3mm scaled version of the SATA-LRS is presented. Methods: A modular, expandable gear mechanism was designed to efficiently rotate and translate the instrument shafts. The 3mm SATA-LRS is controlled as proof. An user-experiment is conducted to test the (de)coupling of the instrument to and from the drive. Results: A video shows the SATA-Driver successfully articulating, rotating and grasping the end-effector. End-effector dis- and reassembly is possible in 36 (13 SD) seconds, while complete instrument coupling requires 28(8 SD) seconds and de-coupling requires 16 (7 SD) seconds. Discussion: A non-surgical robot arm, mounted with the SATA-drive has effectively been transformed into a system similar to robot assisted laparoscopy. The modularity of the drive's segmented build can easily be adapted and could benefit the adoption of future instruments. The SATA-LRS's cleanability features and its end-effector changes without disassembly are expected to benefit medical robotics. The 3mm SATA-LRS shows the instrument's potential for mini-laparoscopy.

Hospitals in Europe produce approximately 6 million tons of medical waste annually, about one-third of this originating in operating rooms. Most of it is solid waste, which can be recycled if bodily fluids do not contaminate it. Only 2–3% of hospital waste must be disposed of as infectious waste, and this is much lower than the 50–70% of garbage in the biohazard waste stream. In June 2021, at the main operating room of the Department of General Surgery of the University of Turin, we began a separate collection program for materials consisting of plastic, paper, TNT (material not contaminated by bodily fluids), and biohazardous waste. We calculated the number of boxes and the weight of special waste disposed produced every month in one operating room for 18 months. The monthly number of Sanibox and the monthly weight of biohazardous waste decreased during the observation period. The reduction trend was not constant but showed variations during the 18 months. Direct proportionality between number of low-complexity procedures and production of biohazardous waste was found (p = 0.050). We observed an optimization in the collection and filling of plastic, paper and TNT boxes separated and sent for recycling. One of the barriers to recycling hospital waste, and surgical waste in particular, is the failure to separate infectious waste from clean waste. A careful separate collection of waste in the operating room is the first step in reducing environmental pollution and management costs for the disposal of hospital waste.

Collision feedback about instrument and environment interaction is often lacking in robotic surgery training devices. The PoLaRS virtual reality simulator is a newly developed desk trainer that overcomes drawbacks of existing robot trainers for advanced laparoscopy. This study aimed to assess the effect of haptic and visual feedback during training on the performance of a robotic surgical task. Robotic surgery-naïve participants were randomized and equally divided into two training groups: Haptic and Visual Feedback (HVF) and No Haptic and Visual Feedback. Participants performed two basic virtual reality training tasks on the PoLaRS system as a pre- and post-test. The measurement parameters Time, Tip-to-tip distance, Path length Left/Right and Collisions Left/Right were used to analyze the learning curves and statistically compare the pre- and post-tests performances. In total, 198 trials performed by 22 participants were included. The visual and haptic feedback did not negatively influence the time to complete the tasks. Although no improvement in skill was observed between pre- and post-tests, the mean rank of the number of collisions of the right grasper (dominant hand) was significantly lower in the HVF feedback group during the second post-test (Mean Rank = 8.73 versus Mean Rank = 14.27, U = 30.00, p = 0.045). Haptic and visual feedback during the training on the PoLaRS system resulted in fewer instrument collisions. These results warrant the introduction of haptic feedback in subjects with no experience in robotic surgery. The PoLaRS system can be utilized to remotely optimize instrument handling before commencing robotic surgery in the operating room.