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01.12.2016 | Study protocol | Ausgabe 1/2016 Open Access

Trials 1/2016

Sequential learning of psychomotor and visuospatial skills for laparoscopic suturing and knot tying – study protocol for a randomized controlled trial “The shoebox study”

Trials > Ausgabe 1/2016
Jonathan D. Hendrie, Felix Nickel, Thomas Bruckner, Karl-Friedrich Kowalewski, Carly R. Garrow, Maisha Mantel, Philipp Romero, Beat P. Müller-Stich
Wichtige Hinweise

Competing interests

The authors hereby declare that they have no competing interests.

Authors’ contributions

Study conception and design: BPMS, FN, JDH, MM, K-FK, CRG and PR. Statistical planning: TB. Drafting of manuscript: JDH, FN, K-FK, MM and CRG. Critical revision: BPMS, PR and FN. All authors read and approved the final version of this manuscript.



Laparoscopy training has become an integral part of surgical education. Suturing and knot tying is a basic, yet inherent part of many laparoscopic operations, and should be mastered prior to operating on patients. One common and standardized suturing technique is the C-loop technique. In the standard training setting, on a box trainer, the trainee learns the psychomotor movements of the task and the laparoscopic visuospatial orientation simultaneously. Learning the psychomotor and visuospatial skills separately and sequentially may offer a more time-efficient alternative to the current standard of training.


This is a monocentric, two-arm randomized controlled trial. The participants are medical students in their clinical years (third to sixth year) at Heidelberg University who have not previously partaken in a laparoscopic training course lasting more than 2 hours. A total of 54 students are randomized into one of two arms in a 1:1 ratio to sequential learning (group 1) or control (group 2). Both groups receive a standardized introduction to the training center, laparoscopic instruments, and C-loop technique. Group 1 learn the C-loop using a transparent shoebox, thus only learning the psychomotor skills. Once they reach proficiency, they then perform the same knot tying procedure on a box trainer with standard laparoscopic view, where they combine their psychomotor skills with the visuospatial orientation inherent to laparoscopy. Group 2 learn the C-loop using solely a box trainer with standard laparoscopic view until they reach proficiency. Trainees work in pairs and time is recorded for each attempt. The primary outcome is mean total training time for each group. Secondary endpoints include procedural and knot quality subscore differences. Tertiary endpoints include studying the influence of gender and video game experience on performance.


This study addresses whether the learning of the psychomotor and visuospatial aspects of laparoscopic suturing and knot tying is optimal sequentially or simultaneously, by assessing total training time, procedural, and knot quality differences between the two groups. It will improve the efficiency of future laparoscopic suturing courses and may serve as an indicator for laparoscopic training in a broader context, i.e., not only for suturing and knot tying.

Trial registration

This trial was registered on 12 August 2015 with the trial registration number DRKS00008668.
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