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Aims •The use of multiple ports in conventional laparoscopy carries with it a wound infection rate of up to 9% and wound herniation rate of up to 3%1. This rationale, along with a mind to enhance cosmesis, precipitated Single Incision Laparoscopic Surgery (SILS). •Technical challenges of SILS include reduced triangulation, reduced range of motion and instrument collisions2. These have resulted in poorer performance of standardised simulation tasks •Articulating instruments have been used to counter the challenges of SILS, but studies have reported heterogeneous results with some showing improved, equivalent or reduced SILS performance compared to conventional straight instruments2,3,4. •This study aimed primarily to compare SILS performance of surgeons using either two straight instruments (STR), one articulating and one straight (STR-ART) or two articulating instruments (ART). •Secondarily, the study aimed to compare workload between these three instrument combinations 3. Figure 1: Trial CONSORT diagram Methods •Figure 1 shows the trial protocol. Surgeons were stratified into intermediate (5-25 laparoscopic cases as primary operator) or advanced (over 25 cases) and then familiarised themselves with conventional instruments and a conventional setup as shown in figure 2. Baseline testing was one repetition of the peg transfer (PEG) task from the Fundamentals of Laparoscopic Surgery (FLS) curriculum. •After randomisation, 25 repetitions of PEG were undertaken using the SILS modified setup shown in figure 3. FLS scoring for PEG was used and maximum scores compared between groups. •Hand motion analysis was performed using the Imperial College Surgical Assessment Device (ICSAD) and, after completion of the trial, the NASA Raw Task Load Index (RTLX) questionnaire assessed workload. •p<0.05 was considered significant. Randomised (n=21) Excluded (n=0) Up to 5 minute familiarisation Baseline testing Assessed for eligibility (n=21) Post-test NASA-RTLX survey (n=21) 25 repetitions of PEG (n=7) Up to 5 minutes familiarisation Group 1: STR (n=7) Group 2: STR-ART (n=7) Group 3: ART (n=7) Up to 5 minutes familiarisation Up to 5 minutes familiarisation 25 repetitions of PEG (n=7) 25 repetitions of PEG (n=7) Corker HP, Singh P, Sodergren MH, Balaji S, Paraskeva PA Incision Laparoscopic Surgery (SILS) Results •Twenty-one surgeons participated, 7 in each group. •Between groups there were no significant differences in baseline FLS score (p=0.63) or median number of laparoscopic cases as primary operator (p=0.94). •STR-ART achieved higher maximum FLS scores than STR or ART (239 vs. 228 vs. 210, respectively, p=0.002). This is shown in figure 4. •ICSAD analysis revealed no significant difference in total path length (12.27m vs. 12.26m vs. 16.04 m, respectively, p=0.55) or total number of movements (89.64 vs. 86.39 vs. 170.91, respectively, p=0.08). •NASA RTLX revealed no significant difference in scores between the groups (73 vs. 67 vs. 68, respectively, p=0.708). Figure 2: setup used for baseline testing Conclusion •The use of STR-ART conferred improved SILS performance when surgeons undertook a SILS-validated FLS task. •This is in spite of not requiring any significant alteration in hand movements or proving any more taxing in terms of workload. •Thus, STR-ART may, therefore be the optimal instrument configuration for clinical SILS. Figure 3: SILS setup used for 25 PEG repetitions Figure 4: Group 2 (STR-ART) achieved higher maximum FLS scores than group 1 (STR) or group 3 (ART) References 1.Ma J. Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy. Ann Surg 2011;254(1):22. 2.Islam A. Early surgeon impressions and technical difficulty associated with laparoendoscopic single-site surgery: a Society of American Gastrointestinal and Endoscopic Surgeons learning center study. Surg Endosc 2011;25(8):2597-603. 3.Montero PN et al. Single Incision Laparoscopic Surgery (SILS) is Associated with Poorer Performance and Increased Surgeon Workload Compared with Standard Laparoscopy. Am Surg 2011;77(1):73-77. 4.Santos B. Effect of training and instrument type on performance in single-incision laparoscopy. Results of a randomized comparison using a surgical simulator. Surg Endosc 2011;25(12):3798-804. A randomised controlled trial to establish the effect of articulating instruments upon performance in Single