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DOI 10.1007/s00464-016-5240-z
The effect of different training exercises on the performance
outcome on the da Vinci Skills Simulator
U. Walliczek-Dworschak1 • M. Schmitt1 • P. Dworschak2 • I Diogo1
A. Ecke1 • M. Mandapathil1 • A. Teymoortash1 • C. Güldner1
Received: 14 May 2016 / Accepted: 6 September 2016
Ó Springer Science+Business Media New York 2016
Abstract
Background Increasing usage of robotic surgery presents
surgeons with the question of how to acquire the special
skills required. This study aimed to analyze the effect of
different exercises on their performance outcomes.
Methods This prospective study was conducted on the da
Vinci Skills Simulator from December 2014 till August
2015. Sixty robotic novices were included and randomized
to three groups of 20 participants each. Each group per-
formed three different exercises with comparable difficulty
levels. The exercises were performed three times in a row
within two training sessions, with an interval of 1 week in
between. On the final training day, two new exercises were
added and a questionnaire was completed. Technical met-
rics of performance (overall score, time to complete,
economy of motion, instrument collisions, excessive
instrument force, instruments out of view, master work
space range, drops, missed targets, misapplied energy time,
blood loss and broken vessels) were recorded by the sim-
ulator software for further analysis.
Results Training with different exercises led to compara-
ble results in performance metrics for the final exercises
Electronic supplementary material The online version of this
article (doi:10.1007/s00464-016-5240-z) contains supplementary
material, which is available to authorized users.
& U. Walliczek-Dworschak
wallicze@staff.uni-marburg.de
1
Department of Otorhinolaryngology–Head and Neck
Surgery, University Hospital of Marburg, University of
Gießen and Marburg, Baldingerstraße, 35043 Marburg,
Germany
2
Center of Orthopedics and Traumatology, University
Hospital of Marburg, University of Gießen and Marburg,
Marburg, Germany
and Other Interventional Techniques
•
among the three groups. A significant skills gain was
recorded between the first and last exercises, with
improved performance in overall score, time to complete
and economy of motion for all exercises in all three groups.
Conclusions As training with different exercises led to
comparable results in robotic training, the type of exercise
seems to play a minor role in the outcome. For a robotic
training curriculum, it might be important to choose exer-
cises with comparable difficulty levels. In addition, it
seems to be advantageous to limit the duration of the
training to maintain the concentration throughout the entire
session.
Keywords da Vinci Skills Simulator
Robotic surgery
education
Training program
Robotic surgery
The increasing use of robotic surgery makes it necessary to
take a further look at the possibilities of training for this
special kind of surgery. This is important especially against
the background of more than 100 individual product lia-
bility lawsuits in 2014 in the USA alone, and accusations of
insufficient surgeon training [1–3]. The required skills for
robotic surgery can be developed through surgical simu-
lation systems such as the da Vinci Skills Simulator
(dVSS) (Intuitive Surgical, Sunnyvale, CA, USA). To
evaluate the quality of simulation training, face, content
and construct validity are useful tools. Face validity eval-
uates whether a test measures what it is supposed to [4],
whereas construct validity identifies whether the simulator
is able to differentiate the performance of experts from
novices [5]. Content validity assesses appropriateness and
correctness, in other words whether the simulator training
is useful [4]. Multiple studies have demonstrated the face,
content and construct validity of the dVSS [5–11], which is
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Fig. 1 Exercises selected for trainings curriculum: left column group
1 (above: ‘‘Peg Board 1’’; middle: ‘‘Match Board 2’’; below: ‘‘Needle
Targeting’’), middle column group 2 (above: ‘‘Match Board 1’’;
the reason to apply it for the present study. It works with
the Mimic virtual reality training software (Mimic Tech-
nologies, Seattle, WA), which contains more than 35
exercises for robotic skills training, including basic tasks
such as camera control and more advanced exercises such
as suturing and needle driving [3]. According to Gomez
et al., seven main robotic skills need to be achieved during
a training curriculum: camera control, energy control,
EndoWrist manipulation, basic needle driving, advanced
needle driving, needle control and fourth arm control [12].
They allow surgeons to develop the necessary skills to
master the robotic console. The present study was designed
so that all seven of those skills were trained by undertaking
the chosen exercises.
To our knowledge, at present there is no standard pro-
ficiency-based curriculum for training on the dVSS. Thus
the aim of the present study is to analyze the effect of
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middle: ‘‘Peg Board 2’’; below: ‘‘Ring and Rail 2’’), right column
group 3 (above: ‘‘Ring and Rail 1’’; middle: ‘‘Thread the Rings’’;
below: ‘‘Match Board 3’’)
different training exercises on the performance outcome in
order to contribute to the development of such a curriculum
(Fig. 1).
Materials and methods
The study was conducted from December 2014 until
August 2015 on the dVSS in the operating theater of the
Department of Otorhinolaryngology, Head and Neck Sur-
gery, Philipps University, Marburg, Germany. Sixty
robotic novices, residents in the first training years who
performed no robotic operations and did not have experi-
ence with the dVSS, were included in this study and were
distributed randomly into three equal groups. To minimize
possible effects of age, only persons between 20 and
33 years were included. The training was introduced with a
Surg Endosc
brief demonstration of the da Vinci System provided by the
study team to familiarize the participants with the da Vinci
console and its handling. Thereafter trainees were allowed
to familiarize themselves with the da Vinci console by
performing 3 min of the exercise ‘‘Playground.’’ The
training consisted of two sessions with an interval of
1 week in between. Exercises of comparable difficulty
levels were matched to the three groups. Each group had to
perform three exercises, which consisted of an easy, a
moderately difficult and a difficult exercise, in a defined
order (Table 1; Fig. 2) three times in a row. On the last
study day, two previously unseen exercises were added:
‘‘Stacking Challenge’’ and ‘‘Energy Dissection 2’’ (Fig. 3).
These two exercises were completed just once by all three
groups.
Exercises chosen for this study comprised the ‘‘Match
Board’’ (MB) exercises, whose aim is to position three-
dimensional wooden letters and numbers in corresponding
preformed pattern outcuts. From MB 1 to MB 3, the
required dexterity rises and extra robotic arms need to be
used to free the pattern outcuts where the objects need to be
placed. The second set of exercises chosen for this study is
the ‘‘Ring and Rail’’ (RR) tasks. Here colored rings are led
along a color-matched rod toward the correct platform.
Furthermore the ‘‘Peg Board’’ (PB) exercises were selec-
ted. They consist of picking up and transferring colored
rings from a peg board wall to a single peg on the floor. In
Table 1 Training curriculum of
all three groups
Exercise 1 (easy)
Exercise 2 (moderately difficult)
Exercise 3 (difficult)
Final exercise 1
Final exercise 2
Fig. 2 Final exercises: On the left the exercise ‘‘Energy Dissection 2’’ is shown, on the right the exercise ‘‘Stacking Challenge’’ is pictured
addition the ‘‘Needle Targeting’’ (NT) exercise, where
colored needles are positioned into two color-matched
targets of different sizes, and the Thread the Rings (TTR)
exercise, which required the participant to pass a needle
through different eyelets were trained. The final exercises
comprised ‘‘Stacking Challenge,’’ in which the task was to
build the highest possible tower using different tokens and
‘‘Energy Dissection 2,’’ which required the participants to
cauterize and cut branching blood vessels anchored to a
vessel truncus. The cauterized small vessels tended to re-
bleed, so the participants needed to be attentive to the
whole surgical field to minimize blood loss. Each task was
initiated by a short verbal explanation of the exercise to
follow. The participants then performed the robotic training
autonomously in the presence of the study team. After
successful completion of each exercise, the program ter-
minated automatically and a detailed performance report
was generated by the Mimic da Vinci Trainer software.
The measured metrics were time taken to complete the
exercise, economy of motion, number of instrument colli-
sions, excessive instrument force, instruments out of view,
master work space range, number of drops and overall
performance score (all metrics combined). For the ‘‘Needle
Targeting’’ exercise, the number of missed targets and for
the final exercise ‘‘Energy Dissection 2’’ misapplied energy
time, blood loss and broken vessels were additionally
recorded.
Group 1 Group 2 Group 3
Peg Board 1 Match Board 1 Ring and Rail 1
Match Board 2 Peg Board 2 Thread the Rings
Needle Targeting Ring and Rail 2 Match Board 3
Stacking Challenge Stacking Challenge Stacking Challenge
Energy Dissection 2 Energy Dissection 2 Energy Dissection 2
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Fig. 3 Overview of the performance outcome for the overall score
for exercises of different difficulty levels (at the head easy, beneath
moderate difficulty, at the bottom difficult exercises). The left middle
Having finished each exercise participants were able to
ask questions and receive feedback on how they could
improve their performance. After the second session of
practical training, each participant was asked to fill out a
questionnaire, where different items should be rated on a
5-point likert scale (see attachment).
Statistical data analysis was performed using the pro-
gram SPSS 22.0 (SAS Statistics, Cary, NC, USA). The
performed statistical test was the two sample test for
independent and dependent variables under the assumption
of equal variance for the population. The test was per-
formed with the arithmetic mean of the overall score,
respectively, the individual parameters of one session day,
in accordance with the exercises. A p value B0.05 was
considered statistically significant.
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column shows the results for group 1, the middle column shows the
results for group 2 and the left column shows the results for group 3
Results
Evaluation of the training
In the present study, a total of 60 robotic novices 34 male
(57 %) and 26 female (43 %) mean age 24.4 years
(20–33 years) were enrolled. Most participants were right
handed (57 (95 %) vs. 3 (5 %)). There were no significant
differences between the three groups regarding age and sex
(p [ 0.05).
A significant skills gain in overall score, time to com-
plete and economy of motion was seen for all exercises of
all three groups from the first to the final session (Table 2;
Fig. 1). The time required for each exercise significantly
reduced between the first and second training days in all
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Table 2 Overview over the development of the outcome metrics of the entirety of the exercises performed
Group 1 Group 2 Group 3
Easy Peg Board 1 Match Board 1 Ring and Rail 1
First trial Last trial p value First trial Last trial p value First trial Last trial p value
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Overall 70.9 14.62 90.25 5.12 0.000 60.00 12.3 79.80 7.66 0.000 76.20 12.28 92.75 4.89 0.000
Time to 110.8 44.50 56.85 12.09 0.000 253.35 65.05 150.50 23.72 0.000 73.90 28.02 32.75 10.24 0.000
complete
Economy of 182.55 64.11 129.55 16.91 0.001 381.95 101.43 256.30 33.89 0.000 72.20 38.96 53.45 10.92 0.030
motion

Group 1 Group 2 Group 3

Medium Match Board 2 Peg Board 2 Thread the Rings
First trial Last trial p value First trial Last trial p value First trial Last trial p value
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Overall 53.5 12.70 79.9 6.94 0.000 80.10 6.97 91.65 5.27 0.000 46.90 21.25 79.20 7.21 0.000
Time to 248.15 90.53 126.15 19.91 0.000 140.15 31.35 95.3 29.9 0.000 274.30 99.80 147.30 28.55 0.000
complete
Economy of 398.15 134.52 270.05 46.20 0.000 269.80 40.44 222.35 28.95 0.000 351.40 132.58 229.50 31.38 0.000
motion

Group 1 Group 2 Group 3

Difficult Needle Targeting Ring and Rail 2 Match Board 3
First trial Last trial p value First trial Last trial p value First trial Last trial p value
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Overall 71.85 25.76 90.95 10.65 0.001 50.65 19.34 70.90 17.07 0.000 29.60 10.42 61.60 17.09 0.000
Time to 277.00 135.00 147.85 56.41 0.000 382.55 114.29 240.50 86.04 0.000 562.55 200.55 262.55 46.19 0.000
complete
Economy 329.95 211.9 209.90 58.69 0.009 558.30 171.14 432.9 87.87 0.005 896.30 296.04 542.60 76.94 0.000
of motion

three groups (Table 5). Group 1 trained in average
22.25 ± 6.65 min per day, group 2 29.25 ± 6.71 min per
day and group 3 30.33 ± 8.74 min per day. Proficiency
level, defined as overall score [80 % according to the
recommendation of the developer, was reached in two
exercises (PB 1, NT) in group 1, in one exercise (PB 2) in
group 2 and in one exercise in group 3 (RR1) (Table 2).
For the final exercises, a slight significant difference in
the performance metrics overall score (group 1 vs. 3
p = 0.34; group 2 vs. 3 p = 0.47) and points (group 1 vs. 3
p = 0.32; group 2 vs. 3 p = 0.47) between groups 2 versus
3 and groups 1 versus 3 was found for ‘‘Stacking Chal-
lenge’’ (Table 4).
Evaluation of the questionnaire
Almost all participants (59 of 60) (98 %) completed the
16-item survey. Analyzing the main results of the
questionnaire, most of the participants rated the training
on the dVSS as useful (83.3 %) and pleasant (96.7 %)
and stated furthermore that they even think that this kind
of training should be integrated into residency programs
(71.6 %) (see attachment). The duration of the training
was rated as acceptable as most participants could
maintain their concentration during the whole training
period (83.3 %). Concerning the effects of the training,
most of the participants reported that their dexterity
(90 %), their handling of the da Vinci instruments
(88.3 %) and their three-dimensional visualization (75 %)
improved subjectively after the training. A few partici-
pants reported pain in the wrists (20 %) and neck (8.3 %)
after the training, although 60 % thought that their hand
posture improved during the robotic training. Body pos-
ture also subjectively improved for 25 % of the trainees
(see attachment).

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Discussion
Increasing usage of robotic surgery systems makes it nec-
essary to address the question of how to sufficiently pre-
pare for this particular kind of surgery. Here, specialized
skills need to be acquired before performing surgery. A
possible simulator for robotic training is the dVSS, which
was used in this study. Multiple studies have demonstrated
its face, content and construct validity [5–10]. In addition it
has been rated as very meaningful for resident training by
expert robotic surgeons [10]. Other working groups have
demonstrated the advantages of using a simulator for
warming up before surgery [13, 14]. At present to our
knowledge there is no recommended structured training
curriculum for the dVSS. Therefore, the aim of the present
study was in general to clarify the necessary foundations of
a possible training curriculum and in detail to analyze
whether training outcomes are strongly dependent on the
chosen exercises. Three groups of 20 robotic novices were
recruited, and different exercises of comparable difficulty
levels were allocated to the groups. The chosen exercises
with a basic difficulty level in this study were PB 1, RR 1
and MB 1. For the intermediate difficulty level MB 2, PB 2
and TTR were selected. For the more advanced difficulty
level NT, RR 2 and MB 3 were chosen. Compared with
prior published studies regarding training on the dVSS, this
study had a high number of participants and comprised 11
exercises in total, providing a good overall picture of
robotic simulation training. For all exercises, a significant
improvement in the main performance metrics (overall
score, time taken to complete and economy of motion)
after the training could be demonstrated (Tables 2, 3). This
finding is in agreement with various previous studies
[12, 15, 16]. Lyons et al. [17] reported differences in those
metrics between novices and experts, which might suggest
that evaluation of these parameters could be used to eval-
uate increased proficiency of robotic novices. It is our
belief that especially the economy of motion parameter is
an important factor that can show how efficiently a surgeon
works. Improved economy of motion might help to mini-
mize damage of the tissue surrounding the operating field.
Other metrics did not reach significance for the exercises in
the present study, which might be explained by the low
mean numbers of the listed metrics, so that the benefit is
difficult to interpret. Participants reached the proficiency
level in four out of nine exercises (two exercises (PB 1,
NT) in group 1, one exercise (PB 2) in group 2 and one
exercise in group 3 (RR1)) (Tables 2, 3). One could expect,
therefore, that in the final exercises group 1 would achieve
better results than the other groups, but interestingly this
was not found (Table 4). This indicates that although the
proficiency level was not achieved, these exercises still
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trained skills sufficiently to achieve comparable results
with the other groups that reached proficiency level more
frequently. The exercises in which the overall score was
rather far away from the 80 % proficiency level were RR2,
MB3 and TTR. This is not surprising as they seem to be
more advanced as indicated by their low starting overall
scores and longer times required for completion. In fact
MB 3 and RR 2 seem to be the most difficult exercises with
the lowest overall starting scores and most trainees being
rather far away from reaching the 80 % level.
These findings are comparable with a previous pub-
lished study [16] emphasizing the advanced level of these
exercises. In contrast two exercises just failed to reach the
80 % score in the present study: MB1 and 2. The type of
exercise chosen seems to play a minor role for the out-
come, and it might be important though to choose exercises
of comparable difficulty levels. In this study, an interval of
1 week between the two training sessions was chosen, to
perform the study in a time-efficient manner. For the same
reason, a total of six exercise repetitions were selected,
although it was known that this repetition frequency might
not be sufficient to reach proficiency level in the more
advanced exercises [12, 16]. However, other studies had
reported reaching proficiency level after 4–5 attempts on
average [18]. We therefore suggest choosing a frequency of
six repetitions for a training curriculum. The duration of
the training in the present study was subjectively accept-
able for most participants as they could maintain their
concentration during the whole training period (83.3 %)
(see attachment). According to the survey, more than half
of the participants rated the training as useful and pleasant
believing that the training improved their dexterity and
handling of the robotic instruments. These findings are in
agreement with a study published by Tergas et al. [19],
involving 20 medical students and gynecology trainees. In
contrast to their findings, only a few participants of the
present study reported adverse effects such as wrist sore-
ness (20 vs. 42 %) or neck pain (8.3 vs. 16 %) caused by
the robotics training [19]. Possible explanations might be
the longer training time (60 min) per session in their study
and that they chose suturing exercises. Depending on the
kind of exercises performed, the duration of robotics
training should be adjusted to avoid adverse muscu-
loskeletal effects. Most of our participants believe that the
use of robotic surgery will increase during the next years
and would appreciate the integration of robotic training
into residency programs. In the future structured and
standardized virtual training programs might be integrated
into residency programs, to familiarize surgeons with
robotic surgery systems through videos and practice with
the console’s hand control instruments and foot pedals
(Table 5).
 Surg Endosc

Table 3 Comparison of the performance metrics of the different groups among each other
Group 1 versus Group 2 Group 1 versus Group 3 Group 2 versus Group 3
Easy exercise Peg Board 1 versus Match Board 1 Peg Board 1 versus Ring and Rail 1 Match Board 1 versus Ring and Rail 1
Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value

Overall 70.90 ± 14.62 60.0 ± 13 0.015 70.90 ± 14.62 76.20 ± 12.28 0.222 60.00 ± 12.30 76.20 ± 12.28 0.000
First trial 90.25 ± 5.12 79.8 ± 7.66 0.000 90.25 ± 5.12 92.75 ± 4.89 0.122 79.80 ± 7.66 92.75 ± 4.89 0.000
Last trial 110.80 ± 44.50 253.35 ± 65.05 0.000 110.80 ± 44.50 73.90 ± 28.02 0.004 253.35 ± 65.05 73.90 ± 28.02 0.000
Time to complete 56.85 ± 12.09 150.5 ± 23.72 0.000 56.85 ± 12.09 32.75 ± 10.24 0.000 150.50 ± 23.72 32.75 ± 10.24 0.000
First trial 182.25 ± 64.11 381.95 ± 101.43 0.000 182.55 ± 64.11 72.20 ± 38.97 0.000 381.95 ± 101.43 72.20 ± 38.97 0.000
Last trial 129.55 ± 16.91 256.30 ± 33.89 0.000 129.55 ± 16.91 53.45 ± 10.92 0.000 256.30 ± 33.89 53.45 ± 10.92 0.000

Medium exercise Match Board 2 versus Peg Board 2 Match Board 2 versus Thread the Rings Peg Board 2 versus Thread the Rings
Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value

Overall 53.50 ± 12.70 80.10 ± 6.97 0.000 53.5 ± 12.70 46.9 ± 21.25 0.241 80.10 ± 6.96 46.90 ± 21.25 0.000
First trial 79.90 ± 6.94 91.65 ± 5.27 0.000 79.90 ± 6.94 79.20 ± 7.21 0.756 91.65 ± 5.27 79.20 ± 7.20 0.000
Last trial 248.15 ± 90.53 140.15 ± 31.35 0.000 248.15 ± 90.53 274.3 ± 99.80 0.391 140.15 ± 31.35 274.30 ± 99.80 0.000
Time to complete 126.05 ± 19.91 95.30 ± 29.9 0.001 126.05 ± 19.91 147.30 ± 28.55 0.010 95.30 ± 29.90 147.30 ± 28.55 0.000
First trial 398.15 ± 134.52 269.80 ± 40.44 0.000 398.15 ± 134.52 351.4 ± 132.58 0.275 269.80 ± 40.44 351.40 ± 132.58 0.012
Last trial 270.05 ± 46.20 222.35 ± 28.95 0.000 270.05 ± 46.20 229.50 ± 31.38 0.003 222.35 ± 28.95 229.50 ± 31.38 0.459

Difficult exercise Needle Targeting versus Ring and Rail 2 Needle Targeting versus Match Board 3 Ring and Rail 2 versus Match Board 3
Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value Mean ± SD Mean ± SD p value

Overall 71.85 ± 25.76 50.65 ± 19.34 0.006 71.85 ± 25.76 29.60 ± 10.42 0.000 50.65 ± 19.34 29.60 ± 10.42 0.000
First trial 90.95 ± 10.65 70.90 ± 17.07 0.000 90.95 ± 10.65 61.60 ± 17.09 0.000 70.90 ± 17.07 61.60 ± 17.09 0.003
Last trial 277.00 ± 135.00 382.55 ± 114.29 0.011 277.00 ± 135.00 562.55 ± 200.55 0.000 382.55 ± 114.29 562.55 ± 200.55 0.001
Time to complete 147.85 ± 56.41 240.50 ± 86.04 0.000 147.85 ± 56.41 262.50 ± 46.19 0.000 240.50 ± 86.04 262.55 ± 46.19 0.319
First trial 329.95 ± 211.9 558.3 ± 171.14 0.001 329.95 ± 211.9 896.30 ± 296.04 0.000 558.30 ± 171.13 896.30 ± 296.04 0.000
Last trial 209.90 ± 58.69 432.90 ± 87.87 0.000 209.90 ± 58.69 542.60 ± 76.94 0.000 432.90 ± 87.87 542.60 ± 76.94 0.000

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Table 4 Comparison of the metrics of the final exercises

Final exercise Energy Dissection 2 Energy Dissection 2 Energy Dissection 2
Group 1 versus Group 2 Group 2 versus Group 3 Group 1 versus Group 3
Score ? SD Score ? SD Score ? SD Score ? SD Score ? SD Score ? SD

Overall 70.6 ± 9.17 71.5 ± 6.65 71.5 ± 6.5 70.5 ± 5.02 70.6 ± 9.17 70.5 ± 15.02
Time to complete 233.45 ± 74.20 225.15 ± 35.27 225.15 ± 35.27 218.4 ± 57.25 233.45 ± 74.20 218.4 ± 57.25
Economy of motion 220.9 ± 50.31 229.0 ± 34.54 229 ± 34.36 227.2 ± 49.53 220.9 ± 50.31 227.2 ± 49.53
Final exercise Stacking Challenge Stacking Challenge Stacking Challenge
Group 1 versus Group 2 Group 2 versus Group 3 Group 1 versus Group 3
Score ± SD Score ± SD Score ± SD Score ± SD Score ± SD Score ± SD

Overall 28.4 ± 10.10 28.45 ± 12.25 28.45 ± 12.25 19.85 ± 14.13 28.4 ± 10.10 19.85 ± 14.13
Points 42.2 ± 15.16 42.15 ± 18.43 29.25 ± 21.15 42.2 ± 15.16 29.25 ± 21.15

Table 5 Overview of the time needed for each exercise, respectively, each day
Group 1 Group 2 Group 3
Mean (in minutes) ± SD p value Mean (in minutes) ± SD p value Mean (in minutes) ± SD p value

Exercise 1
Time for exercise day 1 4.65 ± 1.5 10.50 ± 1.88 3.10 ± 0.85
Time for exercise day 2 3.3 ± 0.86 0.001 8.25 ± 1.37 0.000 2.00 ± 0.79 0.000
Exercise 2
Time for exercise day 1 9.70 ± 2.15 6.40 ± 1.57 11.00 ± 3.03
Time for exercise day 2 6.70 ± 0.92 0.000 5.10 ± 1.17 0.000 7.80 ± 1.74 0.000
Exercise 3
Time for exercise day 1 11.85 ± 4.22 15.90 ± 4.27 22.25 ± 5.81
Time for exercise day 2 8.2 ± 2.9 0.000 12.35 ± 3.03 0.000 14.40 ± 2.87 0.000
Time for the day
Time for day 1 26.15 ± 6.52 32.80 ± 6.36 36.20 ± 8.13
Time for day 2 18.35 ± 4.03 0.000 25.70 ± 5.04 0.000 24.45 ± 4.24 0.000
Time for day in total 22.25 ± 6.65 29.25 ± 6.71 30.33 ± 8.74

Conclusion Compliance with ethical standards

Disclosures Drs. Ute Walliczek-Dworschak, Marie Schmitt, Philipp

For the establishment of a training curriculum to achieve
robotic skills, the type of exercise chosen seems to play a
minor role for the outcome, it might be more important to
choose exercises of comparable difficulty levels. Further-
more it seems to be crucial to limit the duration of the
training to an acceptable length to be able to maintain the
concentration throughout the whole training period and to
avoid possible adverse side effects caused by the training.
A significant improvement in performance with simulta-
neous maintenance of participants concentration during the
whole training period is achievable with a repetition fre-
quency of six times.
Otto Georg Dworschak, Isabel Diogo, Anja Ecke, Magis Mandap-
athil, Afshin Teymoortash and Christian Güldner have no conflicts of
interest or financial ties to disclose.
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