J. Biomedical Science and Engineering, 2010, 3, 422-429 JBiSE
doi:10.4236/jbise.2010.34058 Published Online April 2010 (http://www.SciRP.org/journal/jbise/).
Published Online April 2010 in SciRes. http://www.scirp.org/journal/jbise
The opinion and experience of surgeons with laparoscopic
bowel grasper haptics
Eleonora P. Westebring-van der Putten1, Margriet C. J. Berben1, Richard H. M. Goossens1,
Jack J. Jakimowicz1,2, Jenny Dankelman3
1Department of Applied Ergonomics and Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft,
the Netherlands;
2Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands;
3Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Sciences, Delft University of Technol-
ogy, Delft, the Netherlands.
Received 17 December 2009; revised 28 December 2009; accepted 12 January 2010.
ABSTRACT
Background: In order to develop new and better
laparoscopic bowel instruments, which reduces pa-
tient risks, the opinions and experience that surgeons
have with current laparoscopic bowel grasper haptics
is important. In this study we explored this by means
of a questionnaire. Method: A total of 386 online-
questionnaires, were sent to laparoscopic surgeons
working in European hospitals. They were all mem-
bers of the European Association of Endoscopic Sur-
gery and perform laparoscopic obesities or bowel sur-
gery. Surgeons where divided into different age and
experience groups. Results: A total of 174 completely
filled out forms were analyzed. In total, 16% of the
surgeons cannot prevent damage when they pinch too
hard, although they (10%) might have seen or felt it.
Seven percent of the respondents were not able to see
or feel tissue slippage. Whereas 31% can see or feel
slippage they cannot do anything to prevent it. Over-
all, most of the respondents would appreciate techni-
cal changes in the laparoscopic bowel graspers to
reduce tissue damage. Of all the respondents, 79%
maintain that it is necessary to have a new laparo-
scopic grasper with augmented feedback. The major-
ity of the respondents (77%) would like to have tac-
tile feedback as an indication of the level of pinch
force. There are not many differences in the opinions
of surgeons at different skill levels. Conclusion: From
the results of the questionnaire and the other com-
ments made by respondents it is evident that research
and developments in the field of new laparoscopic
graspers sho uld cont inue .
Keywords: Laparoscopy; Vision and Experience; Bowel
Graspers; Questionnaire; Haptic Feedback
1. INTRODUCTION
Laparoscopic surgery has many benefits for the patient,
such as fewer traumas, shorter hospital stays and re-
duced recovery times [1-5]. However, this technique
gives rise to difficulties for the surgeon such as reduced
haptics and indirect vision [6], which in turn may lead to
a higher rate of adverse events [7]. During laparoscopic
bowel surgery stress injury, which leads to tissue dam-
age (e.g. perforation), pathological scar tissue formation,
bleeding, adhesions, and loss of bowel motility may oc-
cur when the instrument is pinched with excessive force
or when tissue slips from the grasper [8,9].
Many studies are currently being performed to estab-
lish the best way of reducing tissue damage during
laparoscopic procedures (for a review of this see [10]).
One of our own projects concerns laparoscopic grasp
control. There we are trying to determine whether aug-
mented feedback in relation to excessive pinch force and
tissue slippage during laparoscopic grasping may im-
prove performance. Preliminary tests with augmented
feedback containing grasp force information have shown
that the accuracy/level of grasping forces has indeed
increased. The main aim of the project is thus to find the
best kind of augmented feedback in relation to grasp
force during laparoscopic grasping. Laparoscopic obesi-
ties and bowel surgery is chosen as the applicable field,
as the tissue of the bowel is very delicate. Good grasp
control is therefore a prerequisite in the correct per-
formance of bowel surgery.
Apart from gaining results from experiments, we are
interested in surgeons’ opinions and experience with the
current laparoscopic graspers during bowel surgery. This
way researcher can develop instruments that fulfill the
demands and wishes of the surgeons who are going to
use the instruments. Current literature does not provide

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 423
us with information retrieved from large groups of sur-
geons. Individual surgeons are asked to provide research
groups with their opinion and experiences, although,
these opinions are useful they might not represent the
opinion of the whole user group. The amount of research
done in the field of improving haptics sugges that this
need is obvious, however, this has not been confirmed
by large user groups. To collect this information, we
compiled a questionnaire, which was first approved by
the technical committee of the European Association for
Endoscopic Surgery (EAES). The questionnaire was
distributed to surgeons who use laparoscopic techniques.
It included questions on laparoscopic surgery in general,
laparoscopic bowel surgery, (augmented) feedback on
pinch force information during laparoscopic grasping,
involvement in hospital innovation and awareness and
participation in research projects devoted to augmented
feedback. This article will present the findings of that
questionnaire.
2. METHODS
In total, 386 surgeons from different European hospitals
(members of the EAES who perform laparoscopic bowel
and obesities surgery), were approached by email and
asked to fill in a questionnaire via the Internet (devel-
oped using NETQuestionnaires 6.0).
Apart from the overall opinions of the whole group
we were also interested to see whether there were dif-
ferences in the answers given by surgeons of different
ages or levels of experience. We therefore distinguished
three categories based on experience in terms of number
of operations, experience in terms of years and age. All
the surgeons were divided into one of the four levels
given within each category (see Table 1 in the Result
section).
Table 1. Devision in groups of the 174 respondents.
Respondents (%)
< 500 30
500-1000 17
1000-2000 20
Experience (no. of operations)
> 2000 33
< 5 9
5-10 22
10-15 28
Experience (years)
15-20 41
< 40 6
40-50 26
50-60 40
Age (years)
> 60 28
The collected data was exported and processed into
SPSS 16.0 for Microsoft Windows XP. The questions
asked can be found in the appendix. Most questions had
a one-answer option. Questions 6, 7, 8 and 10 allowed
several answers. With each question it was possible to
give additional comment.
To make sure that each respondent used the same
definitions, we used the following explan ation for tactile
and proprioceptive feedback. Tactile perception relates
to the perception of pressu re, vibration, and texture (also
sometimes called discriminative touch or cutaneous
sense), and relies on different receptors in the skin (cu-
taneous mechanoreceptors). Proprioception (haptics)
concerns the perception of posture and the position of
the limbs, body and head in space and their positioning
relative to each other, including the vestibular system,
cutaneous sense and kinesthesia [11].
3. RESULTS AND DISCUSSION
A total of 281 surgeons responded. Of the 281 respon-
dents, 174 submit ted a completely filled -in q uestionn aire.
This resulted in a completely filled out rate of 45%. The
experience level of the surgeons ranged from 80 to more
than 10.000 operations and from < 5 to 15-20 years of
experience. The age of the surgeons ranged from 29 to
69 years. The amount of surgeons that responded is
enough to make rough conclusions about their opinion.
Although, each new development in this field should
check its specific need with the user group. The results
can be biased, as it is possible that the surgeons that did
not fill the questionnaire are indifference for th e topic.
3.1. Results from the Complete Group of
Respondents
Forty-six percent of the respondents use grasper 1 to
grasp bowel tissue, fo llowed by 24% who use grasper 2.
Graspers 3 , 4 and 5 wh ere used by 10, 10 and 3% of the
respondents respectively and only 7% of the respondents
reported using another type of grasper. Grasper 1 was
used in our previous studies [9,12,13]. The answers to
this question co nfirmed that this choice of bowel grasper
was suitable for representing the bowel graspers used in
practice.
From Figure 2 it can been seen that 51% of the re-
spondents can feel when they apply excessive pinch
force to the tissue and are able to adjust the pinch force
to prevent damage. In total, 33% of the respondents can
see when they apply excessive pinch force and are able
to prevent damage. Six percent of the respondents can-
not see or feel when they apply excessive pinch force to
the tissue. Finally 16% of the surgeons cannot prevent
damage although 10% might see or feel it.
Figures 3 shows that 32% of the respondents can
feel, 30% can see tissue slippage and are able to prevent
it. In total, seven percent of the respondents can not

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 424
Figure 1. Images of laparoscopic grasp-
ers (see question 2).
see or feel when tis sue is about to slip. Some 31% o f the
respondents can see or feel slippage but they cannot do
anything to prevent it. The results state that 94% of the
respondents indicate that they notice tissue slippage,
however, 38% of the respondents indicate that they can-
not prevent it. These results show that there is a high
percentage of the surgeons who cannot prevent tissue
damage through slip. Heijnsdijk et al. [8] discovered
during a study carried out during 10 laparoscopic colec-
tomies and 15 cholecystectomics conducted by experi-
enced surgeons that the bowel slipped out of the grasper
in 7% of the grasp actions, whereas the gallbladder
slipped out in 17% of cases. Thus, it seems that even
experienced surgeons have difficulty maintaining an
accurate p i nch force.
In total, 32% of the respondents are aware of the exis-
tence of research projects linked to augmented feedback
on pinch force information within laparoscopy and the
respondents this questionnaire was the first time they
heard anything about it. This could indicate that sur-
geons are not concerned about this issue. However, if we
look at the questionnaire response rate, we see that sur-
geons are concerned. Further research into this topic is
therefore important. In addition, the results of these
studies should be made easily accessible to surgeons.
Figure 2. Respondent awareness of excessive pinch force usage. Answer on question 3. “Do you notice
when you are about to apply too much pinch force on the tissue?”
Figure 3. Respondent awareness of tissue slippage. Answer on question 4. “Do you notice when tissue
is about to slip?”

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 425
Ultimately 12% of the respondents had experience
with some form of augmented feedback regarding pinch
force within laparoscopy. Table 3 shows which form of
augmented feedback these surgeons had experience with.
Some respondents had experience with more than one
form of augmented feedback. The majority used visual
(95%) or tactile feedback (81%).
In total, 18% of the respondents had used a form of
augmented feedback on pinch force information, during
their virtual reality training. Table 4 shows the form of
augmented feedback that the respondents used during
virtual reality training. Some respondents had had experi-
ence with various forms of augmented feedback during
their virtual reality training. However, the majority used
visual or tactile feedback.
The results of questions six and seven show that tac-
tile and visual augmented feedback is used in research
much more frequently than audible and proprioceptive
feedback. This can be explained by the fact that addi-
tional audible signals in the operating room will distract
the surgeon, as there are so many other sounds already.
Augmented proprioceptive feedback is technically more
difficult to implement and it will be hard for the surg eon
to interpret unless a natural reaction is provoked.
The questionnaire gave the respondents the opportu-
nity to indicate their preferred augmented feedback form
as an indication of the levels of pinch force. Figure 4
shows the preferences of the respondents. Most of the
respondents would prefer to use tactile feedback as an
indication of the level of pinch force (77%), followed by
visual feedback (39%). Only 7% of the respondents do
not like to use augmented feedback as an indication of
the level of pinch force.
Table 3. The form of augmented feedback regarding pinch
force that respondents had experienced within laparoscopy.
Form of addition a l
feedback Number of respondents* % of respondents
Visu al feedback 20 95
Audible feedback 0 0
Tactile feedback 17 81
Proprioceptive feedback 7 33
Otherwise, (open response)0 0
*Twelve percent of the total number or respondents answered question
6 with ‘yes’. The number and percentage of respondents out of this
twelve percent who used this form of augmented feedback during
laparoscopy is indicated.
Note that some respondents had experienced multiple forms of aug-
mented feedback.
Table 4. The form of augmented feedback regarding pinch
force that respondents had experienced during virtual reality
training.
Form of augme n ted
feedback Number of respondents* % of respondents
Visu al feedback 19 61
Audible feedback 6 19
Tactile feedback 19 61
Proprioceptive feedback 5 16
Otherwise, (open response)2 6
*Eighteen percent of the total number or respondents answered ques-
tion 6 with ‘yes’. The number and percentage of respondents out of
this eighteen percent who used this form of augmented feedback dur-
ing laparoscopy is indicated.
Note that some respondents had experienced multiple forms of aug-
mented feedback.
Figure 4. Preferred form of augmented feedback as indication of the levels of applied pinch force. Answer on question
8. “Which form of feedback would you like to use as an indication of the levels of pinch force ?”

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 426
During laparoscopic procedures, 64% of the respon-
dents do not look at their hands while performing la pa ro -
scopic surgery, while 7% do look several times, 9%
look frequently and 20% regularly look at their hands.
When the respondents look at their hands, 30% (n = 19)
of them look at the hand position on th e handle, 2 4% (n
= 15) look at the fingers on the handle, 49% (n = 31)
look at the position of the handle and 21% (n = 13) look
at other things, for example the hand position relative to
the abdomen, angle of instrument to the abdomen and
the open or closed position of the handle. These results
show that the handle is not the most suitable place to
position a visual augmented feedback display but that it
might be appropriate to have a tactile or proprioceptive
display on the handle .
Twenty-one percent of the respondents have taken
part in the modification and/or development of laparo-
scopic instruments. Twenty surgeons of that group (56%)
initiated the innovations themselves, and 25% (9) of
them indicated that a colleague instigated the develop-
ments. Manufactures were cited in 19% (7) of cases as
being responsible for the modification and/or develop-
ment of laparoscopic instruments. None of the modifica-
tions or developments was enforced by the hospitals.
This means that surgeons will use/develop new instru-
ments when they are convinced of the added value with
respect to the old instrument.
The respondents were asked if a new atraumatic
grasper with additional haptic feedback is necessary.
This question was answered with a ‘yes’ by 79% of the
respondents. In their reply the respondents emphasized
the safety of the grasper and the fact that it will prevent
damage. The respondents who indicated that a new
atraumatic grasper is not necessary are satisfied with the
current laparoscopic instruments. Even though some of
the respondents indicated that they notice when tissue is
about to slip and that they can prevent it happening, 93
percent would like to have a laparoscopic instrument that
provides some form of augmented feedback for slipping
tissue. The conc lusion theref ore is that a new atraumatic
grasper with augmented haptic feedback might help to
reduce tissue damage.
Finally, 99% of the respondents are open to technical
changes in the field of laparoscopic instruments; only
1% of the respondents were not open to changes and
indicated that the current laparoscopic instruments are
fine. Should this research be continued, 95% of the re-
spondents declared themselves willing to participate in
follow-up studies. This could mean that when a new
laparoscopic instrument is introduced which contains
augmented haptic feedback, a high proportion of the
surgeons will want to use it.
3.2. Results of the Categories
There were no major differences in the response between
the twelve groups (4 levels in each category). However,
there were some minor differences and these are listed
below.
Experienced surgeons (1000-2000 operations), use
grasper 1 (62%) more frequently than the less experi-
enced ones (33%). More experienced surgeons (> 2000
operations or 15-20 years of experience) indicate more
frequently (63 and 61% respectiv ely) than surgeo ns with
less than 5 years of experience (19%) that they can feel
when they are applying excessive pinch force to the tis-
sue. Regarding the use of visual verification to deter-
mine whether they are about to apply excessive pinch
force, the difference between these categories is minimal.
Less experienced surgeons find it more difficult to pre-
vent tissue damage than experienced surgeons (> 2000
operations, 15-20 years experience and > 60 age). This
means that experience leads to a better interpretation of
the task-intrinsic feedback. However, the learning curve
for laparoscopic grasp control is long and even experi-
enced surgeons do have difficulty using task-intrinsic
feedback.
Surgeons of 60 years an d older are no t always the per-
sons with the most experience in laparoscopic proce-
dures. In contrast to the others, the category over the age
of 60 does not have experience (0%) with virtual reality
training regarding augmented feedback on pinch force.
This is probably due to the fact that these techniques did
not exist when they where being educated. In addition,
this category of surgeons looks more to their hands dur-
ing any given procedure (50% in this category as op-
posed to 30% in the categories > 2000 operations or with
15-20 years of experience). The last minor difference is
that less experienced surgeons (< 500 operations, < 5
years experience or < 40 years) indicate not having been
involved in new developments compared to the other
categories. This is obviously attributable to the fact that
less experienced surgeons might think they do not have
enough experience to innovate change.
4. CONCLUSIONS
The aim of this study was to estimate the opinions and
experiences of surgeons with the use of laparoscopic
bowel graspers from the point of view of haptics, Thanks
to the large number of respondent’s research and devel-
opment of new instruments can now address the needs of
the surgeons themselves.
In 38% of the cases the damage, according to the re-
spondents, emanates from slip and in 16% of cases
damage is attributable to excessive pinch force. This
kind of tissue damage has to be reduced, possibly by
using a laparoscopic instrument with augmented feed-
back on the levels of pinch force. The outcome of this
study indicates a clear need for research and for the de-
velopment of a new instrument with augmented feed-
back on force information and slippage.

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 427
REFERENCES
[1] Cuschieri, A. (1995) Whither minimal access surgery:
Tribulations and expectations. American Journal of Sur-
gery, 169, 9-19.
[2] Moreno-Egea, A., Torralba, J., Morales, G., Fernandez, T.,
Guzman, P., Hita, G., Girela, E., Corral, M., Campillo, A.
and Aguayo, J. (2005) Laparoscopic repair of secondary
lumbar hernias: Open vs. laparoscopic surgery. A pro-
spective, nonrandomized study. Cirugia Espanola, 77,
159-162.
[3] Dedemadi, G., Sgourakis, G., Karaliotas, C., Christofides,
T., Kouraklis, G. and Karaliotas, C. (2006) Comparison
of laparoscopic and open tension-free repair of recurrent
inguinal hernias: A prospective randomized study. Surgi-
cal Endosco py, 20, 1099-1104.
[4] Roumm, A., Pizzi, L., Goldfarb, N. and Cohn, H. (2005)
Minimally invasive: Minimally reimbursed? An exami-
nation of six laparoscopic surgical procedures. Surgical
Innovations, 12, 261-287.
[5] Stefanoni, M., Casciola, L., Ceccarelli, G., Spaziani, A.,
Conti, D., Bartoli, A., Zitti, L.D., Bellocchi, R. and Valeri,
R. (2006) The biliopancreatic diversion. A comparison of
laparoscopic and laparotomic techniques. Minerva Chi-
rurgica, 61, 205-213.
[6] Stassen, H.G., Dankelman, J., Grimbergen, C.A. and
Meijer, D.W. (2001) Man-machine aspects of minimally
invasive surgery. Annual Reviews in Contr o l, 25, 111-122.
[7] Dankelman, J., Wentink, M. and Stassen, H.G. and Gouma,
D.J. (2003) Human reliability and training in minimally
invasive surgery. Minimally Invasive Therapy and Allied
Technologies, 12, 129-135.
[8] Heijnsdijk, E.A.M., Dankelman, J. and Gouma, D.J.
(2002) Effectiveness of grasping and duration of clamp-
ing using laparoscopic graspers. Surgical Endoscopy, 16,
1329-1331.
[9] Westebring-van der Putten, E.P., van den Dobbelsteen,
J.J., Goossens, R.H., Ja kimowicz, J.J. and Dankelman, J.
(2009) Force feedback requirements for efficient laparo-
scopic grasp control. Ergonomics, 52, 1055-1066.
[10] Westebring-van der Putten, E.P., Goossens, R.H.M., Jaki-
mowicz, J.J. and Dankelman, J. (2008) Haptics in mini-
mally invasive surgery-a review. Minimally Invasive
Therapy and Allie d Te chnol og ies , 17, 3-16.
[11] Widmaier, E.P., Hershel, R. and Strang, K.T. (2004) Vand er,
Sherman, and Lucano's Human Physiology, The mecha-
nisms of body function, 9th Edition, McGraw-Hill, 207-
266.
[12] Westebring-van der Putten, E.P., van den Dobbelsteen,
J.J., Goossens, R. H.M., Jakimowic z, J.J. and Danke lman,
J. (2009) Effect of laparoscopic grasper force transmission
ratio on grasp control. Surgical Endoscopy, 23, 818-824.
[13] Westebring-van der Putten, E.P., Lysen, W.W., Hensen,
V.D., Koopmans, N., Goossen, R.H.M., van den Dobbel-
steen, J.J., Dankelman, J. and Jakimowicz, J.J. (2009)
Tactile Feedback exceeds visual feedback to display tis-
sue slippage in a laparoscopic grasper, Ios Press, 142,
420-425.

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Appendix: Questionaire
Laparoscopic operations in general
1. How many years have you been using laparoscopic surgery?
2. Which of the pictures below best represents the laparoscopic grasper you use to grasp bowel tissue ? The pictures are pre-
sented in Figure 1.
3. Do you notice when you are about to apply too much pinch force on the tissue?
- Yes, I can feel it, but I cannot do anything to prevent it.
- Yes, I can feel it, and am able to adjust my pinch force to prevent damage.
- Yes, I can see it on the monitor, but I cannot do anything to prevent it.
- Yes, I can see it on the monitor, and am able to adjust my pinch force to prevent damage.
- No, I cannot see or feel it when I apply too much pinch force to the tissue.
4. Do you notice when tissue is about to slip?
- Yes, I can feel it, but I cannot do anything to prevent slippage.
- Yes I can feel it, and am able to prevent the tissue from actually slipping.
- Yes, I can see it on the monitor, but I cannot do anything to prevent slippage.
- Yes, I can see it on the monitor, and am able to prevent the tissue from actually slipping.
- No, I cannot see or feel slippage before the tissue is actually out of the grasper.
Laparoscopic surgery and augmented feedback
5. Are you well informed on research into augmented feedback on pinch force information within laparoscopy?
- Yes, I have read studies.
- Yes, I take/took part in similar research.
- Yes, (open response).
- No, (open response).
The following definitions are used in questions 6 ,7 and 8: Tactile perception relates to the perception of pressure, vibration, and texture (also
sometimes called discriminative touch or cutaneous sense), and relies on different receptors in the skin (cutaneous mechanoreceptors). Proprio-
ception (haptics) concerns the perception of posture and the position of the limbs, body and head in space and their positioning relative to each
other, including the vestibular system, cutaneous sense and kinesthesia
6. Do you have experience with a form of additional feedback regarding pinch force within laparoscopy?
- Yes, from another research project. This research is about:
- Visual feedback.
- Auditive feedback.
- Tactile feedback.
- Proprioceptive feedback.
- Otherwise, (open response).
- No.
7. Have you used a form of additional/alternative feedback on pinch force information, during a virtual reality training exer-
cise?
- Yes, what kind of fe edback have you used?
- Visual feedback.
- Auditive feedback.
- Tactile feedback.
- Proprioceptive feedback.
- Otherwise, (open response).
- No.
8. Which form of feedback would you like to use as an indication of the levels of pinch force?
- Visual feedback.
- Auditive feedback.
- Tactile feedback.
- Proprioceptive feedback
- Otherwise, (open response).
- No feedback.
9. Do you look at your hands while performing laparoscopic surgery?
- Yes, several times (once or twice every 10 minutes) during surgery.
- Yes, frequently ( once or twice during every surgical procedure).
- Yes, regularly (but not during every surgical procedure).
- No, never.

E. P. Westebrin g-van der Pu tt en et al. / J. Biomedical Science and Engineering 3 (2010) 422-429 429
10. When you look at your hands what do you look at?
- My hand position on the handle.
- My fingers on the handle.
- The position of the handle.
- Otherwise, (open response).
Laparoscopic surgery and involvement
11. Have you taken part in the modificatio n/development in laparoscopic instruments?
- Yes.
- No.
12. Who was responsible for the initiation of these changes?
- Self initiated.
- Instigated by a colleague.
- Enforced by the hospital.
- Enforced by the manufacturer.
13. Do you think a new atraumatic grasper with additional haptic feedback is necessary?
- Yes, because (open response).
- No, because (open response).
14. Are you open to technical changes in the field of laparoscopic instrumentation?
- Yes, I am open to changes and their applications.
- Yes, I am open to changes, will probably continue to use the current laparoscopic instruments.
- Yes, (open response).
- No, I am not open to changes, the current laparoscopic instruments are working fine.
- No, (open response).
15. Are you willing to take part in follow-up research, possibly including a test with a prototype?
- Yes, you may contact me in the future.
- No, I am not interested.