Control Location Using Two Commands: Hand Versus Foot, Workload and Accuracy Response Trial: A Randomized Controlled Trial in Robotic Surgery Simulation

Study Rationale and Scientific Background Surgical techniques have evolved from conventional open surgery to minimally invasive laparoscopic approaches, which reduce surgical trauma, postoperative pain, and length of hospital stay. Despite these advancements, complex operations remain time-consuming and physically demanding, placing significant ergonomic strain on surgeons. Robotic-assisted surgery addresses these limitations by enhancing precision, improving visualization, and optimizing ergonomics.[4] As robotic platforms become integrated into modern surgical practice, trainees face exposure to these systems early in their careers. Effective use of robotic technology requires motor and cognitive skills that differ fundamentally from open or laparoscopic approaches.[7] Among these skills, mastery of clutch control plays a pivotal role in ensuring efficient instrument positioning, maintaining a stable working posture, and minimizing unnecessary movements.[6,8,10] Inappropriate or inefficient clutch use can disrupt surgical workflow, increase cognitive workload, prolong task completion time, and contribute to early operator fatigue.[3,6] These challenges are particularly evident during the initial learning phase of robotic surgery. Inefficiencies during this early period have downstream clinical implications, as increased operative time, excessive instrument movement, and higher cognitive workload are associated with technical errors, surgeon fatigue, and potentially compromised patient safety.[1,5] Optimizing fundamental console skills like clutch control may improve simulator performance and contribute to safer, more efficient operative performance in clinical practice.[7,10] Foundational habits established early may persist throughout a surgeon's career, making early training critical.

Modern platforms like the Da Vinci Xi system offer multiple clutch control modalities, most commonly the hand clutch and the foot clutch. Previous simulation research has primarily focused on validating simulator platforms, assessing general psychomotor skill acquisition, or comparing novice and expert performance. Few investigations have specifically examined how different clutch control modalities influence performance metrics during early skill acquisition, as existing literature largely evaluates overall proficiency rather than isolating clutch control as a specific technical component. Consequently, the relative advantages of hand clutch versus foot clutch in facilitating efficient instrument repositioning and minimizing cognitive workload remain poorly defined. Additionally, prior studies often include heterogeneous participant groups with varying laparoscopic or robotic exposure, making it difficult to isolate the true effect of clutch modality on individuals without prior robotic experience. Clarifying this effect in true novice users is essential for developing structured training curricula.

Definitions for Intervention Group

The trial isolates and compares the two distinct control interfaces provided by the Da Vinci Xi console for instrument clutching:

1. Hand Clutch group This control utilizes a dedicated finger clutch button located on the master controllers. Proper execution requires the user to place their thumb and middle finger into the Velcro loops of the controllers, leaving the index finger free to manipulate the button. To execute a clutch, the user must pull back the button and hold it, move their hand to the desired ergonomic location, and then release the button to re-engage instrument control. This modality allows for the repositioning of individual hands independently to optimize workspace placement.
2. Foot Clutch group: This control utilizes the footswitch panel located at the base of the console. The master clutch pedal allows for the simultaneous repositioning of both hands without moving the surgical instruments. Depressing the pedal disengages the master controllers from the instrument arms, allowing the user to reposition their hands to a neutral, ergonomic posture before releasing the pedal to resume active manipulation.