Minimally invasive surgery for the left-handed surgeon: a narrative review

Introduction

Left-handedness is a rare trait with only 12% of the US population identified as left-hand dominant. Left-handed individuals face multiple practical concerns in a mainly right-hand dominant population. This translates to technical fields involving manual dexterity, namely surgery. In surgical fields, left-handed trainees are forced to adapt to standardized operating approaches favoring right-handed surgeons. Trainees are therefore at an inherent disadvantage. There is also a true lack of attention given to trainee handedness. Left-handed trainees are recognized late, exposed to poor mentorship, and leave training with a diminished sense of confidence in their technical skills. Appropriate mentorship is crucial for the appropriate development and education of left-handed surgical trainees (1). We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-23-26/rc).

Methods

A comprehensive literature search was employed using the following search strategy on PubMed: ((“Thoracoscopy”[Mesh]) OR (“Minimally Invasive Surgical Procedures”[Mesh]) OR (“Laparoscopy”[Mesh]) OR (“Hand-Assisted Laparoscopy”[Mesh])) and (“left-handed” OR “left handed” OR “left-hand” OR “left hand”). Excluded titles were those involving non-general surgery (e.g., cardiac, neurosurgical, etc.) as presented in Figure 1. The reason for those exclusions is that the authors were most interested in performing this literature review from the focus of the general surgeon. All articles were first screened manually, and then final selection was determined by the primary authors (P.K.F. and A.H.V.). The articles were specifically selected on the basis of their ability to provide a synopsis of left-handed proceduralists in general surgery. A total of 225 articles were obtained and screened for applicability, with a total of 14 included in this review. This is summarized in Table 1.

Figure 1 PRISMA flow diagram for detailed literature search.

In this comprehensive review, we address the following questions: (I) What are the general challenges of left-handed surgeons? (II) What are the challenges of laparoscopic surgery and left-handed surgeons? (III) What are the challenges of robotic surgery and left-handed surgeons?

General overview of left-handedness in general surgery

Left-handed surgeons represent a minority by making up 10–12% of all surgeons in practice (2). Most general surgery training is designed for the right-handed trainee. Left-handed trainees are forced to conform to right-hand dominant techniques. They must accommodate themselves to an environment that is otherwise not conducive to their handedness. This can lead to lack of comfort and the development of bad habits. A retrospective study by Nagaraj et al. investigated the effect of handedness in surgery for first year trainees (3). It was noted that only 13% of residents were reported to have access to left-handed instruments (3). Also, less than 10% of residents received left-handed specific mentoring during residency. This apparent lack of resources, specifically instrument availability and mentorship, can present left-handed trainees with many challenges. It is most important to acknowledge how this translates to their self-perception. Approximately 10% of left-handed surgeons reported that, if they were the patient, they would not be comfortable having surgery performed by a left-handed surgeon (4). This implies that there is a true lack of awareness and need for change in their training.

Studies have shown that left-handed surgeons tend to make more unnecessary moves compared to their right-handed counterparts when performing laparoscopic tasks (4). As a result, mentors instruct left-handed individuals to preferentially use their non-dominant hand. This can negatively affect the efficiency and flow of a case. Hence, appropriate mentorship is crucial for the appropriate development and education of left-handed trainees (4). Dedicated training can allow for improved intra-operative safety and limited inherent risks to the patient associated with a lesser technical ability.

Left-handed trainees are often paired with right-handed trainers. These mentors may not have had experience nor formal training in teaching left-handed individuals. Anderson et al. surveyed 30 medical institutions to gauge how handedness affects teaching abilities (5). Left-handed surgeons demonstrated more experience in teaching left-handed trainees as opposed to right-handed surgeons (84% vs. 75%) (5). About 46% of right-handed surgeons reported increased difficulty in teaching left-handed trainees compared to 16% of left-handed surgeons (5). Lastly, 28% of right-handed surgeons were more comfortable teaching right-handed trainees as opposed to 4% of left-handed surgeons (5). This survey demonstrates the bias within the traditional general surgery curriculum. This brings to attention the inherent difficulty experienced by the attending surgeon when training an individual with contralateral handedness.

Further studies have demonstrated that use of the non-dominant hand in surgery is associated with inadequate performance regardless of handedness. Cho et al. investigated how handedness affected medical student suturing curricula (6). Students randomized to concordant training curricula performed significantly better in comparison to students facing discordance in their hand preference. There was no statistical difference between left-handed and right-handed individuals in concordant groups (6). This study revealed that appropriate left-handed instruction could significantly reduce the disadvantages that left-handed trainees face in right-hand focused training environments (6). There is potential for a dedicated training curriculum to be developed to eliminate these disadvantages.

Laparoscopy in general surgery and left-handedness

Laparoscopy and robotic surgery can be affected by surgeon handedness. Adusumilli and colleagues refute the idea that laparoscopy has eliminated the disadvantage of left-handed trainees. In fact, as laparoscopy requires a static position of the neck and torso, trainees are forced to contort their extremities to extremes in order to proceed with their tasks. This makes ergonomics a significant factor in surgeon comfort and performance (4). Multiple studies have shown that left-handed surgeons tend to make more unnecessary and less accurate movements when performing laparoscopic tasks. In response to this, mentors instruct left-handed individuals to use their non-dominant hand preferentially, which may negatively affect patient safety. For example, let’s consider a standard laparoscopic cholecystectomy. Camera guidance or retraction is traditionally performed by the surgeon’s left hand whereas dissection is performed by the right hand. This meticulous dissection necessary to achieve a critical view of safety with one’s non-dominant hand can present as a challenge.

In order to teach left-handed trainees, it is vital to incorporate laterality-specific training paradigms to improve efficiency and shorten surgeon learning curves. An example of this includes various configurations of surgeon positioning and port placement.

Multiple studies have presented these configurations to overcome this barrier. Pouw et al. recommend that the left-handed surgeon stands either between the legs or on the patient’s left side (7). The patient is positioned supine. Camera port is placed at the umbilicus and the trocar for the fundus-retracting forceps is placed in the right iliac fossa. Next, a mid-epigastrium port is placed to grasp Hartmann’s pouch and the working port is placed in the right subcostal region. Dissection of Calot’s triangle is performed similar to the standard approach though the dissection of cystic duct and artery is performed from the right side of the patient. Initial dissection to expose the gallbladder is performed similar to standard cholecystectomy (7). Though dissection of the cystic duct and artery is primarily performed on the right side (7). Although this requires the placement of an additional port, it has been a viable alternative for left-handed surgeons.

Tavassoli et al. suggest a slightly different configuration. This configuration involves a modification in trocar placement compared to the standard approach. The left-handed surgeon and first assistant both stand on the patient’s left side (8). The patient is positioned supine. A port is placed into the umbilicus to function as a camera port and the port is placed in the subxiphoid region. This is all consistent with the standard approach. The difference is that the third port is placed in the left paramedian halfway between the umbilicus and subcostal border at midclavicular line (8). Forty surgeries were performed using this modified method with 5% complication rate in two surgeries namely bleeding and bile leak from liver bed (8). There were no reports of associated complications, specifically bile duct injury (8).

These variations in configurations for a laparoscopic cholecystectomy are safe options to consider for the left-handed surgeon. These techniques are possible alternatives for left-handed surgeons who are less comfortable performing advanced maneuvers with their non-dominant hand. It also avoids the need to adapt to a right-handed method which may not otherwise be as ergonomically favorable. Left-handedness in laparoscopy though can inherently also be an advantage. Intra-thoracic and intra-abdominal organs are asymmetric, and in laparoscopic surgery, which is subject to visual field limitations and movement restrictions, left-handed surgeons have the advantage of ambidexterity.

True ambidexterity is defined as an innate ability to equally use both hands. Acquired ambidexterity may be more common in left-handed individuals who self-report naturally alternating their hands for various activities. A case report by Ren et al. discussed port placement for laparoscopic cholecystectomy in a patient with complete situs inversus (9). Surgeons employed a modified four-port placement technique that was left-sided by employing a technique to mirror standard port placement (9). The entire surgery was successfully performed by the left hand of a right-hand dominant surgeon (9). This concept of modifying port placement can also apply to patients without situs inversus. As previously mentioned, Pouw et al. investigates a left-hand favorable modification with assist with laparoscopic cholecystectomy (7). This involves the surgeon positioned on the patient’s left, camera port at umbilicus, fundus-retracting forceps in right iliac fossa, and mid-epigastrium port for grasping Hartmann’s pouch (7). A 10-mm working port is placed in right subcostal region. Initial dissection to expose the gallbladder is performed similar to standard cholecystectomy (7). But dissection of the cystic duct and artery is primarily performed on the right side. The ambidextrous use of both hands can overcome movement limitations. This is possible by allowing the surgeon to exchange dissection and retraction between both hands without significant limitations in technique. Although these cases are rare, these techniques are possible alternatives for left-handed surgeons who are less comfortable performing advanced maneuvers with their non-dominant hand (7).

In laparoscopy-naive surgical residents, a prospective study by Powers et al. concluded that left-handed surgeons had higher baseline pretest scores when performing the six tasks employed by the validated McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) laparoscopy training curriculum (10). Additionally, left-hand dominant trainees demonstrated improved skills in pattern cutting and ligating loop application. These tasks involve simultaneous use of both hands to the use of each hand independently to perform tasks (10). This acquired ambidexterity can be advantageous for any surgeon. This is especially important in laparoscopy where movement is limited. A dedicated curriculum to incorporate laterality-specific training may harness this advantage, and also overcome the previously discussed limitations of left-hand dominant trainees and improve safety.

A retrospective cohort study by Nagaraj et al. shows that acquired ambidexterity may be an important element of mastering laparoscopy, and that being left-hand dominant shows less variability in performance in skills tasks (3). This is not only noted in simple transfer tasks but also more complex tasks with increasing discordance as well. The delta variation or difference in task time between non-dominant and dominant hand supports that this manual asymmetry and variation in skills acquisition is in fact higher in right hand dominant trainees. Right-handed trainees tend to train their dominant hand while neglecting their non-dominant hand compared to those who are left-handed who train both equally. Therefore, there is an advantage in left-hand dominance, namely that acquired ambidexterity is easier for these individuals (3).

Robotics in general surgery and left-handedness

Robotic surgery is thought to eliminate the biases of handedness. This novel technique in surgery has gained significant attention due to its greater degree of freedom in rotational and fine motor capabilities. Laparoscopy has inherent disadvantages, namely movement limitations, two-dimensional visualization and suboptimal ergonomics. Hand dominance and limited dexterity can make laparoscopy difficult to perform because of these limitations. Robotic surgery obviates the limitations in hand dominance experienced in laparoscopy (11). A 2014 study by Badalato et al. studied hand preference in a population of right-handed urology and OBGYN residents (11) Participants were asked to complete certain tasks using open surgical skills and da Vinci robot system (11). Of the 10 subjects, left to right-hand usage ratios dropped from 1.45 down to 1.12 when switching from open techniques to the robot (11). Additionally, times of completion between open and robotic tasks dropped from an average of 12.5 to 8 seconds (11). The sample size is small and excluded left-handed trainees in this study (11). Badalato et al. suggest that left-handed robotic surgeons may be able to operate without having to adjust for their hand preference (11). While studies such as these are small, robotic surgery is an option for left-handed minimally invasive surgeons to operate without the limitation of hand dominance.

In fact, those who have developed manual ambidexterity during their training, such as left-handed trainees performing right-handed laparoscopy, may act as predictors of proficiency in robotic surgery. In a study by Yang et al., 32 patients were evaluated on their dexterity by performing Grooved Pegboard Test (12). Interestingly, the degree of robotic dexterity was dependent on ambidexterity rather than dexterity speed.

In a 2018 prospective study by Choussein et al., surgeons of all levels of training including residents, fellows, both junior and senior attendings were tested on skills within the Fundamentals of Laparoscopic Surgery (FLS) curriculum (13). This curriculum was provided using both robotic versus laparoscopic platforms. Based on performance reviews, robotic platforms essentially eliminated operative handedness and enhanced nondominant hand dexterity. Similar findings of handedness elimination during robotic simulation tasks were also observed in other studies. Mucksavage et al. compared the skillsets of left and right-handed trainees using the da Vinci robotics platform (14). Participants had significant differences between their dominant and non-dominant hand in open skills tasks using the Purdue Pegboard test (P=0.023) and needle targeting test (P=0.015) (14). When performing these same tasks on the da Vinci robot, these differences in performances on the skills tasks were no longer observed (P=0.203, P=0.764) (14).

Robotic surgery has been widely adopted over the past decade and has allowed for newer surgeons to overcome technical limitations of laparoscopy. Multiple studies have suggested that robotics can eliminate the limitations of handedness and allow for ambidexterity. However, this benefit must be balanced with the high financial costs of robotic surgery and its other technical shortcomings (e.g., availability, haptics).

Conclusions

Left-handed surgeons continue to be an under-represented minority in their field and face many technical challenges. As a result, left-handed surgeons have had to adapt to right-handed mentors and right-handed instruments often without any formal training. A dedicated curriculum involving laterality-specific training can bridge this gap in their training. Laterality-specific training can be incorporated by: teaching trainees to adjust body positioning, port placement, and handling of different instruments based on their handedness. A formalized curriculum for both surgical attendings and trainees needs to be developed in order to optimize training for the left-handed surgeon.

We suggest the following areas for further study and implementation:

• Specialized left-handed trays to include commonly used instruments including left-handed scissors, clamp and needle driver.
• Dedicated curriculum to assist with development of technical skills in the left-handed trainee. For example, this involves intensive practice with ratcheting of right-hand specific instruments and how to approximate the blades of right-handed scissors to cut.
• Dedicated curriculum for the right-handed trainer or attending to assist with how to teach and perform surgery with a left-handed trainee. For example, this involves the trainer understanding variations in body positioning relative to the patient to accommodate a left-handed trainee.
• Development of a standard approach to port placement in common laparoscopic general surgeries for left-handed surgeons. These modifications, when standardized, can be adapted by left-handed trainees to perform them independently.
• Adaptation of a structured learning pathway consisting of modules or exercises left-handed trainees can undertake. This can be translated to the operating room (OR) by the early involvement of left-handed mentors in the training of future left-handed surgeons.

It is important to recognize that left-handed surgeons represent a minority. A modified curriculum to assist both the left-handed trainee and right-handed surgeon can assist with promoting equity and inclusion. We recommend that the lack of a dedicated training curriculum for left-handed surgeons should be recognized and addressed.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “Latest MIS Approaches and Data”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-23-26/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-23-26/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-23-26/coif). The series “Latest MIS Approaches and Data” was commissioned by the editorial office without any funding or sponsorship. G.F. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from April 2023 to March 2025. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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