Left-handed resident phacoemulsification training by right-handed trainers – A case series and review of literature

Dear Editor,

The impact of hand dominance on surgical performance has been studied across various medical specialities,[1,2,3,4] but little has been said about how to train and prepare left-handed ophthalmic surgeons. We tried to identify the challenges in training and describe our technique of mentoring left-handed residents for cataracts by right-handed mentors. We also describe our experience in the first 15 cases with our methodology.

A structured training module was formulated for a left-handed trainee (described below). It involved a three-tier training including training on goat eye, surgical simulator (VRMagic, Mannheim, Germany), and hands-on training in the operating room.

Each step of phacoemulsification requires a modification for a left-handed trainee. The trainers watched and guided the resident trainees through the observer side-viewing tube of the operating microscope stationed in the wet lab. For operating on the right eye, the trainee was asked to sit temporally and make the main port between 10 o’clock and 11 o’clock and side ports at 7 o’clock and 2 o’clock [Fig. 1], hence enabling the mentor to assist from the superior side and take over the phaco probe if needed. The port at 2 o’clock was used to stain the anterior capsule. For the left eye, the trainee was asked to perform superior phacoemulsification (with the main port supratemporal) and the trainer sat on the temporal end. In our experience, it was easier for the left-handed trainee to make a capsulorhexis in the clockwise direction [Fig. 2]. If an extension was seen or anticipated, the mentor would complete the capsulorhexis in the anticlockwise direction from the other end of the flap. The trainee used the second instrument in the right hand for the rest of the phacoemulsification steps. If a surgeon’s takeover was needed, it involved changing the foot pedals of the microscope and machine. Intraocular lens (IOL) docking and injection were practiced in the wet lab. Since the IOLs are designed for right-handed trainees, the dialing was only taught clockwise. Stabilization of syringes and their hub with the right hand and using the plunger with left hand were also encouraged. Extension of incision was easier on the right side by left-handed trainees, so this practice was followed. The overall flow of the training is described in Fig. 3. The problems listed by them in a feedback proforma included training by right-handed mentors, anxiety, initial delay in acquiring the right skills and a lack of confidence, feeling out of place, pressure to use the right hand as most surgical instruments are for right-handed people, and unawareness of their problem. Two out of the 15 cases had difficult capsulorhexis, for which the mentor took over (13.3%). Descemet detachment was observed in one case, localized at the side port settled with air injection on table (0.06%). In one case, there was a posterior capsular rent with vitreous loss during phacoemulsification (0.06%). The mentor completed the surgery, and the IOL was implanted in the sulcus. Rest of the surgeries was completed successfully with only passive assistance from the mentor. There was no difference in the complication rates (5.94% vs. 0.06%, P = 0.29) or surgeon takeover rate (10.8% vs. 13.3%, P = 0.7) among right-handed and left-handed residents, respectively, in the same time period.

Figure 1.

Port site selection for a left-handed trainee and a right-handed mentor. By choosing this position, the mentor could easily take over without having to shift their position. MP = main port, SP = side port

Figure 2.

Capsulorhexis in the clockwise direction by the left-handed trainee demonstrated on the simulator (a) Initiation and (b) Completion

Figure 3.

Flow chart with flow of the training schedule and steps followed by all trainees

After a thorough literature search, the major tutoring issues for left-handed ophthalmic trainees were framed and are summarized in Table 1. Table 2 lists the strategies to improve the guidance for left-handed trainees. We disagree with some authors that the handedness of the mentor does not play a role in supervising ophthalmic surgery.[1] When common surgical steps are performed, it is challenging if the trainees’ dominant hand does not match with the supervisor’s dominant hand. Planning surgical steps in such a scenario can enhance the training experience, reduce bias, and alleviate the anxiety of left-handed trainees. The provision of a left-handed mentor and other environmental modifications could be used to minimize the recurring difficulties for left-handed learners.

Table 1.

Training problems of left-handed ophthalmic trainees

1. Handedness affecting the acquisition of certain skills – left-handed trainees may feel necessitated to use the right hand because of instrumentation, literature, and mentors who are right handed. This leads to an initial delay in acquiring the right skills and a lack of confidence[5]

2. Lack of left-handed mentors – Overall, since right-handed trainees are more in number, they may face difficulties assisting left-handed people. Failure to recognize the problems a left-handed trainee faces might make them feel alone and disheartened[6,7]

3. Anxiety and pressure to adapt to right-handed maneuvers

4. Most surgical instruments including intraocular lenses are designed for right-handed people

5. There might be limited advantages to left handed surgeons like easy in chopping by a second instrument. With practice, the left-handed ophthalmic trainee might have lesser complications than the right-handed trainee[1]

6. Potential for needle stick injuries may be more once the trainee reaches over with the left hand when the staff is expecting the right[5]

Table 2.

Strategies to improve training of left-handed ophthalmic trainees

1. Identification of left-handed residents 2. Pairing with left-handed mentor if possible 3. Wet lab and/or simulator structured programs 4. Not forcing left-handed residents to use their right hand for major maneuvers 5. Operating room and phaco machine, trolley positioning 6. Choosing temporal phaco for the right eye and side port positions 7. Practice and more practice 8. Promoting ambidexterity once core training is complete 9. Increasing awareness of problems by left-handed trainees 10. Standardization and policymaking including structured surgical training modules for left-handed residents

Literature is scarce on left-handed surgical maneuvers, and available textbooks describe the training mostly for right-handed trainees. Left-handed trainees may be underrepresented and there is a need to improve their visibility. Accurate mentoring of left-handed trainees is a must. Consultants and trainers responsible for their training programs lack knowledge about the problems faced by left-handed ophthalmic trainees.[8] This paper seeks to eliminate the barriers in formal teaching of left-handed cataract trainees. We need steps to increase awareness and modify training modules to ease their challenges. Simulator training can be advantageous in increasing our dexterity.[9,10] The development of a customized and standardized model for left-handed trainees and adaptations by mentors can reduce the challenges a left-handed cataract trainee faces.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.