Construct validation of a novel hybrid surgical simulator

Background Simulated minimal access surgery has improved recently as both a learning and assessment tool. The construct validation of a novel simulator, ProMis, is described for use by residents in training. Methods ProMis is a surgical simulator that can design tasks in both virtual and actual reality. A pilot group of surgical residents ranging from novice to expert completed three standardized tasks: orientation, dissection, and basic suturing. The tasks were tested for construct validity. Two experienced surgeons examined the recorded tasks in a blinded fashion using an objective structured assessment of technical skills format (OSATS: task-specific checklist and global rating score) as well as metrics delivered by the simulator. Results The findings showed excellent interrater reliability (Cronbach’s α of 0.88 for the checklist and 0.93 for the global rating). The median scores in the experience groups were statistically different in both the global rating and the task-specific checklists (p < 0.05). The scores for the orientation task alone did not reach significance (p = 0.1), suggesting that modification is required before ProMis could be used in isolation as an assessment tool. Conclusions The three simulated tasks in combination are construct valid for differentiating experience levels among surgeons in training. This hybrid simulator has potential added benefits of marrying the virtual with actual, and of combining simple box traits and advanced virtual reality simulation.     

The role of mental rotation and memory scanning on the performance of laparoscopic skills

OBJECTIVE: The rotational angle of the laparoscopic image relative to the true horizon has an unknown influence on performance in laparoscopic procedures. This study evaluates the effect of increasing rotational angle on surgical performance. METHODS: Surgical residents (group 1) (n = 6) and attending surgeons (group 2) (n = 4) were tested on two laparoscopic skills. The tasks consisted of passing a suture through an aperture, and laparoscopic knot tying. These tasks were assessed at 15 degrees intervals between 0 degrees and 90 degrees , on three consecutive repetitions. The participant's performance was evaluated based on the time required to complete the tasks and number of errors incurred. RESULTS: There was an increasing deterioration in suturing performance as the degree of image rotation was increased. Participants showed a statistically significant 20-120% progressive increase in time to completion of the tasks (p = 0.004), with error rates increasing from 10% to 30% (p = 0.04) as the angle increased from 0 degrees to 90 degrees. Knot-tying performance similarly showed a decrease in performance that was evident in the less experienced surgeons (p = 0.02) but with no obvious effect on the advanced laparoscopic surgeons. CONCLUSIONS: When evaluated independently and as a group, both novice and experienced laparoscopic surgeons showed significant prolongation to completion of suturing tasks with increased errors as the rotational angle increased. The knot-tying task shows that experienced surgeons may be able to overcome rotational effects to some extent. This is consistent with results from cognitive neuroscience research evaluating the processing of directional information in spatial motor tasks. It appears that these tasks utilize the time-consuming processes of mental rotation and memory scanning. Optimal performance during laparoscopic procedures requires that the rotation of the camera, and thus the image, be kept to a minimum to maintain a stable horizon. New technology that corrects the rotational angle may benefit the surgeon, decrease operating time, and help to prevent adverse outcomes.     

The surgical efficiency score: a feasible, reliable, and valid method of skills assessment

BACKGROUND: Technical skills assessments are being increasingly used in surgical residency programs, with the objectivity and validity of several techniques well established. However, many of these methods are labor and time intensive, limiting their feasibility. This study aims to compare more efficient techniques of skills appraisals with an established gold standard. METHODS: Thirty surgeons completed 2 previously validated laboratory-based surgical models: small bowel anastomosis and vein patch insertion. Gold standard evaluation was the Objective Structured Assessment of Technical Skills (OSATS) method. "Efficient" techniques used were (1) quality of final product (FP); (2) snapshot assessment (SS), in which task performance was edited to a 2-minute sound bite and scored with OSATS; and (3) the surgical efficiency score (SES), a combination of final product quality and hand-motion analysis. All human observer evaluations used retrospective video analysis with 3 trained observers. Nonparametric tests were used to analyze the results. RESULTS: With respect to small bowel anastomosis, correlations with OSATS were as follows: FP 0.341 (P=.07), SS 0.577 (P<.001), and SES 0.842 (P<.001). For vein patch insertion, the correlations were as follows: FP 0.545 (P=.001), SS 0.609 (P<.001), and SES 0.700 (P<.001). Interobserver concordance was high for both models with respect to FP (Cronbach's alpha 0.80 for small bowel anastomosis and 0.84 for vein patch insertion). With respect to SS, interobserver reliability was high for vein patch insertion (Cronbach's alpha 0.80) but only moderate for small bowel anastomosis (0.59). CONCLUSIONS: The surgical efficiency score and snap shot assessments both show significant correlations with the traditional OSATS appraisals and suggest that skills assessment can be made more feasible. Correlations were closer with the former and interobserver concordance more variable with the latter, suggesting the surgical efficiency score as the most reliable of the methods evaluated.     

Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures

BACKGROUND: Minimally invasive surgery (MIS) has introduced a new and unique set of psychomotor skills for a surgeon to acquire and master. Although assessment technologies have been proposed, precise and objective psychomotor skills assessment of surgeons performing laparoscopic procedures has not been detailed. STUDY DESIGN: Two hundred ten surgeons attending the 2001 annual meeting of the American College of Surgeons in New Orleans who reported having completed more than 50 laparoscopic procedures participated. Subjects were required to complete one box-trainer laparoscopic cutting task and a similar virtual reality task. These tasks were specifically designed to test only psychomotor and not cognitive skills. Both tasks were completed twice. Performance of tasks was assessed and analyzed. Demographic and laparoscopic experience data were also collected. RESULTS: Complete data were available on 195 surgeons. In this group, surgeons performed the box-trainer task better with their dominant hand (p < 0.0001) and there was a strong and statistically significant correlation between trials (r = 0.47 - 0.64, p < 0.0001). After transforming raw data to z-scores (mean = 0 and SD = 1) it was shown that between 2% and 12% of surgeons performed more than two standard deviations from the mean. Some surgeons' performance was 20 standard deviations from the mean. Minimally Invasive Surgical Trainer Virtual Reality metrics demonstrated high measurement consistency as assessed by coefficient alpha (alpha = 0.849). CONCLUSIONS: Objective assessment of laparoscopic psychomotor skills is now possible. Surgeons who had performed more than 50 laparoscopic procedures showed considerable variability in their performance on a simple laparoscopic and virtual reality task. Approximately 10% of surgeons tested performed the task significantly worse than the group's average performance. Studies such as this may form the methodology for establishing criteria levels and performance objectives in objective assessment of the technical skills component of determining surgical competence.     

A Novel Clinical-Simulated Suture Education for Basic Surgical Skill: Suture on the Biological Tissue Fixed on Standardized Patient Evaluated with Objective Structured Assessment of Technical Skill (OSATS) Tools

Background: Clinical-simulated training has shown benefit in the education of medical students. However, the role of clinical simulation for surgical basic skill training such as suturing techniques remains unclear. Materials and Methods: Forty-two medical students were asked to perform specific suturing tasks at three stations with the different settings within four minutes (Station 1: Synthetic suture pad fixed on the bench, Station 2: Synthetic suture pad fixed on the standardized patient, Station 3: Pig skin fixed on the standardized patient); the OSATS (Objective Structured Assessment of Technical Skill) tool was used to evaluate the performance of students. A questionnaire was distributed to the students following the examination. Results: Mean performance score of Station 3 was significant lower than that of Station 1 and 2 in the general performance including tissue handling, time, and motion. The suturing techniques of students at Station 2 and 3 were not as accurate as that at Station 1. Inappropriate tension was applied to the knot at Station 2 compared with Station 1 and 3. On the questionnaire, 93% of students considered clinical-simulated training of basic surgical skills was necessary and may increase their confidence in future clinical work as surgeons; 98% of students thought the assessment was more objective when OSATS tool was used for evaluation. Conclusion: Clinical simulation examination assessed with OSATS might throw a novel light on the education of basic surgical skills and may be worthy of wider adoption in the surgical education of medical students.     

An ergonomic comparison of robotic and laparoscopic technique: the influence of surgeon experience and task complexity

BACKGROUND: This study compares the mental and physical workload of laparoscopic and robotic technique while performing simulated surgical tasks in a laboratory setting. MATERIALS AND METHODS: Ten volunteer surgeons performed two tasks in a laparoscopic trainer using laparoscopic (LAP) and robotic (ROB) techniques. Outcome measures included: Task time, task-error, vertical/horizontal arm displacement, percent maximum electromyographic signal from the thenar, forearm flexor, and deltoid muscle compartments, skin conductance, and perceived difficulty and discomfort levels. A two-way repeated-measures ANOVA compared surgical technique and laparoscopic experience level (E = expert, N = novice). RESULTS: For the simple task, ROB technique was slower and had higher errors, and the surgeon's arm was more elevated. For the complex task, ROB electromyographic signal was lower. Stress was lower in both tasks for ROB, but the decrease was not statistically significant. CONCLUSIONS: Robotic technique appears slower and less precise than laparoscopic technique for simple tasks, but equally fast and possibly less stressful for complex tasks. Previous laparoscopic experience has a complex influence on the physical and mental adaptation to robotic surgery.     

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients

OBJECTIVE: To identify the most prevalent patterns of technical errors in surgery, and evaluate commonly recommended interventions in light of these patterns. SUMMARY BACKGROUND DATA: The majority of surgical adverse events involve technical errors, but little is known about the nature and causes of these events. We examined characteristics of technical errors and common contributing factors among closed surgical malpractice claims. METHODS: Surgeon reviewers analyzed 444 randomly sampled surgical malpractice claims from four liability insurers. Among 258 claims in which injuries due to error were detected, 52% (n = 133) involved technical errors. These technical errors were further analyzed with a structured review instrument designed by qualitative content analysis. RESULTS: Forty-nine percent of the technical errors caused permanent disability; an additional 16% resulted in death. Two-thirds (65%) of the technical errors were linked to manual error, 9% to errors in judgment, and 26% to both manual and judgment error. A minority of technical errors involved advanced procedures requiring special training ("index operations"; 16%), surgeons inexperienced with the task (14%), or poorly supervised residents (9%). The majority involved experienced surgeons (73%), and occurred in routine, rather than index, operations (84%). Patient-related complexities-including emergencies, difficult or unexpected anatomy, and previous surgery-contributed to 61% of technical errors, and technology or systems failures contributed to 21%. CONCLUSIONS: Most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors. Surgical safety research should instead focus on improving decision-making and performance in routine operations for complex patients and circumstances.     

The effects of stress on surgical performance

BACKGROUND: Although the general literature on stress and performance is extensive, little is known about specific effects of stress in surgical practice. This qualitative study explored key surgical stressors, their impact on performance, and coping strategies used by surgeons. METHODS: Individual in-depth semistructured interviews with surgeons were analyzed by 2 researchers independently. Key themes were discussed within the research team. RESULTS: Sixteen interviews were performed, including interviews with consultants (n = 9) and surgeons in training (n = 7). A wide range of intraoperative stressors was identified. Although stress had both positive and negative effects, undue levels of stress impaired judgment, decision making, and communication. Although junior surgeons showed uncertainty about their ability to cope, senior surgeons had developed sophisticated strategies for controlling each situation. CONCLUSIONS: Although stress poses significant risks, coping strategies are not taught explicitly during surgical training. This article presents a framework for categorizing surgical stress and suggests key elements for effective coping strategies.     

Learning curve of robotic-assisted microvascular anastomosis in the rat

We hypothesized that the learning plateau and learning rate of robotic-assisted microvascular anastomosis could be estimated statistically using curve-fitting method. Three surgeons with various microsurgical experiences performed 20 microsurgical anastomoses of the rat femoral artery using the da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA). We evaluated the anastomosis time, patency rate, and quality of anastomosis. Objective structured assessment of technical skills (OSATS) score which is introduced to assess surgical dexterity was also measured. The average starting anastomosis time was 101?±?30 minutes, and the estimated mean learning plateau was 33?±?15 minutes. The estimated mean learning rate for anastomosis time was 22?±?5 trials and the estimated mean learning rate for OSATS score was 8?±?1 trials. Overall patency rate was 90?±?5%. Anastomosis patency correlated with OSATS score and quality of anastomosis rather than anastomosis time. Important aspects of learning curve can be estimated by fitting inverse curves for robotic-assisted microvascular anastomosis. As anastomosis time does not necessarily correlate with the patency rate, OSATS score might be a valuable tool to evaluate surgeons during training for this complicated surgical task.     

Spatial awareness in urologists: are they different?

OBJECTIVE: To compare innate spatial awareness skills, using the MIST-VR system (Ethicon Ltd, Edinburgh, a computer-based virtual reality system that objectively tests spatial awareness) among three groups of people (consultant urologists, urological trainees and controls who were not surgeons), because urological surgeons require spatial awareness for endoscopic and laparoscopic surgery, but trainees are selected by academic prowess rather than surgical aptitude. SUBJECTS AND METHODS: The MIST-VR system was used to test 122 volunteers in three groups, i.e. 39 consultant urologists, 46 urological trainees and 37 controls (not surgeons). The demographic data recorded for each group included age, sex, eyesight, handedness, and endoscopic and laparoscopic experience. Volunteers performed a repetitive series of three tasks using the system. Their performance was measured in terms of time, errors and economy of movement, as well as the duration and accuracy of diathermy in Task 3. RESULTS: The consultants were significantly older than the trainees and controls (both P<0.001) and had more endoscopic experience (P=0.005). In Task 1, the trainees made significantly fewer errors (P=0.045) and had a greater economy of movement (P=0.03) than the controls. In Task 2 the trainees performed the task more rapidly than the consultants (P=0.04) and controls (P=0.02). Trainees were more economical in movement than were consultants (P=0.031) and controls (P=0.046). In the more complex Task 3, trainees outperformed consultants in terms of errors (P=0.03), economy of movement (P=0.046), total diathermy time (P=0.005) and diathermy error (P=0.03). Controls performed similarly to the consultants. Although there was a trend towards better performance by trainees over controls, this was only significant for time (P=0.04) and total diathermy time (P=0.011). A few participants had results that were >2 SD above the mean and several people could not complete Task 3. CONCLUSIONS: Urologists do not differ from the general population in terms of innate spatial ability in this setting. There are several people who may have a defect in spatial awareness but the incidence was the same in each group. Urological trainees outperformed consultants in these tasks; the reasons for this are unclear. The MIST-VR system is of no help in aptitude testing for urological trainees, although it may have a role in teaching laparoscopic surgery. Testing other psychometric components may be more important for acquiring surgical skills than innate spatial-awareness skills. Further studies are required to investigate this possibility.     

Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance

BACKGROUND: This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS: Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS: Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS: Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.     

Retention of fundamental surgical skills learned in robot-assisted surgery

Evaluation of the learning curve for robotic surgery has shown reduced errors and decreased task completion and training times compared with regular laparoscopic surgery. However, most training evaluations of robotic surgery have only addressed short-term retention after the completion of training. Our goal was to investigate the amount of surgical skills retained after 3?months of training with the da Vinci? Surgical System. Seven medical students without any surgical experience were recruited. Participants were trained with a 4-day training program of robotic surgical skills and underwent a series of retention tests at 1 day, 1 week, 1 month, and 3 months post-training. Data analysis included time to task completion, speed, distance traveled, and movement curvature by the instrument tip. Performance of the participants was graded using the modified Objective Structured Assessment of Technical Skills (OSATS) for robotic surgery. Participants filled out a survey after each training session by answering a set of questions. Time to task completion and the movement curvature was decreased from pre- to post-training and the performance was retained at all the corresponding retention periods: 1 day, 1 week, 1 month, and 3 months. The modified OSATS showed improvement from pre-test to post-test and this improvement was maintained during all the retention periods. Participants increased in self-confidence and mastery in performing robotic surgical tasks after training. Our novel comprehensive training program improved robot-assisted surgical performance and learning. All trainees retained their fundamental surgical skills for 3?months after receiving the training program.     

Surgical volume is related to the rate of positive surgical margins at radical prostatectomy in European patients

OBJECTIVE: To assess the association between surgical volume (SV) and the rate of positive surgical margins (PSM) after radical prostatectomy (RP) in a large single-institution European cohort of patients. PATIENTS AND METHODS: In all, 2402 men had a RP by a group of 11 surgeons, all of whom were trained by the surgeon with the highest SV; all surgeons used the same surgical technique. Variables assessed before RP were prostate-specific antigen (PSA) level, clinical stage and biopsy Gleason sum; variables assessed after RP were PSA level, extracapsular extension, seminal vesicle invasion, lymph node invasion and pathological Gleason sum. These were used to predict the rate of PSM in models before or after RP. Multivariate models were complemented with SV to test its independent and multivariate statistical significance and to quantify its impact on the model's overall (and 200 bootstrap-corrected) predictive accuracy. RESULTS: The mean (range) SV was 201 (1-1293) RPs; the mean (median, range) rate of PSM was 20.2 (21.4, 0-32.9)%. In multivariate models, SV was a highly statistically significant independent predictor of PSM (P < 0.001) and increased the predictive accuracy in multivariate models both before (2.0%) and after RP (1.5%, both P < 0.001). However, when the surgeon with the highest SV, who contributed to 1293 cases, was removed from the analyses, the multivariate independent prediction and the gains in predictive accuracy related to adding SV, disappeared in the models both before (P = 0.9, accuracy gain 0.1%) and after (P = 0.4, accuracy gain - 0.3%) RP. CONCLUSIONS: These results indicate that patients treated by surgeons with a very high volume can expect to have a significantly lower rate of PSM, after accounting for clinical and pathological case-mix differences. However, SV is not a predictor of PSM when analyses are restricted to intermediate- and low-volume surgeons.     

Multiple Objective Measures of Skill (MOMS): a new approach to the assessment of technical ability in surgical trainees

OBJECTIVE: The assessment of surgical technical skills has become an important topic in recent years. This study presents the validation of a 6-task skills examination for junior surgical trainees (at the level of the Membership of the Royal College of Surgeons). SUMMARY BACKGROUND DATA: Six tasks were evaluated in a project that also examined the feasibility of this method of assessment. The tasks were knowledge of sutures and instruments; knowledge of surgical devices; knot formation; skin-pad suturing, closure of an enterotomy; excision of a skin lesion; and laparoscopic manipulation. Comparisons were made between a group of junior trainees (n = 13), and a group of seniors (n = 8). RESULTS: Each of the 6 tasks was able to be used to discriminate between the 2 groups. In all, there were 19 primary analyses across the 6 tasks, and 17 of these showed significant differences between the groups (P values ranging from 0.037 to < 0.001). There was generally a strong correlation between the analyses, and when a mean rank was calculated, the difference between groups was significant (P = 0.005 on Mann-Whitney U test; mean ranks 13.9 and 6.3 [of 21], for juniors and seniors respectively). Reliability of the 6-task assessment was very good at 0.70 (Cronbach's Alpha). CONCLUSIONS: A skills examination is a feasible and effective method of assessing the technical ability of basic surgical trainees.     

Value of an objective assessment tool in the operating room

Background

Concerns about the achievement of surgical proficiency during residency are increasing. To objectify surgical skills, the Objective Structured Assessment of Technical Skills (OSATS) was developed and proven valid, feasible and reliable for use in laboratory settings. This study aimed to evaluate the value of this tool for intra-operative use.

Methods

Residents were assessed with an OSATS after every procedure they performed as the primary surgeon during a 3-month clinical rotation in gynecological surgery. We mapped individual learning curves (OSATS scores plotted against experience) and established the average procedure-specific learning curve. We used linear mixed models to assess the relation between performance and experience.

Results

Nine residents were recruited and 319 OSATS analyzed. Individual learning curves revealed progression beyond 24 of 30 OSATS points for 7 residents. Performance on the average procedure improved with experience, and the OSATS score increased by an average of 1.10 points per assessed procedure (p = 0.008, 95%confidence interval 0.44–1.77). Median OSATS scores ranged from 18 to 30 among the 21 assessors.

Conclusion

Intraoperative implementation of OSATS seems to offer important advantages: structured feedback is facilitated, and learning curves enable insight into individual progression. However, doubts have been raised about the objectivity of the tool. Therefore, caution is warranted in using it for graduation and certification.     

Effects of cognitive distraction on performance of laparoscopic surgical tasks

HYPOTHESIS: To quantify the effects of cognitive distraction on surgical task performance in residents and medical students using a laparoscopic surgical simulator. DESIGN: Within-subjects design. SETTING: A surgical skills laboratory. PARTICIPANTS: Thirteen surgical residents and medical students who volunteered for the study. METHODS AND MATERIALS: Subjects performed six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR), under two different conditions (distracted and undistracted). Task order remained the same for all subjects, but the order of distraction was counterbalanced. In the distracted condition, distractions consisted of mental arithmetic problems posed sequentially so that subjects were continually distracted. MAIN OUTCOME MEASURES: Time to task completion, surgical errors committed, economy of motion, and overall performance scores were generated by the MIST-VR program software. Arithmetic error was not a factor in the overall performance score. RESULTS: Time to task completion was significantly greater when subjects were distracted for all six tasks performed. Overall score and economy of motion were negatively affected by distraction but the effect did not reach th level of statistical significance. There was no effect of distract on surgical errors. CONCLUSION: Cognitive distraction appears to negatively influence the performance of laparoscopic surgical tasks by increasing task completion time. Further study is required to determine what the effects would be on experienced surgeons and actual surgical outcomes.     

Use of an Intuitive Telemanipulator System for Remote Trauma Surgery: An Experimental Study

Background: Death from battlefield trauma occurs rapidly. Potentially salvageable casualties generally exsanguinate from truncal hemorrhage before operative intervention is possible. An intuitive telemanipulator system that would allow distant surgeons to remotely treat injured patients could improve the outcome from severe injuries.

Study Design: We evaluated a prototype, four-degree-of-freedom, telesurgery system that provides a surgeon with a stereoscopic video display of a remote operative field. Using dexterous robotic manipulators, surgical instruments at the remote site can be precisely controlled, enabling operative procedures to be performed remotely. Surgeons (n = 3) used the telesurgery system to perform organ excision, hemorrhage control, suturing, and knot tying on anesthetized swine. The ability to complete tasks, times required, technical quality, and subjective impressions were recorded.

Results: Surgeons using the telesurgery system were able to close gastrotomies remotely, although times required were 2.7 times as long as those performed by conventional techniques (451 ± 83 versus 1,235 ± 165 seconds, p < 0.002). Cholecystectomies, hemorrhage control from liver lacerations, and enterotomy closures were successfully completed in all attempts. Force feedback and stereoscopic video display were important for achieving intuitive performance with the telesurgery system, although tasks were completed adequately in the absence of these sensory cues.

Conclusions: We demonstrated the feasibility of performing standard surgical procedures remotely, with the operating surgeon linked to the distant field only by electronic cabling. Complex manipulations were possible, although the times required were much longer. The capabilities of the system used would not support resuscitative surgery. Telesurgery is unlikely to play a role in early trauma management, but may be a unique research tool for acquiring basic knowledge of operative surgery.     

The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy

Introduction Evidence from other professions suggests that training in teamwork and general cognitive abilities, collectively described as non-technical skills, may reduce accidents and errors. The relationship between non-technical teamwork skills and technical errors was studied using a behavioural marker system validated in aviation and adapted for use in surgery. Method 26 elective laparoscopic cholecystectomies were observed. Simultaneous assessments were made of surgical technical errors, by observation clinical human reliability assessment (OCHRA) task analysis, and non-technical performance, using the surgical NOTECHS behavioural marker system. NOTECHS assesses four categories: (1) leadership and management, (2) teamwork cooperation, (3) problem-solving and decision-making, (4) situation awareness. Each subteam (nurses, surgeons and anaesthetists) was scored separately on each of the four dimensions. Two observers – one surgical trainee and one human factors expert – were used to assess intra-rater reliability. Results The mean NOTECHS team score was 35.5 (95% C.I. ± 1.88). The mean subteam scores for surgeons, anaesthetists and nurses were 13.3 (95% C.I. ± 0.64), 11.4 (95% C.I. ± 1.05), and 10.8 (95% C.I. ± 0.87), respectively, with a significant difference between surgeons and anaesthetists (U = 197, p = 0.009), and surgeons and nurses (U = 0.134, p ≤ 0.001). Inter-rater reliability was found to be strong (α = 0.88). There were between zero and six technical errors per operation, with a mean of 2.62 (95% C.I. ± 0.55), which were negatively correlated with the surgeons situational awareness scores (ρ = –0.718, p < 0.001). Conclusions Non-technical skills are an important component of surgical skill, particularly in relation to the development and maintenance of a surgeon’s situational awareness. Experience from other industries suggests that it may be possible to improve the ability of surgeons to manage their own situation awareness, through training, intraoperative briefings and intraoperative workload management. In the future, it may be possible to use non-technical performance as a surrogate measure for technical performance, either for early identification of surgical difficulties, or as a method of evaluation by which non-surgically trained observers.     

Mental training in surgical education: a randomized controlled trial

OBJECTIVE: To evaluate the impact of a cognitive training method on the performance of simulated laparoscopic cholecystectomy in laparoscopic training courses. SUMMARY BACKGROUND DATA: Surgeons are like professional sportsmen in that they have to be able to perform complicated, fine-motor movements under stressful conditions. Mental training, systematically and repeatedly imagining a movement's performance, is a well-established technique in sports science, and this study aimed to determine its value in training surgeons. METHODS: A total of 98 surgeons undergoing basic laparoscopic training participated in a randomized controlled trial; 31 received additional mental training, 32 additional practical training, and 35 received no additional training (control group). All used a Pelvi-Trainer simulator to perform laparoscopic cholecystectomy at baseline and follow-up, after any additional intervention. We used a modified Objective Structured Assessment of Technical Skills (OSATS) instrument to assess performance. Principle outcome variables were the OSATS task-specific checklist (11 procedural steps, scored as correctly [1] or wrongly [0] performed) and the global rating scale (an overall performance evaluation, scored 1-5). RESULTS: Improvement in the task-specific checklist score between baseline and follow-up differed significantly between groups (P = 0.046 on ANOVA). Least significant difference tests yielded differences between the mental and practical training groups (P = 0.024) and between the mental training and control groups (P = 0.040), but not between the practical training and control groups (P = 0.789). Paired Student t test showed that performance at follow-up was significantly better in the mental training and control groups (mental training group, P = 0.001; control group, P = 0.018) but not the practical training group (P = 0.342). There were no significant intergroup differences in global rating scale results. CONCLUSION: Additional mental training is an effective way of optimizing the outcomes of further training for laparoscopic cholecystectomy. It is associated with fewer costs and with better outcomes in some crucial assessment scales than additional practical training.