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Expertise Differences in Fixation, Quiet Eye Duration, and Surgical Performance During Identification and Dissection of the Recurrent

Laryngeal NerveHarvey, A.1 Vickers, JN. 2 Snelgrove, R. 1 Scott, M. 2 &

Morrison, S. 2

Department of Surgery 1

Faculty of Kinesiology 2

Association of Surgical Education

Orlando, Florida

April 24, 2013

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Background Halsted Model

Apprenticeship Based

Graded Responsibility

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Background

High level athlete gaze, focus of attention, and relation to motor skill has been studied for years

Extensive research in sport on the Quiet Eye (QE)

Over 70 refereed studies to date in over 15 sports

Quiet eyelocation

Background Quiet eye fixation = fixation on a specific

location within 1 degree of visual angle (foveal vision) for more than 100 ms prior to successful completion of a critical movement

Elite performers have longer duration quiet eye characteristic

Quiet eye is also longer during high levels of performance

QE training has proven successful in a wide range of sports

Background Limited literature

focus of attention in surgical skills acquirement or training

Moulton et al – “Slowing Down” at critical moments

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Purpose

To examine the surgical movements, fixation durations, and Quiet Eye durations of highly experienced (HE) & less experienced (LE) surgeons/residents

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Hypotheses HE surgeons will be ranked higher than LE

surgeons (blinded external review)

HE surgeons will ‘slow down’ using longer Quiet Eye durations on the Recurrent Laryngeal Nerve

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Methods

Ten Volunteers3 HE surgeons (M = 2391

operations)7 LE surgeons (M = 37

operations)

EquipmentASL mobile eye trackerSynchronized external

video of surgical movements

Surgical Movements and Gaze Data

Gaze DataSurgical Movements

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Results – Global Rating Scores

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Results – Global Rating ScoreRespect for Tissue x Phase

p < .04

Phase 1: Identify Inferior Thyroid ArteryPhase 2: Identify Recurrent Laryngeal NervePhase 3: Divide Ligament of Berry

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Results – Movement Time (MT%)

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p < .98

Total Fixation Duration by Phase

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Quiet Eye (QE) Duration on Recurrent Laryngeal

Nerve

p < .008

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Summary Relative to LE, HE surgeons had:

Higher global rating scores

No significant differences in operating time, or hand movement times (MT%)

Longer fixation durations on the Ligament of Berry

Higher QE duration on the RLN prior to blunt and sharp dissections

Conclusions HE surgeon’s longer QE duration reveals greater

focus of attention on critical structures prior to and during surgical movements

HE surgeon’s longer fixations on the LofB suggest the use of a perceptual anchor that is used to define the underlying structures

HE surgeons cognitively slow down during critical phases of the operation

Moulton & Epstein are correct, “slowing down” is a critical cognitive skill of expert surgeons

Future Directions

Quiet Eye TrainingDurableRobust under conditions of stress/anxietyIncreases success under conditions of

exhaustion

July 2013 – knot tying for R1 surgical residents