randomized double-blinded trial investigating the impact of a curriculum focused on error...
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Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic
suturing training
J Bingener, T Boyd, K Van Sickle, I Jung, A Saha, J Winston, P Lopez, H Ojeda, W Schwesinger, D Anastakis
Background
• Laparoscopic intracorporeal suturing not easy to learn
• Best learned outside patient care setting
• Computer and box training tools
Background• Suturing skills – imitation learning
• “ this is how I do it” - “don’t do it like this”
• Knowledge based errors
Surgical skill is predicted by the ability to detect errors
(Bann S et al. Am J Surg 189 (2005) 412-415)
Error detection on 22 models presented
Ob
serv
ed
surg
ica
l ski
ll (O
SA
TS
)
Question
Will the inclusion of an error recognition module in the laparoscopic suturing curriculum
• enable error recognition and
• improve the technical proficiency of the learner?
Study design
• Study population:
• 30 novices
• randomized to
A: control group
B: intervention group
• Learners blinded to group assignment
• Video-instruction for laparoscopic suturing
Group A
Pretest:
Error counting video (3)
Suturing practice
Suturing task time
post test:
suturing task time
OSATS video score
Error recognition video (2)
Questionnaire Suturing video (1)
Error counting video (3)
OSATS video score
post test:
OSATS video score
Group B
Suturing practice
Suturing task time
Study design
• No feed-back during study
• Same investigator
• Study period: 2 summer months
• Time line
Group A Group B
Metrics
• Pre and post training laparoscopic suturing task time (seconds)
• Pre and post training OSATS score (1-5)
• Post training error recognition score (% errors recognized in video compared to experts)
Reviewer preparation
• Reviewers watched novice and expert video for “calibration”
• Blinded to group assignment • Independent review after study period
• Kendall’s Tau for correlation0.6 <τ <0.99
DemographicsGroup B Group A
Gender Female 8 (53.3) 4 (26.7)
Male 7 (46.7) 11 (73.3)
Total 15 15
P-value1 0.264
Video game
Novice 11 (73.3) 5 (33.3)
Intermediate 4 (26.7) 6 (40)
Experienced 0 (0) 4 (26.7)
Total 15 15
P-value1 0.031
Results – Task Time
Group A (SE) Group B (SE)
Task time difference
(SE) P-value
Pretest task time (sec)
521 (27.74) 535.5 (18.69) 14.5 (32.68) 0.658
Posttest task time (sec)
337.7 (29.04) 462.3 (30.36) 124.5 (41.4) 0.003
Task time Difference (sec)
-183.3 (23.71) -73.2 (22.11)
P-value <.001 0.001
Task Time by covariates
Gamer Level 1
Control (Female)Control (Male)Variable (Female)Variable (Male)
CCCCCCVVVVVV
100
200
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600
700
Timepoint
1 2 3 4 5 6
C
C C
CC C
C
C C
CC C
V
VV
VV
V
V
VV
VV
V
Gamer Level 2
Control (Female)Control (Male)Variable (Female)Variable (Male)
CCCCCCVVVVVV
100
200
300
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600
700
Timepoint
1 2 3 4 5 6
C
C C
CC C
C
C C
CC C
V
VV
VV
V
V
VV
VV
V
Gamer Level 3
Control (Female)Control (Male)Variable (Female)Variable (Male)
CCCCCCVVVVVV
100
200
300
400
500
600
700
Timepoint
1 2 3 4 5 6
C
C C
CC C
C
C C
CC C
V
VV
VV
V
V
VV
VV
V
Mean overall OSATS scores
Group A Group B Difference P-value
Pretest 1.6 (0.13) 1.7 (0.13) 0.1 (0.19) 0.784
Posttest 2.3 (0.13) 2.2 (0.13) -0.1 (0.19) 0.558
Difference 0.7 (0.06) 0.5 (0.06)
P-value <.001 <.001
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Timepoint
1 2 3 4 5 6
C
C C
C C
C
VV
V
V VV
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Timepoint
1 2 3 4 5 6
C
C
C
C C
C
V V
V
V VV
Mean OSATS scores for task forward flow Mean OSATS scores for instrument handling
p=0.63
P=0.53
OSATS sub-scores
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Timepoint
1 2 3 4 5 6
C
C C
C C C
V V
V
V
V
V
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Timepoint
1 2 3 4 5 6
C
C C
C
CC
VV
V
VV
V
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Timepoint
1 2 3 4 5 6
C
C
C
C C
C
V V
VV
VV
Mean OSATS scores for respect for tissue
Mean OSATS scores for time motion efficiency
Mean OSATS scores for knowledge of task
p=0.066
p=0.62
p=0.43
Errors recognized (video 3)Group A
Control Group (n=15)
Group B Error Recognition
Group (n=15)
#Errors (%) #Errors (%) P-value
No C Loop 2 (13.3) 10 (66.7) 0.008
No surgeons knot
(wrapped once)
11 (73.3) 13 (86.7) 0.651
No square knot (didn’t switch hands)
12 (80) 8 (53.3) 0.245
Total 2 (0, 4) 4 (1, 7) <.001
Results - summary
• Additional error recognition teaching
– Slowed down learner in task performance– Did not change OSAT scores– Led to cognitive error recognition
Visual information overload?
Error pattern
Corrrect pattern
Incorrect pattern
Group B
Group A
•Timing of error teaching module•Time to practice•Repetitive practice•Separate days
Attentional capacity threshold
Use of Attentional Resources
Novice surgeon Pre-trained Novice Master surgeon
Attentionalresources
Psychomotorperformance
Comprehending Attendinginstruction
Gaining additionalknowledge
Depth & Spatialjudgments
Judgement &Decision making
Gallagher et al
Future Research Directions
• Modify instruction timing
• Modify learner group (pre-trained novice/ intermediate learner)
• Use video-game experience as randomization criterion
Thank you