Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room

OBJECTIVE

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance.

BACKGROUND

Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context.

RESULTS

From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making.

CONCLUSIONS

The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

Cognitive models for mentally visualizing a sharp instrument in a blind procedure

Purpose

Our objective was to understand the cognitive strategies used by surgeons to mentally visualize navigation of a surgical instrument through blind space.

Methods

We conducted semi-structured interviews with 15 expert and novice surgeons following simulated retropubic trocar passage on 3D-printed models of pelvises segmented from preop MRIs. Midurethral sling surgery involves blind passage of a trocar among the urethra, bladder, iliac vessels, and bowel while relying primarily on haptic feedback from the suprapubic bone (SPB) for guidance. Our conceptual foundation was based on Lahav's study on blind people's mental mapping of spaces using haptic cues. Participants detailed how they mentally pictured the trocar's location relative to vital anatomy. We coded all responses and used constant comparative analysis to generate themes, confirmed with member checking.

Results

Expert and novice participants utilized multiple cognitive strategies combined with haptic feedback to accomplish safe trocar passage. Some used a step-by-step route strategy, visualizing sequential 2D axial images of anatomy adjacent to the SPB. Others used a map strategy, forming global 3D pictures. Although these mental pictures vanished when they were "lost," a safe zone could be reestablished by touching the SPB. Experts were more likely to relate their body position to the trocar path and rely on minor variations in resistance. Novices were more inclined toward backtracking of the trocar.

Conclusions

Our findings may be extended to any blind surgical procedure. Teaching visualization strategies and incorporating tactile feedback can be used intraoperatively to help learners navigate their instrument safely around vital organs.

Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training

OBJECTIVE

Technical and non-technical skills are traditionally investigated separately in simulation-based surgical training (SBST). Recent literature has indicated an interrelation of these skills, but a clear relationship is yet to be established. This scoping review aimed to identify published literature on the use of both technical and non-technical learning objectives in SBST and investigate how the entities are related. Additionally, this scoping study reviewed the literature with the aim of mapping how publications on technical and non-technical skills within SBST have changed over time.

DESIGN

We conducted a scoping review using the 5 step framework by Arksey and O'Malley and reported our results according to the PRISMA guidelines for scoping reviews. Four databases, PubMed, Web of Science, Embase and Cochrane Library, were systematically searched for empirical studies on SBST. Studies within surgical training addressing both technical and non-technical learning objectives and presenting primary data were included for further analysis.

RESULTS

Our scoping review identified 3144 articles on SBST published between 1981 and 2021. During our analysis, an emphasis on technical skills training in published literature was identified. However, recent years have seen an immense increase of publications within either technical or non-technical skills. A similar trend is seen in publications addressing both technical and non-technical. In total, 106 publications addressed both technical and non-technical learning objectives and were included for further analysis. Only 45 of the included articles addressed the relationship between technical and non-technical skills. These articles mainly focused on the effect of non-technical skills on technical skills.

CONCLUSIONS

Though literature on the relationship between technical and non-technical skills remains scarce, the included studies on technical skills and non-technical skills such as mental training suggest such a relationship exists. This implies that the separation of the skill sets is not necessarily beneficial for the outcome of SBST. A shift towards seeing technical and non-technical skills as intertwined may enhance learning outcomes from SBST.

The Action Cycle Theory of Perception and Mental Imagery

The Action Cycle Theory (ACT) is an enactive theory of the perception and a mental imagery system that is comprised of six modules: Schemata, Objects, Actions, Affect, Goals and Others' Behavior. The evidence supporting these six connected modules is reviewed in light of research on mental imagery vividness. The six modules and their interconnections receive empirical support from a wide range of studies. All six modules of perception and mental imagery are influenced by individual differences in vividness. Real-world applications of ACT show interesting potential to improve human wellbeing in both healthy people and patients. Mental imagery can be applied in creative ways to make new collective goals and actions for change that are necessary to maximize the future prospects of the planet.

Mental practice for laparoscopic salpingectomy

Mental practice (MP) is a method of enhancing surgical training by rehearsal of a task without physical action. The primary objective of the study was to develop and validate a MP tool for laparoscopic salpingectomy (LS). An imagery script for LS was developed and used to facilitate a structured MP session for trainees in Obstetrics and Gynaecology and expert gynaecologists across three teaching hospitals in the UK. A virtual platform was used for one trainee group to assess its feasibility compared to a face-to-face approach. Pre- and post-session assessments were conducted to evaluate the impact of the script on motivation, confidence, preparedness and quality of imagery and demonstrated a significant improvement in global imagery scores for both novice groups. The expert group scored significantly higher than the face-to-face novice group on all items both before and after MP, indicating construct validity. There were no significant differences demonstrated between the two novice groups, thus demonstrating the virtual platform to be a non-inferior approach - an important consideration in the current COVID era.

Effectiveness of telesimulation for pediatric minimally invasive surgery essential skills training

BACKGROUND

In the context of the COVID-19 pandemic and social distancing rules, access to in-person training activities had temporarily been interrupted, speeding up the implementation of telesimulation for minimally invasive surgery (MIS) essential skills training (T-ESTM, Telesimulation - Essential Skills Training Module) in our center. The aim of this study was to explore the effectiveness of T-ESTM.

METHODS

T-ESTM was scheduled into 2 sessions of 3 h through the Zoom® virtual meeting platform. The academic lectures, the tutorials for box-trainer set-up and 7 performance tasks were accessed through an online campus previous to the remote encounter for personalized guidance and debriefing. Initial (pre-telementoring) and final (post 6-hour telementoring) assessment scoring as well as timing for Task 2 (circle-cutting pattern), 3 (extracorporeal Roeder knot) and 5 (intracorporeal Square knot) were registered.

RESULTS

61 participants were recruited. The mean age was 31±5 years. 65% were surgical residents. 48% performed low complexity procedures. 52% had previous experience with simulation training. In Task 2, there was a 21% improvement in the final score obtained, as well as a significant decrease in time of 33%; in Task 3, there was an increase of 39% in the scoring and a decrease of 49% in the timing; and in Task 5, participants improved their technique a 30% and decreased the performance time a 47%. All the differences were statistically significant.

DISCUSSION

Our data support T-ESTM as a reproducible and effective educational tool for remote MIS essential skills hands-on training.

LEVEL OF EVIDENCE

II.

Mental Simulation to Promote Exercise Intentions and Behaviors

Mental simulation, which employs specific patterns of imagery, can increase the intention to exercise as well as actual engagement in exercise. The present studies explored the effects of mental simulation on the intention to engage in exercise while regulating emotions. The first study confirmed that mental simulation did promote intentions of participants. The second found that video-primed mental simulation was a more effective method of exercise intention promotion than semantic-primed and image-primed mental simulation. In the third study, it was found that combining process-based and outcome-based mental simulations increased exercise intentions. Positive emotions mediated imagery ability and intention to exercise. The final study found that the mental simulation interventions most effective for exercise adherence were those that balanced the valence of process and outcome components in such a way that a challenging process results in a positive outcome, or a smooth process results in a negative outcome. Each of these results has practical implications for exercise interventions that will be discussed.

Impact of mental imagery on enhancing surgical skills learning in novice's surgeons: a pilot study

OBJECTIVE

Mental imagery (MI) has long been used in learning in both fields of sports and arts. However, it is restrictively applied in surgical training according to the medical literature. Few studies have evaluated its' feasibility and usefulness. The aim of this study is to assess the impact of mental imagery on surgical skills learning among novice's surgeons.

MATERIAL AND METHODS

In this pilot prospective randomized comparative study; we recruited 17 residents and interns of surgery education curriculum. They were all included in their first semester of the curricula. Two groups were randomly designed. Group (a) including "Mental Imagery" volunteers (n = 9) which benefited from a mental imagery rehearsal exercise prior to physical practice, while the control group (b) (n = 8) didn't underwent any MI process prior to surgery practice. Each participant of both groups was invited to perform an intestinal hand-sewn anastomosis on bovine intestine. Each procedure was evaluated and analyzed according to 14 qualitative criteria while each criterion was scored 0, 1 or 2 respectively assigned to the gesture was not acquired, gesture was performed with effort, or mastered gesture. The final score is 28 for those who master all 14 gestures. A non-parametric statistical comparison between the both studied groups was performed.

RESULTS

Both groups of surgery students demonstrated equivalent age, sex ratio, laterality, and surgical experience. The mean overall score is significantly higher in the MI group (a) (17.78; SD = 2.42) compared to the control group (b) (10.63, SD = 2.85). However, advanced analysis of individual assessment items showed significant statistical difference between both groups only in 6 out of 14 assessed items.

CONCLUSION

Indeed, mental imagery will not be able to substitute the traditional learning of surgery for novice surgeons; it is an important approach for improving the technical skills acquisition and shortening the physical learning.

Surgical cognitive simulation improves real-world surgical performance: randomized study

BACKGROUND

Despite the acknowledgement of human factors, application of psychological methods by surgeons to improve surgical performance is sparse. This may reflect the paucity of evidence that would help surgeons to use psychological techniques effectively. There is a need for novel approaches to see how cognitive training might be used to address these challenges.

METHODS

Surgical trainees were divided into intervention and control groups. The intervention group received training in surgical cognitive simulation (SCS) and was asked to apply the techniques while working in operating theatres. Both groups underwent procedure-based assessment based on the UK and Ireland Intercollegiate Surgical Curriculum Programme (ISCP) before the training and 4 months afterwards. Subjective evaluations of SCS application were obtained from the intervention group participants.

RESULTS

Among 21 participants in the study, there was a statistically significant improvement in 11 of 16 procedure-based assessment domains (P < 0.050) as well as a statistically significant mean reduction in time to complete the procedure in the intervention group (-15.98 versus -1.14 min; P = 0.024). Subjectively, the intervention group experienced various benefits with SCS, especially in preoperative preparedness, intraoperative focus, and overall performance.

CONCLUSION

SCS training has a statistically significant impact in improving surgical performance. Subjective feedback suggests that surgeons are able to apply it in practice. SCS may prove a vital adjunct for skill acquisition in surgical training.

Adapting Motor Imagery Training Protocols to Surgical Education: A Systematic Review and Meta-Analysis

Objective. Motor imagery (MI) is widely used to improve technical skills in sports and has been proven to be effective in neurorehabilitation and surgical education. This review aims to identify the key characteristics of MI protocols for implementation into surgical curricula. Design. This study is a systematic review and meta-analysis. PubMed, MEDLINE, Embase and PsycINFO databases were systematically searched. The primary outcome was the impact of MI training on measured outcomes, and secondary outcomes were study population, MI intervention characteristics, study primary outcome measure and subject rating of MI ability (systematic review registration: PROSPERO CRD42019121895). Results. 456 records were screened, 60 full texts randomising 2251 participants were reviewed and 39 studies were included in meta-analysis. MI was associated with improved outcome in 35/60 studies, and pooled analysis also showed improved outcome on all studies with a standardised mean difference of .39 (95% CI: .12, .67, P = .005). In studies where MI groups showed improved outcomes, the median duration of training was 24 days (mode 42 days), and the median duration of each individual MI session was 30 minutes (range <1 minute-120 minutes). Conclusions. MI training protocols for use in surgical education could have the following characteristics: MI training delivered in parallel to existing surgical training, in a flexible format; inclusion of a brief period of relaxation, followed by several sets of repetitions of MI and a refocusing period. This is a step towards the development of a surgical MI training programme, as a low-cost, low-risk tool to enhance practical skills.

Mental rehearsal: A useful simulation adjunct to surgical training

BACKGROUND

Simulation is an effective adjunct to surgical training. There is increasing interest in the use of mental rehearsal as a form of cognitive simulation. The mental visualisation of a motor skill is recognised to enhance performance; a concept not novel to surgeons. Despite this, mental rehearsal has yet to be formally incorporated into surgical training. This study aims to assess the use of mental rehearsal amongst general surgical trainees and consultants.

METHOD

A six-item questionnaire was designed and electronically circulated to general surgical core trainees, registrars, fellows and consultants. Qualitative and quantitative analysis was independently performed.

RESULTS

153 responses (consultants = 51.6%, trainees = 48.4%) were received over 3 weeks. 91.5% of surgeons mentally rehearse prior to operating. Its use predominates for complex cases only. There is no difference in case complexity and the surgeon's grade in regard to when mental rehearsal is performed (χ² = 1.027, p = 0.31). Individual mental rehearsal is preferred. Consultants are more likely to mentally rehearse with others, although there was no statistical difference compared to trainees (χ² = 0.239, p = 0.63). Clarification, confidence and anticipation of potential difficulties were the perceived benefits of mental rehearsal reported in 58.6% of responses.

CONCLUSIONS

Mental rehearsal prior to operating appears instinctive for general surgeons irrespective of seniority and case complexity. Whether the efficacy of mental rehearsal on training is sustained and continues as surgeons progress along the training curve are unknown. Alternative methods of surgical training are very much needed. We propose mental rehearsal.

Effect of motor imagery and actual practice on learning professional medical skills

BACKGROUND

The peripheral venous catheter is the most frequently used medical device in hospital care to administer intravenous treatment or to take blood samples by introducing a catheter into a vein. The aim of this study was to examine the effect of motor imagery associated with actual training on the learning of peripheral venous catheter insertion into a simulated venous system.

METHOD

This was a prospective monocentre study in 3rd year medical students. Forty medical students were assigned to the experimental group (n = 20) performing both real practice and motor imagery of peripheral venous catheter insertion or to the control group (n = 20) trained through real practice only. We also recruited a reference group of 20 professional nurses defining the benchmark for a target performance.

RESULTS

The experimental group learned the peripheral venous catheter insertion faster than the control group in the beginning of learning phase (p < 0.001), reaching the expected level after 4 sessions (p = .87) whereas the control group needed 5 sessions to reach the same level (p = .88). Both groups were at the same level at the end of the scheduled training.

CONCLUSIONS

Therefore, motor imagery improved professional motor skills learning, and limited the time needed to reach the expected level. Motor imagery may strengthen technical medical skill learning.

Effect of mental rehearsal on team performance and non-technical skills in surgical teams: systematic review

BACKGROUND

Simulation-based training in medical education has become a common method to develop both technical and non-technical skills in teams. Mental rehearsal (MR) is the cognitive act of simulating a task in our heads to pre-experience tasks imaginatively. It has been used widely to improve individual and collective performance in fields outside healthcare, and offers potential for more efficient training in time-pressured surgical and medical team contexts. This study aimed to review the available literature to determine the impact of MR on team performance and non-technical skills in healthcare.

METHODS

MEDLINE, Embase, British Educational Index, CINAHL, Web of Science, PsycInfo and Cochrane databases were searched for the period 1994-2018. The primary outcome measure was improvement in team performance and non-technical skills. Study quality of RCTs was assessed using the Medical Education Research Quality Instrument. The reported impacts of MR in all included studies were mapped on to the Kirkpatrick framework for evaluation of educational interventions.

RESULTS

Eight studies with 268 participants were identified that met the inclusion criteria, of which there were six randomized trials, one prospective pragmatic trial and one qualitative study. Three studies found MR to be effective in improving team non-technical skills. MR practices were varied and often poorly defined. MR benefited team non-technical skills when it was specifically designed to do so, but was not an automatic consequence of technical MR alone. The majority of studies demonstrated benefits of MR for technical performance, but only three showed positive impacts on teamwork. Overall the studies were of low quality and lacked sufficient discriminatory focus to examine impacts on teamwork dynamics.

CONCLUSION

MR can improve technical performance, but the benefits on non-technical skills are less clear. Future research should look at longitudinal mixed-method evaluation designs and focus on real clinical teams.

Mental Skills Training and Resident Surgical Outcomes: A Systematic Review

OBJECTIVE

Mental skills training (MST) in surgical education varies greatly in quality and outcomes. This systematic review assessed the effectiveness of MST on surgical trainee performance in simulated and operating room (OR) settings.

DESIGN

We searched PubMed/MEDLINE, EMBASE, and PsycINFO for randomized controlled trials using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Peer-reviewed studies published in the English language between January 1, 2000 and March 1, 2020 were considered for inclusion. Articles that did not study surgical residents, assess surgical performance as an outcome, or report findings were excluded. Study characteristics, methodologies, and outcomes were qualitatively analyzed. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to measure the quality of the studies, and the Oxford quality scoring system for risk of bias ratings.

RESULTS

Seven randomized controlled trials met study inclusion criteria; interventions were mental practice, relaxation exercises, action observation, and Mindfulness-Based Stress Reduction. Targeted interventions based on mental practice, relaxation exercises, and MBSR significantly improved surgical performance in four (57%) studies. Risk of bias was low for all included studies, and quality of evidence was moderate for both simulated and OR performance.

CONCLUSIONS

Mental practice, relaxation, and mindfulness training improved simulation and OR performance for surgical residents. There was insufficient evidence to support other MST interventions or the intermediate- and long-term efficacy of MST.

Alternatives to High-Fidelity Simulation

Simulation-based education improves health care professionals' performance in managing critical events. Limitations to widespread uptake of high-fidelity simulation include barriers related to training, technology, and time. Alternatives to high-fidelity simulation that overcome these barriers include in situ simulation, classroom-based simulation, telesimulation, observed simulation, screen-based simulation, and game-based simulation. Some settings have limited access to onsite expert facilitation to design, implement, and guide participants through simulation-based education. Alternatives to onsite expert debriefing in these settings include teledebriefing, scripted debriefing, and within-group debriefing. A combination of these alternatives promotes successful implementation and maintenance of simulation-based education for managing critical health care events.

Home Surgical Skill Training Resources for Obstetrics and Gynecology Trainees During a Pandemic

Resources are available for remote laparoscopic and basic surgical training, including core skills, psychomotor, visual–spatial, and cognitive, to improve gaps in surgical training during the coronavirus disease 2019 (COVID-19) pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created a unique educational circumstance in which medical students, residents, and fellows find themselves with a gap in their surgical training. We reviewed the literature, and nine categories of resources were identified that may benefit trainees in preventing skill decay: laparoscopic box trainers, virtual reality trainers, homemade simulation models, video games, online surgical simulations, webinars, surgical videos, smartphone applications, and hobbies including mental imagery. We report data regarding effectiveness, limitations, skills incorporated, cost, accessibility, and feasibility. Although the cost and accessibility of these resources vary, they all may be considered in the design of remote surgical training curricula during this unprecedented time of the COVID-19 pandemic.

In Search of Characterizing Surgical Skill

OBJECTIVE

This paper provides a literature review and detailed discussion of surgical skill terminology. Culminating in a novel model that proposes a set of unique definitions, this review is designed to facilitate shared understanding to study and develop metrics quantifying surgical skill.

DESIGN

Objective surgical skill analysis depends on consistent definitions and shared understanding of terms like performance, expertise, experience, aptitude, ability, competency, and proficiency.

STRUCTURE

Each term is discussed in turn, drawing from existing literature and colloquial uses.

IMPLICATIONS

A new model of definitions is proposed to cement a common and consistent lexicon for future skills analysis, and to quantitatively describe a surgeon's performance throughout their career.

Spatial cognition in minimally invasive surgery: a systematic review

Background

Spatial cognition is known to play an important role in minimally invasive surgery (MIS), as it was found to enable faster surgical skill acquisition, reduce surgical time and errors made and significantly improve surgical performance. No prior research attempted to summarize the available literature, to indicate the level of importance of the individual spatial abilities and how they impact surgical performance and skill acquisition in MIS.

Methods

Psychological and medical databases were systematically searched to identify studies directly exploring spatial cognition in MIS learning and performance outcomes. Articles written in the English language articles, published between 2006 and 2016, investigating any and all aspect of spatial cognition in direct relation to influence over performance or learning of MIS, were deemed eligible.

Results

A total of 26 studies satisfied this criterion and were included in the review. The studies were very heterogeneous and the vast majority of the participants were novice trainees but with variable degree of skills. There were no clinical studies as almost all studies were conducted on either box trainers or virtual reality simulators. Mental rotation ability was found to have a clear impact on operative performance and mental practice was identified as an effective tool to enhance performance, pre-operatively. Ergonomic set-up of the MIS equipment has a marked influence on MIS performance and learning outcomes.

Conclusions

Spatial cognition was found to play an important role in MIS, with mental rotation showing a specific significance. Future research is required to further confirm and quantify these findings in the clinical settings.

The role of cognitive training in endourology: a randomised controlled trial

INTRODUCTION

Cognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior.

METHODS

This prospective, comparative study recruited 59 medical students and randomised them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomised to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received.

RESULTS

This study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (P=.017, P=.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (P=.0125). Other parameters analysed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training.

CONCLUSION

This study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments

Resilience is built, not born, and there is no single strategy that reliably manufactures resilient performance in all circumstances. Optimizing team performance in dynamic environments involves the complex interplay of strategies that target individual preparation, team interaction, environmental optimization, and systems-level resilience engineering. To accomplish this, health care can draw influence from human factors research to inform tangible, practical, and measurable improvements in performance and outcomes, modified to suit local and domain-specific needs.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η²=0.34, DA: 0 vs. 1 p = 0.02 η² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Training Tools for Nontechnical Skills for Surgeons-A Systematic Review

OBJECTIVE

Development of nontechnical skills for surgeons has been recognized as an important factor in surgical care. Training tools for this specific domain are being created and validated to maximize the surgeon's nontechnical ability. This systematic review aims to outline, address, and recommend these training tools.

DESIGN

A full and comprehensive literature search, using a systematic format, was performed on ScienceDirect and PubMed, with data extraction occurring in line with specified inclusion criteria.

SETTING

Systematic review was performed fully at King's College London.

RESULTS

A total of 84 heterogeneous articles were used in this review. Further, 23 training tools including scoring systems, training programs, and mixtures of the two for a range of specialities were identified in the literature. Most can be applied to surgery overall, although some tools target specific specialities (such as neurosurgery). Interrater reliability, construct, content, and face validation statuses were variable according to the specific tool in question.

CONCLUSIONS

Study results pertaining to nontechnical skill training tools have thus far been universally positive, but further studies are required for those more recently developed and less extensively used tools. Recommendations can be made for individual training tools based on their level of validation and for their target audience. Based on the number of studies performed and their status of validity, NOTSS and Oxford NOTECHS II can be considered the gold standard for individual- and team-based nontechnical skills training, respectively, especially when used in conjunction with a training program.

Mental practice with interactive 3D visual aids enhances surgical performance

BACKGROUND

Evidence suggests that Mental Practice (MP) could be used to finesse surgical skills. However, MP is cognitively demanding and may be dependent on the ability of individuals to produce mental images. In this study, we hypothesised that the provision of interactive 3D visual aids during MP could facilitate surgical skill performance.

METHODS

20 surgical trainees were case-matched to one of three different preparation methods prior to performing a simulated Laparoscopic Cholecystectomy (LC). Two intervention groups underwent a 25-minute MP session; one with interactive 3D visual aids depicting the relevant surgical anatomy (3D-MP group, n = 5) and one without (MP-Only, n = 5). A control group (n = 10) watched a didactic video of a real LC. Scores relating to technical performance and safety were recorded by a surgical simulator.

RESULTS

The Control group took longer to complete the procedure relative to the 3D&MP condition (p = .002). The number of movements was also statistically different across groups (p = .001), with the 3D&MP group making fewer movements relative to controls (p = .001). Likewise, the control group moved further in comparison to the 3D&MP condition and the MP-Only condition (p = .004). No reliable differences were observed for safety metrics.

CONCLUSION

These data provide evidence for the potential value of MP in improving performance. Furthermore, they suggest that 3D interactive visual aids during MP could potentially enhance performance, beyond the benefits of MP alone. These findings pave the way for future RCTs on surgical preparation and performance.

Application of Mental Skills Training in Surgery: A Review of Its Effectiveness and Proposed Next Steps

INTRODUCTION

Mental skills training, which refers to the teaching of performance enhancement and stress management psychological strategies, may benefit surgeons. Our objective was to review the application of mental skills training in surgery and contrast it to other domains, examine the effectiveness of this approach in enhancing surgical performance and reducing stress, and provide future directions for mental skills training in surgery.

MATERIALS AND METHODS

A systematic literature search of MEDLINE, PubMed, PsycINFO, and ClinicalKey was performed between 1996 and 2016. Keywords included were mental readiness, mental competency, mental skill, mental practice, imagery, mental imagery, mental rehearsal, stress management training, stress coping, mental training, performance enhancement, and surgery. Reviews of mental skills interventions in sport and well-regarded sport psychology textbooks were also reviewed. Primary outcome of interest was the effect of mental skills on surgical performance in the simulated or clinical environment.

RESULTS

Of 490 identified abstracts, 28 articles met inclusion criteria and were reviewed. The majority of the literature provides evidence that mental imagery and stress management training programs are effective at enhancing surgical performance and reducing stress. Studies from other disciplines suggest that comprehensive mental skills programs may be more effective than imagery and stress management techniques alone.

CONCLUSIONS

Given the demonstrated efficacy of mental imagery and stress management training in surgery and the incremental value of comprehensive mental skills curricula used in other domains, a concerted effort should be made to apply comprehensive mental skills curricula during surgical training.

Effect of Rehearsal Modality on Knowledge Retention in Surgical Trainees: A Pilot Study

OBJECTIVE

The operating room is an exciting learning environment. With growing curriculum limitations and increasing complexity of care, existing education opportunities need to be optimized. Rehearsal has benefits for surgeon performance in the operating room, but its role for enhancing operative learning remains unclear. This pilot study aimed to differentiate the effects of physical rehearsal (PR) and cognitive rehearsal (CR) modalities on surgical trainee technical knowledge retention.

DESIGN

Participants took part in a 2-day (sequential Fridays), instructed operative workshop performing midline laparotomy, splenectomy, left nephrectomy, and hand-sewn, side-to-side small bowel anastomosis (SBA). Participants were randomized to 10 minutes of either a (PR; n = 5) or (CR; n = 5) activity each day before operating. PR consisted of practicing SBA on a felt bowel model. CR entailed viewing narrated operative footage detailing the steps of SBA. Participants' technical knowledge of all procedures was assessed at 1 and 12 weeks postworkshop using a 31-question test.

SETTING

Animal operative suites at an academic medical center.

PARTICIPANTS

A total of 10 general surgery postgraduate year 1 interns participated in the workshop; all completed the study. Participants had similar levels of operative exposure at the time of study participation.

RESULTS

At 1-week postworkshop, mean assessment scores for CR were higher than PR (Mean ± Standard Deviation) (CR = 24.7 ± 1.6 vs. PR = 21.8 ± 1.7, p = 0.02). After 12 weeks, there was no difference in mean scores (CR = 23.3 ± 2 vs. PR = 21.7 ± 1.8, p = 0.22). Knowledge decay for the 12-week period was similar between groups (CR = -1.4 ± 1.6 vs. PR = -0.1 ± 2.4, p = 0.36). Study participants performed better on SBA-related questions than unrelated questions (laparotomy, splenectomy, and nephrectomy) at 1-week (related = 81.5% ± 11.3 vs. unrelated = 71.9% ± 6.6, p = 0.03) and 12 weeks (related = 81% ± 13.1 vs. unrelated = 68.6% ± 8.8, p = 0.02).

CONCLUSION

This pilot data suggests the modality of the rehearsal activity may not significantly effect surgical learners' technical knowledge retention. Participants did score higher on questions related to the rehearsal topic, indicating a potential supplementary role for rehearsal activities.