Perceptual impairment and psychomotor control in virtual laparoscopic surgery

Eye-tracking in surgery: a systematic review

BACKGROUND

Surgery is constantly evolving with the assistance of rapidly developing novel technology. Eye-tracking devices provide opportunities to monitor the acquisition of surgical skills, gain insight into performance, and enhance surgical practice. The aim of this review was to consolidate the available evidence for the use of eye-tracking in the surgical disciplines.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines. A search of OVID Medline, EMBASE, Cochrane library, Scopus, and Science Direct was conducted January 2000 until December 2022. Studies involving eye-tracking in surgical training, assessment and technical innovation were included in the review. Non-surgical procedures, animal studies, and studies not involving surgical participants were excluded from the review.

RESULTS

The search returned a total of 12 054 articles, 80 of which were included in the final analysis and review. Seventeen studies involved eye-tracking in surgical training, 48 surgical assessment, and 20 were focussing on technical aspects of this technology. Twenty-six different eye-tracking devices were used in the included studies. Metrics such as the number of fixations, duration of fixations, dwell time, and cognitive workload were able to differentiate between novice and expert performance. Eight studies demonstrated the effectiveness of gaze-training for improving surgical skill.

CONCLUSION

The current literature shows a broad range of utility for a variety of eye-tracking devices in surgery. There remains a lack of standardization for metric parameters and gaze analysis techniques. Further research is required to validate its use to establish reliability and create uniform practices.

An Eye Tracking Based Framework for Safety Improvement of Offshore Operations

Offshore drilling operations consist of complex and high-risk processes. Lack of situational awareness in drilling operations has become an important human factor issue that causes safety accidents. Prolonged work shifts and fatigue are some of the crucial issues that impact performance. Eye tracking technology can be used to distinguish the degree of awareness or alertness of participants that might be related to fatigue or onsite distractions. Oculomotor activity can be used to obtain visual cues that can quantify the drilling operators' situational awareness that might enable us to develop warning alarms to alert the driller. Such systems can help reduce accidents and save non-productive time. In this paper, eye movement char-acteristics were investigated to differentiate the situational awareness between a representa-tive expert and a group of novices using a scenario-based Virtual Reality Drilling Simulator. Significant visual oculomotor activity differences were identified between the expert and the novices that indicate an eye-tracking based system can detect the distraction and alert-ness exhibited by the workers. Results show promise on developing a framework which implements a real-time eye tracking technology in various drilling operations at drilling rigs and Real Time Operation Centers to improve process safety.

Developing surgical skill level classification model using visual metrics and a gradient boosting algorithm

Objective

Assessment of surgical skills is crucial for improving training standards and ensuring the quality of primary care. This study aimed to develop a gradient boosting classification model (GBM) to classify surgical expertise into inexperienced, competent, and experienced levels in robot-assisted surgery (RAS) using visual metrics.

Methods

Eye gaze data were recorded from 11 participants performing four subtasks; blunt dissection, retraction, cold dissection, and hot dissection using live pigs and the da Vinci robot. Eye gaze data were used to extract the visual metrics. One expert RAS surgeon evaluated each participant's performance and expertise level using the modified Global Evaluative Assessment of Robotic Skills (GEARS) assessment tool. The extracted visual metrics were used to classify surgical skill levels and to evaluate individual GEARS metrics. Analysis of Variance (ANOVA) was used to test the differences for each feature across skill levels.

Results

Classification accuracies for blunt dissection, retraction, cold dissection, and burn dissection were 95%, 96%, 96%, and 96%, respectively. The time to complete only the retraction was significantly different among the 3 skill levels (p-value = 0.04). Performance was significantly different for 3 categories of surgical skill level for all subtasks (p-values<0.01). The extracted visual metrics were strongly associated with GEARS metrics (R2>0.7 for GEARS metrics evaluation models).

Conclusions

Machine learning (ML) algorithms trained by visual metrics of RAS surgeons can classify surgical skill levels and evaluate GEARS measures. The time to complete a surgical subtask may not be considered a stand-alone factor for skill level assessment.

Training and proficiency level in endoscopic sinus surgery change residents' eye movements

Nose surgery is challenging and needs a lot of training for safe and efficient treatments. Eye tracking can provide an objective assessment to measure residents' learning curve. The aim of the current study was to assess residents' fixation duration and other dependent variables over the course of a dedicated training in functional endoscopic sinus surgery (FESS). Sixteen residents performed a FESS training over 18 sessions, split into three surgical steps. Eye movements in terms of percent fixation on the screen and average fixation duration were measured, in addition to residents' completion time, cognitive load, and surgical performance. Results indicated performance improvements in terms of completion time and surgical performance. Cognitive load and average fixation duration showed a significant change within the last step of training. Percent fixation on screen increased within the first step, and then stagnated. Results showed that eye movements and cognitive load differed between residents of different proficiency levels. In conclusion, eye tracking is a helpful objective measuring tool in FESS. It provides additional insights of the training level and changes with increasing performance. Expert-like gaze was obtained after half of the training sessions and increased proficiency in FESS was associated with increased fixation duration.

Gaze Behaviors of Neurosurgeon in Performing Gross Movements under Microscope

BACKGROUND

Frequent intermittent bleeding control and suction are often necessary during microneurosurgical procedures. We compared the visual searching strategy that guides these types of gross hand movements between expert surgeons and neurosurgical residents.

METHODS

A total of 70 trials of a microsurgical task consisting of moving a cotton ball with bipolar forceps and a suction instrument under the microscope were recorded. Based on surgical videos, we extracted total task time, boarding time, gaze-tool time gap, number of fixations during the boarding time, and target-locked fixation duration. A comparison of these measures between experts and resident surgeons were performed.

RESULTS

No significant difference was found for total task time, boarding time, and number of fixations during the boarding time between the 2 groups of surgeons. However, we found significant differences in the measure of gaze-tool time gap (P < 0.001, partial η² = 0.54) and the target-locked fixation (P < 0.001, partial η² = 0.24). Specifically, expert microsurgeons' eyes move to the target board earlier before their tools in hands move (1.01 ± 0.30 seconds) compared with resident microsurgeons (0.44 ± 0.17 seconds). The target-locked fixation duration was also longer among experts comparing to residents (experts: 1.16 ± 0.82 seconds, residents: 0.40 ± 0.30 seconds).

CONCLUSIONS

Task time analysis for this basic microsurgical task is not sufficient to evaluate participants' level of expertise. Gaze behavior analysis helps to reveal hidden differences between experts and residents. This research provides more evidence that supports the use of gaze analysis for assessing surgeons' skills in microsurgery.

The development of an eye movement-based deep learning system for laparoscopic surgical skills assessment

The development of valid, reliable, and objective methods of skills assessment is central to modern surgical training. Numerous rating scales have been developed and validated for quantifying surgical performance. However, many of these scoring systems are potentially flawed in their design in terms of reliability. Eye-tracking techniques, which provide a more objective investigation of the visual-cognitive aspects of the decision-making process, recently have been utilized in surgery domains for skill assessment and training, and their use has been focused on investigating differences between expert and novice surgeons to understand task performance, identify experienced surgeons, and establish training approaches. Ten graduate students at the National Taiwan University of Science and Technology with no prior laparoscopic surgical skills were recruited to perform the FLS peg transfer task. Then k-means clustering algorithm was used to split 500 trials into three dissimilar clusters, grouped as novice, intermediate, and expert levels, by an objective performance assessment parameter incorporating task duration with error score. Two types of data sets, namely, time series data extracted from coordinates of eye fixation and image data from videos, were used to implement and test our proposed skill level detection system with ensemble learning and a CNN algorithm. Results indicated that ensemble learning and the CNN were able to correctly classify skill levels with accuracies of 76.0% and 81.2%, respectively. Furthermore, the incorporation of coordinates of eye fixation and image data allowed the discrimination of skill levels with a classification accuracy of 82.5%. We examined more levels of training experience and further integrated an eye tracking technique and deep learning algorithms to develop a tool for objective assessment of laparoscopic surgical skill. With a relatively unbalanced sample, our results have demonstrated that the approach combining the features of visual fixation coordinates and images achieved a very promising level of performance for classifying skill levels of trainees.

Patterns of Skills Acquisition in Anesthesiologists During Simulated Interscalene Block Training on a Soft Embalmed Thiel Cadaver: Cohort Study

BACKGROUND

The demand for regional anesthesia for major surgery has increased considerably, but only a small number of anesthesiologists can provide such care. Simulations may improve clinical performance. However, opportunities to rehearse procedures are limited, and the clinical educational outcomes prescribed by the Royal College of Anesthesiologists training curriculum 2021 are difficult to attain. Educational paradigms, such as mastery learning and dedicated practice, are increasingly being used to teach technical skills to enhance skills acquisition. Moreover, high-fidelity, resilient cadaver simulators are now available: the soft embalmed Thiel cadaver shows physical characteristics and functional alignment similar to those of patients. Tissue elasticity allows tissues to expand and relax, fluid to drain away, and hundreds of repeated injections to be tolerated without causing damage. Learning curves and their intra- and interindividual dynamics have not hitherto been measured on the Thiel cadaver simulator using the mastery learning and dedicated practice educational paradigm coupled with validated, quantitative metrics, such as checklists, eye tracking metrics, and self-rating scores.

OBJECTIVE

Our primary objective was to measure the learning slopes of the scanning and needling phases of an interscalene block conducted repeatedly on a soft embalmed Thiel cadaver over a 3-hour period of training.

METHODS

A total of 30 anesthesiologists, with a wide range of experience, conducted up to 60 ultrasound-guided interscalene blocks over 3 hours on the left side of 2 soft embalmed Thiel cadavers. The duration of the scanning and needling phases was defined as the time taken to perform all the steps correctly. The primary outcome was the best-fit linear slope of the log-log transformed time to complete each phase. Our secondary objectives were to measure preprocedural psychometrics, describe deviations from the learning slope, correlate scanning and needling phase data, characterize skills according to clinical grade, measure learning curves using objective eye gaze tracking and subjective self-rating measures, and use cluster analysis to categorize performance irrespective of grade.

RESULTS

The median (IQR; range) log-log learning slopes were -0.47 (-0.62 to -0.32; -0.96 to 0.30) and -0.23 (-0.34 to -0.19; -0.71 to 0.27) during the scanning and needling phases, respectively. Locally Weighted Scatterplot Smoother curves showed wide variability in within-participant performance. The learning slopes of the scanning and needling phases correlated: ρ=0.55 (0.23-0.76), P<.001, and ρ=-0.72 (-0.46 to -0.87), P<.001, respectively. Eye gaze fixation count and glance count during the scanning and needling phases best reflected block duration. Using clustering techniques, fixation count and glance were used to identify 4 distinct patterns of learning behavior.

CONCLUSIONS

We quantified learning slopes by log-log transformation of the time taken to complete the scanning and needling phases of interscalene blocks and identified intraindividual and interindividual patterns of variability.

Eye Tracking Use in Surgical Research: A Systematic Review

INTRODUCTION

Eye tracking (ET) is a popular tool to study what factors affect the visual behaviour of surgical team members. To our knowledge, there have been no reviews to date that evaluate the broad use of ET in surgical research. This review aims to identify and assess the quality of this evidence, to synthesize how ET can be used to inform surgical practice, and to provide recommendations to improve future ET surgical studies.

METHODS

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was conducted. An electronic search was performed in MEDLINE, Cochrane Central, Embase, and Web of Science databases up to September 2020. Included studies used ET to measure the visual behaviour of members of the surgical team during surgery or surgical tasks. The included studies were assessed by two independent reviewers.

RESULTS

A total of 7614 studies were identified, and 111 were included for data extraction. Eleven applications were identified; the four most common were skill assessment (41%), visual attention assessment (22%), workload measurement (17%), and skills training (10%). A summary was provided of the various ways ET could be used to inform surgical practice, and three areas were identified for the improvement of future ET studies in surgery.

CONCLUSIONS

This review provided a comprehensive summary of the various applications of ET in surgery and how ET could be used to inform surgical practice, including how to use ET to improve surgical education. The information provided in this review can also aid in the design and conduct of future ET surgical studies.

Eye-Hand Coordination of Neurosurgeons: Evidence of Action-Related Fixation in Microsuturing

OBJECTIVE

We examined performance differences between expert and novice neurosurgeons under a surgical microscope with the goal to evaluate surgical expertise.

METHODS

The Tobii eye-tracker was used to record surgeons' eye movements while they performed a microsuturing task. A total of 19 expert and 18 novice trials were recorded under the microscope. Surgical videos were annotated to label subtasks and critical actions. Total suturing time and subtask times were also compared between novice and expert surgeons. At 3 critical and discrete surgical actions (needle piercing into tissue, exiting, and thread cutting) we examined eye fixation that was directly coupled to each of these actions.

RESULTS

Compared with novices, expert surgeons completed the suture with shorter total time (258.52 ± 102.14 seconds vs. 330.02 ± 96.52 seconds, P = 0.038), penetration time (17.15 ± 3.50 seconds vs. 26.26 ± 18.58 seconds, P = 0.043), and knot-tying time (194.63 ± 94.55 seconds vs. 262.52 ± 79.05 seconds, P = 0.025). On average, experts displayed longer fixation (1.62 seconds) and preaction fixation time (1.3 seconds) than novices (fixation time = 1.24 seconds, P = 0.048; preaction fixation = 0.82 seconds, P = 0.005)). Experts maintained their visual engagement constantly over the 3 levels of subtasks while novices required a longer fixation time for the challenging piercing action than for the exiting and cutting action.

CONCLUSIONS

The action-related fixation can be used to evaluate microsurgeons' level of expertise and in surgical education for gaze training.

Neurosurgical performance between experts and trainees: Evidence from drilling task

BACKGROUND

Lumbar laminectomy is a common neurosurgery that requires precise manipulation of power drills. We examined the fine movement controls of novice neurosurgeons in drilling tasks and compared its accuracy to expert surgeons' performance.

METHODS

Four experts and three novice neurosurgeons performed a lumbar laminectomy on a three-dimensional printed spine model. Scene video and surgeons' eye movements were recorded. Independent sample t-Tests were conducted on the number of jump, total fixation durations, pre-jump fixation durations, post-jump fixation durations and jump distances over novice and expert surgeons.

RESULTS

No statistically significant differences were recorded in terms of total fixations and pre-jump fixation durations. However, novices had more jumping events, greater jump distances and longer post-jump fixation durations when compared to expert neurosurgeons.

CONCLUSION

Differences in movement accuracy and eye measures were found between expert and novice neurosurgeons during a simulated microscopic lumbar laminectomy. A more comprehensive understanding of surgeon's fine movement control mechanism and eye-hand coordination in microsurgery is essential for us before building an enhanced training protocol for surgical residents in neurosurgery.

Action-related eye measures to assess surgical expertise

Background

Eye-tracking offers a new list of performance measures for surgeons. Previous studies of eye-tracking have reported that action-related fixation is a good measuring tool for elite task performers. Other measures, including early eye engagement to target and early eye disengagement from the previous subtask, were also reported to distinguish between different expertise levels. These parameters were examined during laparoscopic surgery simulations in the present study, with a goal to identify the most useful measures for distinguishing surgical expertise.

Methods

Surgical operators, including experienced surgeons (expert), residents (intermediate), and university students (novice), were required to perform a laparoscopic task involving reaching, grasping, and loading, while their eye movements and performance videos were recorded. Spatiotemporal features of eye–hand coordination and action-related fixation were calculated and compared among the groups.

Results

The study included five experienced surgeons, seven residents, and 14 novices. Overall, experts performed tasks faster than novices. Examining eye–hand coordination on each subtask, it was found that experts managed to disengage their eyes earlier from the previous subtask, whereas novices disengaged their eyes from previous subtask with a significant delay. Early eye engagement to the current subtask was observed for all operators. There was no difference in action-related fixation between experienced surgeons and novices. Disengage time was strongly associated with the surgical experience score of the operators, better than both early-engage time and action-related fixation.

Conclusion

The spatiotemporal features of surgeons’ eye–hand coordination can be used to assess level of surgical experience.

Review: The Quiet Eye in Sports Performance-Is the Quiet Eye the Ultimate Explanation or Only the Beginning?

SIGNIFICANCE

The quiet eye is a gaze behavior that seems to differentiate both expert-novice performance and successful and unsuccessful performance in experts; however, the quiet eye may only represent one aspect of the perceptual-cognitive expertise differences that exist between athletes and nonathletes.Research suggests that expert-novice differences in vision and visual-motor coordination skills exist between athletes and nonathletes, although the underlying mechanisms driving these differences are not well understood. The quiet eye is the final fixation or tracking gaze made before the initiation of the action of importance in a motor coordination task and is quite possibly the most well-studied vision strategy variable in sport. The quiet eye has been shown to be a key component of both expert ability and successful performance. However, the quiet eye is not without its criticisms, and the perceptual mechanisms underlying this unique gaze behavior are not yet well understood. The question that remains to be answered is whether the differences in vision and visual-motor coordination skills that exist between athletes and nonathletes can be explained by the quiet eye alone or if the explanation is more complicated.

Sensors for Expert Grip Force Profiling: Towards Benchmarking Manual Control of a Robotic Device for Surgical Tool Movements

STRAS (Single access Transluminal Robotic Assistant for Surgeons) is a new robotic system based on the Anubis^® platform of Karl Storz for application to intra-luminal surgical procedures. Pre-clinical testing of STRAS has recently permitted to demonstrate major advantages of the system in comparison with classic procedures. Benchmark methods permitting to establish objective criteria for 'expertise' need to be worked out now to effectively train surgeons on this new system in the near future. STRAS consists of three cable-driven sub-systems, one endoscope serving as guide, and two flexible instruments. The flexible instruments have three degrees of freedom and can be teleoperated by a single user via two specially designed master interfaces. In this study, small force sensors sewn into a wearable glove to ergonomically fit the master handles of the robotic system were employed for monitoring the forces applied by an expert and a trainee (complete novice) during all the steps of surgical task execution in a simulator task (4-step-pick-and-drop). Analysis of grip-force profiles is performed sensor by sensor to bring to the fore specific differences in handgrip force profiles in specific sensor locations on anatomically relevant parts of the fingers and hand controlling the master/slave system.

Comparison of 3- vs 2-Dimensional Endoscopy Using Eye Tracking and Assessment of Cognitive Load Among Surgeons Performing Endoscopic Ear Surgery

Importance

Endoscopic ear surgery (EES) is an emerging technique to treat middle ear diseases; however, the interventions are performed in 2-dimensional (2D) endoscopic views, which do not provide depth perception. Recent technical developments now allow the application of 3-dimensional (3D) endoscopy in EES.

Objective

To investigate the usability, advantages, and disadvantages of 3D vs 2D endoscopy in EES under standardized conditions.

Design, Setting, and Participants

This cohort study conducted at a tertiary academic medical center in Bern, Switzerland, included 16 residents and consultants of the Department of Otorhinolaryngology, Head & Neck Surgery, Inselspital, Bern.

Interventions

Each participant performed selected steps of a type I tympanoplasty and stapedotomy in 3D and 2D views in a cadaveric model using a randomized, Latin-square crossover design.

Main Outcomes and Measures

Time taken to perform the EES, number of attempts, and accidental damage during the dissections were compared between 3D and 2D endoscopy. Eye tracking was performed throughout the interventions. Cognitive load and subjective feedback were measured by standardized questionnaires.

Results

Of the 16 surgeons included in the study (11 inexperienced residents; 5 experienced consultants), 8 were women (50%); mean age was 36 years (range, 27-57 years). Assessment of surgical time revealed similar operating times for both techniques (181 seconds in 2D vs 174 seconds in 3D). A total of 64 surgical interventions were performed. Most surgeons preferred the 3D technique (10 for 3D vs 6 for 2D), even though a higher incidence of eye strain, measured on a 7-point Likert scale, was observed (3D, 2.19 points vs 2D, 1.44 points; mean difference , 0.74; 95% CI, 0.29-1.20; r = 0.67). Eye movement assessment revealed a higher duration of fixation for consultants in 2D (0.79 seconds) compared with 3D endoscopy (0.54 seconds), indicating a less-efficient application of previously acquired experiences using the new technique. Residents (mean [SD], 49.02 [16.4]) had a significantly higher workload than consultants (mean [SD], 27.21 [12.20]), independent of the used technique or task.

Conclusions and Relevance

Three-dimensional endoscopy is suitable for EES, especially for inexperienced surgeons whose mental model of the intervention has yet to be consolidated. The application of 3D endoscopy in clinical routines and for educational purposes may be feasible and beneficial.

A Human⁻Machine Interface Based on Eye Tracking for Controlling and Monitoring a Smart Home Using the Internet of Things

People with severe disabilities may have difficulties when interacting with their home devices due to the limitations inherent to their disability. Simple home activities may even be impossible for this group of people. Although much work has been devoted to proposing new assistive technologies to improve the lives of people with disabilities, some studies have found that the abandonment of such technologies is quite high. This work presents a new assistive system based on eye tracking for controlling and monitoring a smart home, based on the Internet of Things, which was developed following concepts of user-centered design and usability. With this system, a person with severe disabilities was able to control everyday equipment in her residence, such as lamps, television, fan, and radio. In addition, her caregiver was able to monitor remotely, by Internet, her use of the system in real time. Additionally, the user interface developed here has some functionalities that allowed improving the usability of the system as a whole. The experiments were divided into two steps. In the first step, the assistive system was assembled in an actual home where tests were conducted with 29 participants without disabilities. In the second step, the system was tested with online monitoring for seven days by a person with severe disability (end-user), in her own home, not only to increase convenience and comfort, but also so that the system could be tested where it would in fact be used. At the end of both steps, all the participants answered the System Usability Scale (SUS) questionnaire, which showed that both the group of participants without disabilities and the person with severe disabilities evaluated the assistive system with mean scores of 89.9 and 92.5, respectively.

Guiding Low Spatial Ability Individuals through Visual Cueing: The Dual Importance of Where and When to Look

Research suggests that spatial ability may predict success in complex disciplines including anatomy, where mastery requires a firm understanding of the intricate relationships occurring along the course of veins, arteries, and nerves, as they traverse through and around bones, muscles, and organs. Debate exists on the malleability of spatial ability, and some suggest that spatial ability can be enhanced through training. It is hypothesized that spatial ability can be trained in low-performing individuals through visual guidance. To address this, training was completed through a visual guidance protocol. This protocol was based on eye-movement patterns of high-performing individuals, collected via eye-tracking as they completed an Electronic Mental Rotations Test (EMRT). The effects of guidance were evaluated using 33 individuals with low mental rotation ability, in a counterbalanced crossover design. Individuals were placed in one of two treatment groups (late or early guidance) and completed both a guided, and an unguided EMRT. A third group (no guidance/control) completed two unguided EMRTs. All groups demonstrated an increase in EMRT scores on their second test (P < 0.001); however, an interaction was observed between treatment and test iteration (P = 0.024). The effect of guidance on scores was contingent on when the guidance was applied. When guidance was applied early, scores were significantly greater than expected (P = 0.028). These findings suggest that by guiding individuals with low mental rotation ability "where" to look early in training, better search approaches may be adopted, yielding improvements in spatial reasoning scores. It is proposed that visual guidance may be applied in spatial fields, such as STEMM (science, technology, engineering, mathematics and medicine), surgery, and anatomy to improve student's interpretation of visual content. Anat Sci Educ. © 2018 American Association of Anatomists.

Eye tracking in surgical education: gaze-based dynamic area of interest can discriminate adverse events and expertise

BACKGROUND

Eye-gaze metrics derived from areas of interest (AOIs) have been suggested to be effective for surgical skill assessment. However, prior research is mostly based on static images and simulated tasks that may not translate to complex and dynamic surgical scenes. Therefore, eye-gaze metrics must advance to account for changes in the location of important information during a surgical procedure.

METHODS

We developed a dynamic AOI generation technique based on eye gaze collected from an expert viewing surgery videos. This AOI updated as the gaze of the expert moved with changes in the surgical scene. This technique was evaluated through an experiment recruiting a total of 20 attendings and residents to view 10 videos associated with and another 10 without adverse events.

RESULTS

Dwell time percentage (i.e., gaze duration) inside the AOI differentiated video type (U = 13508.5, p < 0.001) between videos with the presence (Mdn = 16.75) versus absence (Mdn = 19.95) of adverse events. This metric also differentiated participant group (U = 14029.5, p < 0.001) between attendings (Mdn = 15.45) and residents (Mdn = 19.80). This indicates that our dynamic AOIs reflecting the expert eye gaze was able to differentiate expertise, and the presence of unexpected adverse events.

CONCLUSION

This dynamic AOI generation technique produced dynamic AOIs for deriving eye-gaze metrics that were sensitive to expertise level and event characteristics.

Comparison of gaze behaviour of trainee and experienced surgeons during laparoscopic gastric bypass

Background

Eye tracking presents a novel tool that could be used to profile skill levels in surgery objectively. The primary aim of this study was to identify differences in gaze behaviour between expert and junior surgeons performing a laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity.

Methods

This prospective observational study used a lightweight eye-tracking apparatus to determine the difference in gaze behaviours between expert (more than 75 procedures) and junior (75 or fewer procedures) surgeons at defined stages of LRYGB. Primary endpoints were normalized dwell time and fixation frequency. Secondary endpoints were blink rate, maximum pupil size and rate of pupil change.

Results

A total of 20 procedures (12 junior, 8 expert) were analysed. Compared with juniors, experts showed a prolonged dwell time on the screen during angle of His dissection (median (range) 91·20 (83·40–94·40) versus 68·95 (59·80–87·60) per cent; P = 0·001), formation of the retrogastric tunnel (91·50 (85·80–95·50) versus 73·60 (34·60–90·50) per cent; P = 0·001) and gastric pouch formation (86·95 (83·60–90·20) versus 67·60 (37·10–80·00) per cent P &lt; 0·001). Juniors had a greater blink frequency throughout all recorded segments (P &lt; 0·010) and had a larger maximum pupil size during all recorded operative segments (P &lt; 0·010). Rate of pupil change was greater in juniors in all analysed segments (P &lt; 0·010).

Conclusion

These results suggest that experts display more focused attention on significant stimuli, alongside experiencing a reduced mental workload and having increased concentration. This has the potential for future use in validation of surgical skill in high-stakes assessment.

Time limits in testing: An analysis of eye movements and visual attention in spatial problem solving

Individuals with an aptitude for interpreting spatial information (high mental rotation ability: HMRA) typically master anatomy with more ease, and more quickly, than those with low mental rotation ability (LMRA). This article explores how visual attention differs with time limits on spatial reasoning tests. Participants were assorted to two groups based on their mental rotation ability scores and their eye movements were collected during these tests. Analysis of salience during testing revealed similarities between MRA groups in untimed conditions but significant differences between the groups in the timed one. Question-by-question analyses demonstrate that HMRA individuals were more consistent across the two timing conditions (κ = 0.25), than the LMRA (κ = 0.013). It is clear that the groups respond to time limits differently and their apprehension of images during spatial problem solving differs significantly. Without time restrictions, salience analysis suggests LMRA individuals attended to similar aspects of the images as HMRA and their test scores rose concomitantly. Under timed conditions however, LMRA diverge from HMRA attention patterns, adopting inflexible approaches to visual search and attaining lower test scores. With this in mind, anatomical educators may wish to revisit some evaluations and teaching approaches in their own practice. Although examinations need to evaluate understanding of anatomical relationships, the addition of time limits may induce an unforeseen interaction of spatial reasoning and anatomical knowledge. Anat Sci Educ 10: 528-537. © 2017 American Association of Anatomists.

Examining the Spatiotemporal Disruption to Gaze When Using a Myoelectric Prosthetic Hand

The aim of this study was to provide a detailed account of the spatial and temporal disruptions to eye-hand coordination when using a prosthetic hand during a sequential fine motor skill. Twenty-one able-bodied participants performed 15 trials of the picking up coins task derived from the Southampton Hand Assessment Procedure with their anatomic hand and with a prosthesis simulator while wearing eye-tracking equipment. Gaze behavior results revealed that when using the prosthesis, performance detriments were accompanied by significantly greater hand-focused gaze and a significantly longer time to disengage gaze from manipulations to plan upcoming movements. The study findings highlight key metrics that distinguish disruptions to eye-hand coordination that may have implications for the training of prosthesis use.

Seeing virtual while acting real: Visual display and strategy effects on the time and precision of eye-hand coordination

Effects of different visual displays on the time and precision of bare-handed or tool-mediated eye-hand coordination were investigated in a pick-and-place-task with complete novices. All of them scored well above average in spatial perspective taking ability and performed the task with their dominant hand. Two groups of novices, four men and four women in each group, had to place a small object in a precise order on the centre of five targets on a Real-world Action Field (RAF), as swiftly as possible and as precisely as possible, using a tool or not (control). Each individual session consisted of four visual display conditions. The order of conditions was counterbalanced between individuals and sessions. Subjects looked at what their hands were doing 1) directly in front of them (“natural” top-down view) 2) in top-down 2D fisheye view 3) in top-down undistorted 2D view or 4) in 3D stereoscopic top-down view (head-mounted OCULUS DK 2). It was made sure that object movements in all image conditions matched the real-world movements in time and space. One group was looking at the 2D images with the monitor positioned sideways (sub-optimal); the other group was looking at the monitor placed straight ahead of them (near-optimal). All image viewing conditions had significantly detrimental effects on time (seconds) and precision (pixels) of task execution when compared with “natural” direct viewing. More importantly, we find significant trade-offs between time and precision between and within groups, and significant interactions between viewing conditions and manipulation conditions. The results shed new light on controversial findings relative to visual display effects on eye-hand coordination, and lead to conclude that differences in camera systems and adaptive strategies of novices are likely to explain these.

Different perspectives: Spatial ability influences where individuals look on a timed spatial test

Learning in anatomy can be both spatially and visually complex. Pedagogical investigations have begun exploration as to how spatial ability may mitigate learning. Emerging hypotheses suggests individuals with higher spatial reasoning may attend to images differently than those who are lacking. To elucidate attentional patterns associated with different spatial ability, eye movements were measured in individuals completing a timed electronic mental rotation test (EMRT). The EMRT was based on the line drawings of Shepherd and Metzler. Individuals deduced whether image pairs were rotations (same) or mirror images (different). It was hypothesized that individuals with high spatial ability (HSA) would demonstrate shorter average fixation durations during problem solving and attend to different features of the EMRT than low spatial ability (LSA) counterparts. Moreover, question response accuracy would be associated with fewer fixations and shorter average response times, regardless of spatial reasoning ability. Average fixation duration in the HSA group was shorter than LSA (F(1,8) = 7.99; P = 0.022). Importantly, HSA and LSA individuals looked to different regions of the EMRT images (Fisher Exact Test: 12.47; P = 0.018); attending to the same locations only 34% of the time. Correctly answered questions were characterized by fewer fixations per question (F(1, 8) = 18.12; P = 0.003) and shorter average response times (F(1, 8) = 23.89; P = 0.001). The results indicate that spatial ability may influence visual attention to salient areas of images and this may be key to problem solving processes for low spatial individuals. Anat Sci Educ 10: 224-234. © 2016 American Association of Anatomists.

A randomized controlled trial of a group-based gaze training intervention for children with Developmental Coordination Disorder

The aim of this study was to integrate a gaze training intervention (i.e., quiet eye training; QET) that has been shown to improve the throwing and catching skill of children with Developmental Coordination Disorder (DCD), within an approach (i.e., group therapy) that might alleviate the negative psychosocial impact of these motor skill deficits. Twenty-one children with DCD were split into either QET (8 male 3 female, mean age of 8.6 years (SD = 1.04) or technical training (TT) groups (7 male 3 female, mean age of 8.6 years (SD = 1.84). The TT group were given movement-related instructions via video, relating to the throw and catch phases, while the QET group were also taught to fixate a target location on the wall prior to the throw (QE1) and to track the ball prior to the catch (QE2). Each group partook in a 4-week, group therapy intervention and measurements of QE duration and catching performance were taken before and after training, and at a 6-week delayed retention test. Parental feedback on psychosocial and motor skill outcomes was provided at delayed retention. Children improved their gaze control and catching coordination following QET, compared to TT. Mediation analysis showed that a longer QE aiming duration (QE1) predicted an earlier onset of tracking the ball prior to catching (QE2) which predicted catching success. Parents reported enhanced perceptions of their child’s catching ability and general coordination in the QET group compared to the TT group. All parents reported improvements in their child’s confidence, social skills and predilection for physical activity following the trial. The findings offer initial support for an intervention that practitioners could apply to address deficits in the motor and psychosocial skills of children with DCD.

Trial registration: ClinicalTrials.govNCT02904980

Getting nowhere fast: trade-off between speed and precision in training to execute image-guided hand-tool movements

Background

The speed and precision with which objects are moved by hand or hand-tool interaction under image guidance depend on a specific type of visual and spatial sensorimotor learning. Novices have to learn to optimally control what their hands are doing in a real-world environment while looking at an image representation of the scene on a video monitor. Previous research has shown slower task execution times and lower performance scores under image-guidance compared with situations of direct action viewing. The cognitive processes for overcoming this drawback by training are not yet understood.

Methods

We investigated the effects of training on the time and precision of direct view versus image guided object positioning on targets of a Real-world Action Field (RAF). Two men and two women had to learn to perform the task as swiftly and as precisely as possible with their dominant hand, using a tool or not and wearing a glove or not. Individuals were trained in sessions of mixed trial blocks with no feed-back.

Results

As predicted, image-guidance produced significantly slower times and lesser precision in all trainees and sessions compared with direct viewing. With training, all trainees get faster in all conditions, but only one of them gets reliably more precise in the image-guided conditions. Speed-accuracy trade-offs in the individual performance data show that the highest precision scores and steepest learning curve, for time and precision, were produced by the slowest starter. Fast starters produced consistently poorer precision scores in all sessions. The fastest starter showed no sign of stable precision learning, even after extended training.

Conclusions

Performance evolution towards optimal precision is compromised when novices start by going as fast as they can. The findings have direct implications for individual skill monitoring in training programmes for image-guided technology applications with human operators.

Gaze entropy reflects surgical task load

BACKGROUND

Task (over-)load imposed on surgeons is a main contributing factor to surgical errors. Recent research has shown that gaze metrics represent a valid and objective index to asses operator task load in non-surgical scenarios. Thus, gaze metrics have the potential to improve workplace safety by providing accurate measurements of task load variations. However, the direct relationship between gaze metrics and surgical task load has not been investigated yet. We studied the effects of surgical task complexity on the gaze metrics of surgical trainees.

METHODS

We recorded the eye movements of 18 surgical residents, using a mobile eye tracker system, during the performance of three high-fidelity virtual simulations of laparoscopic exercises of increasing complexity level: Clip Applying exercise, Cutting Big exercise, and Translocation of Objects exercise. We also measured performance accuracy and subjective rating of complexity.

RESULTS

Gaze entropy and velocity linearly increased with increased task complexity: Visual exploration pattern became less stereotyped (i.e., more random) and faster during the more complex exercises. Residents performed better the Clip Applying exercise and the Cutting Big exercise than the Translocation of Objects exercise and their perceived task complexity differed accordingly.

CONCLUSIONS

Our data show that gaze metrics are a valid and reliable surgical task load index. These findings have potential impacts to improve patient safety by providing accurate measurements of surgeon task (over-)load and might provide future indices to assess residents' learning curves, independently of expensive virtual simulators or time-consuming expert evaluation.

Impact of examinees' stereopsis and near visual acuity on laparoscopic virtual reality performance

PURPOSE

Laparoscopic surgery represents specific challenges, such as the reduction of a three-dimensional anatomic environment to two dimensions. The aim of this study was to investigate the impact of the loss of the third dimension on laparoscopic virtual reality (VR) performance.

METHODS

We compared a group of examinees with impaired stereopsis (group 1, n = 28) to a group with accurate stereopsis (group 2, n = 29). The primary outcome was the difference between the mean total score (MTS) of all tasks taken together and the performance in task 3 (eye-hand coordination), which was a priori considered to be the most dependent on intact stereopsis.

RESULTS

The MTS and performance in task 3 tended to be slightly, but not significantly, better in group 2 than in group 1 [MTS: -0.12 (95 % CI -0.32, 0.08; p = 0.234); task 3: -0.09 (95 % CI -0.29, 0.11; p = 0.385)]. The difference of MTS between simulated impaired stereopsis between group 2 (by attaching an eye patch on the adominant eye in the 2nd run) and the first run of group 1 was not significant (MTS: p = 0.981; task 3: p = 0.527).

CONCLUSION

We were unable to demonstrate an impact of impaired examinees' stereopsis on laparoscopic VR performance. Individuals with accurate stereopsis seem to be able to compensate for the loss of the third dimension in laparoscopic VR simulations.

Visual control strategies of surgeons: a novel method of establishing the construct validity of a transurethral resection of the prostate surgical simulator

OBJECTIVE

To examine novice and expert differences in visual control strategies while performing a virtual reality transurethral resection of the prostate (TURP) task and to determine if these differences could provide a novel method for assessing construct validity of the simulator.

SUBJECTS AND METHODS

A total of 11 novices (no TURP experience) and 7 experts (>200 TURPs) completed a virtual reality prostate resection task on the TURPsim (Simbionix USA Corp, Cleveland, OH) while wearing an eye tracker (ASL, Bedford, MA). Performance parameters and the surgeon's visual control strategy were measured and compared between the 2 groups.

RESULTS

Experts resected a greater percentage of prostate than novices (p < 0.01) and had less active diathermy time without tissue contact (p < 0.01). Experts adopted a target-locking visual strategy, employing fewer visual fixations (p < 0.05) with longer mean fixation duration (p < 0.005). With multiple learning trials, novices' performance improved and the adoption of a more expertlike gaze strategy was observed.

CONCLUSION

Significant differences between experts and novices in both performance and visual control strategy were observed. The study of visual control strategies may be a useful adjunct, alongside measurements of motor performance, providing a novel method of assessing the construct validity of surgical simulators.

Eye tracking for skills assessment and training: a systematic review

BACKGROUND

The development of quantitative objective tools is critical to the assessment of surgeon skill. Eye tracking is a novel tool, which has been proposed may provide suitable metrics for this task. The aim of this study was to review current evidence for the use of eye tracking in training and assessment.

METHODS

A systematic literature review was conducted in line with PRISMA guidelines. A search of EMBASE, OVID MEDLINE, Maternity and Infant Care, PsycINFO, and Transport databases was conducted, till March 2013. Studies describing the use of eye tracking in the execution, training or assessment of a task, or for skill acquisition were included in the review.

RESULTS

Initial search results returned 12,051 results. Twenty-four studies were included in the final qualitative synthesis. Sixteen studies were based on eye tracking in assessment and eight studies were on eye tacking in training. These demonstrated feasibility and validity in the use of eye tracking metrics and gaze tracking to differentiate between subjects of varying skill levels. Several training methods using gaze training and pattern recognition were also described.

CONCLUSIONS

Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to surgical training to improve performance. Eye tracking remains a promising area of research with the possibility of future implementation into surgical skill assessment.

Assessing visual control during simulated and live operations: gathering evidence for the content validity of simulation using eye movement metrics

BACKGROUND

Although virtual reality (VR) simulators serve an important role in the training and assessment of surgeons, they need to be evaluated for evidence of validity. Eye-tracking technology and measures of visual control have been used as an adjunct to the performance parameters produced by VR simulators to help in objectively establishing the construct validity (experts vs. novices) of VR simulators. However, determining the extent to which VR simulators represent the real procedure and environment (content validity) has largely been a subjective process undertaken by experienced surgeons. This study aimed to examine the content validity of a VR transurethral resection of the prostate (TURP) simulator by comparing visual control metrics taken during simulated and real TURP procedures.

METHODS

Eye-tracking data were collected from seven surgeons performing 14 simulated TURP operations and three surgeons performing 15 real TURP operations on live patients. The data were analyzed offline, and visual control metrics (number and duration of fixations, percentage of time the surgeons fixated on the screen) were calculated.

RESULTS

The surgeons displayed more fixations of a shorter duration and spent less time fixating on the video monitor during the real TURP than during the simulated TURP. This could have been due to (1) the increased complexity of the operating room (OR) environment (2) the decreased quality of the image of the urethra and associated anatomy (compared with the VR simulator), or (3) the impairment of visual attentional control due to the increased levels of stress likely experienced in the OR.

CONCLUSIONS

The findings suggest that the complexity of the environment surrounding VR simulators needs to be considered in the design of effective simulated training curricula. The study also provides support for the use of eye-tracking technology to assess the content validity of simulation and to examine psychomotor processes during live operations.

A systematic review on low-cost box models to achieve basic and advanced laparoscopic skills during modern surgical training

INTRODUCTION

Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills.

MATERIALS AND METHODS

A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011.

RESULTS

Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees.

CONCLUSIONS

BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.

Gaze training improves the retention and transfer of laparoscopic technical skills in novices

BACKGROUND

Gaze training is an effective way of training basic laparoscopic skills, resulting in faster acquisition periods and more robust subsequent performance under pressure. The current study is a randomized control trial which examines whether the performance benefits of gaze training stand the test of time (delayed retention) and transfer to more complex skills.

METHODS

Thirty-six medical students were trained to proficiency (50 trials) on a one-handed laparoscopic task (picking and dropping balls) in either a discovery learning (DL) or gaze training (GT) group. Both groups performed the one-handed task in baseline, retention and delayed retention (1 month) tests. They also performed baseline, retention and delayed retention tests of a two-handed task (grasping and cutting). Performance (completion time) and gaze control (target locking) were assessed throughout.

RESULTS

For the one-handed task, the GT group displayed superior performance at retention (p < .001), underpinned by more expert-like gaze control (p < .05). The GT group also displayed superior performance in the one-handed task at delayed retention (p < .005), underpinned by more expert-like gaze control strategies (p < .001). Although the DL group's performance fell to 84% of performance at retention, the GT group maintained performance at 100% of retention. There were no differences between the groups for the two-handed task at retention (p = .140); however, at delayed retention, the GT group outperformed the DL group (p < .005) and displayed more expert-like gaze control (p < .001).

CONCLUSIONS

Novices trained to adopt an expert-like gaze control strategy were able to attain higher levels of performance more quickly than novices who learned by discovery alone. Furthermore, these skills were more durable over time and were transferable to more complex skills. Gaze training is a beneficial intervention to aid the acquisition of the basic motor skills required for laparoscopy.

Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills

BACKGROUND

Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopic procedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms is ongoing. We investigated the influence of a four-week structured Nintendo® Wii™ training on laparoscopic skills by analyzing performance metrics with a validated simulator (Lap Mentor™, Simbionix™).

METHODOLOGY/PRINCIPAL FINDINGS

We performed a prospective randomized study on 42 post-graduate I-II year residents in General, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and then randomized to group 1 (Controls, no training with the Nintendo® Wii™), and group 2 (training with the Nintendo® Wii™) with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testing session on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improved significantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement in performance (p<0.05) for 13 of the 16 considered performance metrics.

CONCLUSIONS/SIGNIFICANCE

The Nintendo® Wii™ might be helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room.

Quiet eye training: the acquisition, refinement and resilient performance of targeting skills

How we learn and refine motor skills in the most effective manner and how we prevent performance breakdown in pressurised or demanding circumstances are among the most important questions within the sport psychology and skill acquisition literature. The quiet eye (QE) has emerged as a characteristic of highly skilled perceptual and motor performance in visually guided motor tasks. Defined as the final fixation that occurs prior to a critical movement, over 70 articles have been published in the last 15 years probing the role that the QE plays in underpinning skilled performance. The aim of this review is to integrate research findings from studies examining the QE as a measure of visuomotor control in the specific domain of targeting skills; motor skills requiring an object to be propelled to a distant target. Previous reviews have focused primarily on the differences in QE between highly skilled performers and their less skilled counterparts. The current review aims to discuss contemporary findings relating to 1. The benefits of QE training for the acquisition and refinement of targeting skills; 2. The effects of anxiety upon the QE and subsequent targeting skill performance and 3. The benefits of QE training in supporting resilient performance under elevated anxiety. Finally, potential processes through which QE training proffers this advantage, including improved attentional control, response programming and external focus, will be discussed and directions for future research proposed.

Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills

BACKGROUND

Previous research has demonstrated that trainees can be taught (via explicit verbal instruction) to adopt the gaze strategies of expert laparoscopic surgeons. The current study examined a software template designed to guide trainees to adopt expert gaze control strategies passively, without being provided with explicit instructions.

METHODS

We examined 27 novices (who had no laparoscopic training) performing 50 learning trials of a laparoscopic training task in either a discovery-learning (DL) group or a gaze-training (GT) group while wearing an eye tracker to assess gaze control. The GT group performed trials using a surgery-training template (STT); software that is designed to guide expert-like gaze strategies by highlighting the key locations on the monitor screen. The DL group had a normal, unrestricted view of the scene on the monitor screen. Both groups then took part in a nondelayed retention test (to assess learning) and a stress test (under social evaluative threat) with a normal view of the scene.

RESULTS

The STT was successful in guiding the GT group to adopt an expert-like gaze strategy (displaying more target-locking fixations). Adopting expert gaze strategies led to an improvement in performance for the GT group, which outperformed the DL group in both retention and stress tests (faster completion time and fewer errors).

CONCLUSION

The STT is a practical and cost-effective training interface that automatically promotes an optimal gaze strategy. Trainees who are trained to adopt the efficient target-locking gaze strategy of experts gain a performance advantage over trainees left to discover their own strategies for task completion.

Gaze training enhances laparoscopic technical skill acquisition and multi-tasking performance: a randomized, controlled study

Background

The operating room environment is replete with stressors and distractions that increase the attention demands of what are already complex psychomotor procedures. Contemporary research in other fields (e.g., sport) has revealed that gaze training interventions may support the development of robust movement skills. This current study was designed to examine the utility of gaze training for technical laparoscopic skills and to test performance under multitasking conditions.

Methods

Thirty medical trainees with no laparoscopic experience were divided randomly into one of three treatment groups: gaze trained (GAZE), movement trained (MOVE), and discovery learning/control (DISCOVERY). Participants were fitted with a Mobile Eye gaze registration system, which measures eye-line of gaze at 25 Hz. Training consisted of ten repetitions of the “eye-hand coordination” task from the LAP Mentor VR laparoscopic surgical simulator while receiving instruction and video feedback (specific to each treatment condition). After training, all participants completed a control test (designed to assess learning) and a multitasking transfer test, in which they completed the procedure while performing a concurrent tone counting task.

Results

Not only did the GAZE group learn more quickly than the MOVE and DISCOVERY groups (faster completion times in the control test), but the performance difference was even more pronounced when multitasking. Differences in gaze control (target locking fixations), rather than tool movement measures (tool path length), underpinned this performance advantage for GAZE training.

Conclusions

These results suggest that although the GAZE intervention focused on training gaze behavior only, there were indirect benefits for movement behaviors and performance efficiency. Additionally, focusing on a single external target when learning, rather than on complex movement patterns, may have freed-up attentional resources that could be applied to concurrent cognitive tasks.

Quiet eye training facilitates competitive putting performance in elite golfers

The aim of this study was to examine the effectiveness of a brief quiet eye (QE) training intervention aimed at optimizing visuomotor control and putting performance of elite golfers under pressure, and in real competition. Twenty-two elite golfers (mean handicap 2.7) recorded putting statistics over 10 rounds of competitive golf before attending training individually. Having been randomly assigned to either a QE training or Control group, participants were fitted with an Applied Science Laboratories Mobile Eye tracker and performed 20 baseline (pre-test) putts from 10 ft. Training consisted of video feedback of their gaze behavior while they completed 20 putts; however the QE-trained group received additional instructions related to maintaining a longer QE period. Participants then recorded their putting statistics over a further 10 competitive rounds and re-visited the laboratory for retention and pressure tests of their visuomotor control and putting performance. Overall, the results were supportive of the efficacy of the QE training intervention. QE duration predicted 43% of the variance in putting performance, underlying its critical role in the visuomotor control of putting. The QE-trained group maintained their optimal QE under pressure conditions, whereas the Control group experienced reductions in QE when anxious, with subsequent effects on performance. Although their performance was similar in the pre-test, the QE-trained group holed more putts and left the ball closer to the hole on missed putts than their Control group counterparts in the pressure test. Importantly, these advantages transferred to the golf course, where QE-trained golfers made 1.9 fewer putts per round, compared to pre-training, whereas the Control group showed no change in their putting statistics. These results reveal that QE training, incorporated into a pre-shot routine, is an effective intervention to help golfers maintain control when anxious.