Assessing mental workload during laparoscopic surgery

3D printing in anatomical lung segmentectomies: A randomized pilot trial

Objective

This pilot study evaluated the impact of using a 3D printed model of the patient's bronchovascular lung anatomy on the mental workload and fatigue of surgeons during full thoracoscopic segmentectomy.

Design

We performed a feasibility pilot study of a prospective randomized controlled trial with 2 parallel arms. All included patients underwent digital 3D visual reconstruction of their bronchovascular anatomy and were randomized into the following two groups: Digital arm (only a virtual 3D model was available) and Digital + Object arm (both virtual and printed 3D models were available). The primary end-point was the surgeons' mental workload measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) score.

Setting

Between October 28, 2020 and October 05, 2021, we successively investigated all anatomic segmentectomies performed via thoracoscopy in the Thoracic Department of the Montsouris Mutualiste Institute, except for S6 segmentectomies and S4+5 left bi-segmentectomies.

Participants

We assessed 102 patients for anatomical segmentectomy. Among the, 40 were randomly assigned, and 34 were deemed analysable, with 17 patients included in each arm.

Results

Comparison of the two groups, each comprising 17 patients, revealed no statistically significant difference in primary or secondary end-points. The consultation of the visual digital model was significantly less frequent when a 3D printed model was available (6 versus 54 consultations, p = 0.001). Notably, both arms exhibited high NASA-TLX scores, particularly in terms of mental demand, temporal demand, and effort scores.

Conclusion

In our pilot study, 3D printed models and digital 3D reconstructions for pre-operative planning had an equivalent effect on thoracoscopic anatomic segmentectomy for experienced surgeons. The originality of this study lies in its focus on the impact of 3D printing of bronchovascular anatomy on surgeons, rather than solely on the surgical procedure.

Experimental evaluation of accuracy and efficiency of two control strategies for a novel foot commanded robotic laparoscope holders with surgeons

The implementation of a laparoscope-holding robot in minimally invasive surgery enhances the efficiency and safety of the operation. However, the extra robot control task can increase the cognitive load on surgeons. A suitable interface may simplify the control task and reduce the surgeon load. Foot interfaces are commonly used for commanding laparoscope-holding robots, with two control strategies available: decoupled control permits only one Cartesian axis actuation, known as decoupled commands; hybrid control allows for both decoupled commands and multiple axes actuation, known as coupled commands. This paper aims to determine the optimal control strategy for foot interfaces by investigating two common assumptions in the literature: (1) Decoupled control is believed to result in better predictability of the final laparoscopic view orientation, and (2) Hybrid control has the efficiency advantage in laparoscope control. Our user study with 11 experienced and trainee surgeons shows that decoupled control has better predictability than hybrid control, while both approaches are equally efficient. In addition, using two surgery-like tasks in a simulator, users' choice of decoupled and coupled commands is analysed based on their level of surgical experience and the nature of the movement. Results show that trainee surgeons tend to issue more commands than the more experienced participants. Single decoupled commands were frequently used in small view adjustments, while a mixture of coupled and decoupled commands was preferred in larger view adjustments. A guideline for foot interface control strategy selection is provided.

Evaluation of mental load using EEG and eye movement characteristics

Mental load is a major cause of human-induced accidents. In this study, an explosive impact sensitivity experiment was used to induce mental load. A combination of subjective questionnaires and objective prospective time-distance tests were used to judge whether subjects experienced mental load. Four indicators, namely, β, γ, mean pupil diameter, and fixation time were selected by statistical analysis and PCA for the construction of a mental load assessment model. The study found that the occipital lobe was the most sensitive to mental load, especially β and γ bands. Lastly, it was found that subjects showed different degrees of mental load for the same mental load induction task. The results of the study are applicable to the evaluation and monitoring of the mental characteristics of workers and provide a scientific basis for adjusting the mental load of workers over time to reduce the rate of accidents and enhance production efficiency.

Developing a novel energy-based approach for measuring mental workload

Minimal research has been conducted to develop non-invasive processes for quantifying and evaluating worker mental workload - a critical concern - at the task level in the construction industry. One reason for this gap in research is the complex and dynamic nature of the construction process, which makes construction work more complicated to measure and predict compared to work in other industries. This paper presents a novel approach and corresponding conceptual model to quantify and evaluate construction worker perception of mental workload at the task level using the energy concept. A conceptual process for assessing mental workload (MWL), i.e., the feeling of stress, pressure, and being overwhelmed due to the task nature, factors, conditions, and resources that accompany the performance of the task, was developed from extant research and interviews. The Delphi method was utilized to characterize the energy-based model and provide initial verification. The results from the literature review, expert insight, and four rounds of the Delphi survey revealed 14 constituents, 51 components, and one metric for each component to measure the level of MWL felt by a worker. These constituents, components, and metrics were used to develop a model for measuring construction worker MWL. This study contributes to knowledge by developing a novel non-invasive method for assessing potential task-level MWL using an energy-based model. The energy-based assessment model contributes to practice by providing a tool that could be used to measure the potential impact of construction tasks on workers perceived mental workload.

Development of performance and learning rate evaluation models in robot-assisted surgery using electroencephalography and eye-tracking

The existing performance evaluation methods in robot-assisted surgery (RAS) are mainly subjective, costly, and affected by shortcomings such as the inconsistency of results and dependency on the raters' opinions. The aim of this study was to develop models for an objective evaluation of performance and rate of learning RAS skills while practicing surgical simulator tasks. The electroencephalogram (EEG) and eye-tracking data were recorded from 26 subjects while performing Tubes, Suture Sponge, and Dots and Needles tasks. Performance scores were generated by the simulator program. The functional brain networks were extracted using EEG data and coherence analysis. Then these networks, along with community detection analysis, facilitated the extraction of average search information and average temporal flexibility features at 21 Brodmann areas (BA) and four band frequencies. Twelve eye-tracking features were extracted and used to develop linear random intercept models for performance evaluation and multivariate linear regression models for the evaluation of the learning rate. Results showed that subject-wise standardization of features improved the R2 of the models. Average pupil diameter and rate of saccade were associated with performance in the Tubes task (multivariate analysis; p-value = 0.01 and p-value = 0.04, respectively). Entropy of pupil diameter was associated with performance in Dots and Needles task (multivariate analysis; p-value = 0.01). Average temporal flexibility and search information in several BAs and band frequencies were associated with performance and rate of learning. The models may be used to objectify performance and learning rate evaluation in RAS once validated with a broader sample size and tasks.

Analysis of KangDuo-SR-1500 and KangDuo-SR-2000 robotic partial nephrectomy from an operative and ergonomic perspective: a prospective controlled study in porcine models

The objective of this study is to explore the safety and effectiveness of two new models of KangDuo surgical robots for partial nephrectomy in porcine models, and evaluate the ergonomic characteristics from both subjective and objective perspectives. Twelve porcine models were equally divided for KD-SR-1500 (three-arm) and KD-SR-2000 (four-arm). The perioperative outcomes, and physical and mental workload of the surgeon were compared. Physical workload was evaluated with surface electromyography. Mental workload was evaluated with NASA-TLX. All surgeries were performed successfully. There were no differences in perioperative variables (p > 0.05). There were no perioperative complications. The mental workload in both groups was at a low level. KD-SR-2000 showed advantages in physical workload (p < 0.01). KD-SR-1500 and KD-SR-2000 are technically feasible, valid, and safe for RAPN in porcine models. KD-SR-2000 had ergonomic advantages over KD-SR-1500.

How a pilot's brain copes with stress and mental load? Insights from the executive control network

In aviation, mental workload and stress are two major factors that can considerably impact a pilot's flight performance and decisions. Their consequences can be even more dramatic in single-pilot aircraft or with the forthcoming single-pilot operations where the pilot will fly alone and will not be able to be assisted in case of difficulty. An accurate and automatic monitoring of the pilot's mental state could help to prevent the potentially dangerous effects of an excess mental workload and stress. For example, some tasks could be allocated to automation or to a ground-based flight crew if a mental overload or significant stress is detected. In the current study, the brain activity of 20 private pilots was recorded with a fNIRS device during two realistic flight simulator scenarios. The mental workload was manipulated with the added difficulty of a secondary task and stress was induced by a social stressor. Our results confirmed the sensitivity of the fNIRS readings to variations in the mental workload, with increased HbO2 concentration in regions of the executive control network (ECN), in particular in the dorsolateral prefrontal cortex and in lateral parietal regions, when the difficulty of the secondary task was high. The social stressor also triggered an HbO2 increase in the ECN, especially when it was combined with high mental workload. This latter result suggests that mental workload and stress together can have cumulative effects, and coping with both factors is possible at the expense of an extra recruitment of the ECN. Finally, results also revealed a time-on-task effect, with a progressive reduction of the HbO2 signal in the ECN during the flight scenario, suggesting that these regions are sensitive to short term habituation to the tasks. Overall, fNIRS efficiently indexed mental load, stress, and practice effects.

Examining workload variations among different surgical team roles, specialties, and techniques: a multicenter cross-sectional descriptive study

BACKGROUND

A high workload may negatively impact the surgical team's performance and jeopardize patient safety. The aim of this study was to measure the workload of the surgical team across different surgical roles, specialties, and techniques in several hospitals.

METHODS

This cross-sectional multicenter study was performed in the operating rooms of eight teaching hospitals affiliated with Isfahan University of Medical Sciences, Iran. At the conclusion of each surgical procedure, all members of the surgical team completed the Surgery Task Load Index (SURG-TLX) questionnaire to assess workload levels. Descriptive statistics, analysis of variance (ANOVA), and Pearson correlations, were performed to compare surgical roles, specialties, techniques, and surgical time on workload overall and by subscale.

RESULTS

A total of 409 workload questionnaires were obtained from 76 surgical teams or cases, involving 346 surgical team members. The total workload among all participants was 32.41 ± 17.21. Surgical complexity, physical demands, and mental demands were the highest workload subscales and distraction was the lowest workload subscale. Cardiovascular specialty had a higher workload compared to other specialties. Open techniques resulted in a higher workload compared to minimally invasive techniques. Surgical technologists who act in both the role of circulating and scrub nurse (C&Ss) experienced the highest workload, followed by surgical residents and surgeons.

CONCLUSIONS

The results of the study showed that the workload for some members of the surgical team is disproportionately high and is influenced by factors such as specialty, technique, role, and surgical duration. By knowing the distribution of workload among the members of the surgical team, efforts can be made to optimize the team members' workload.

Mental workload profile and its relationship with presenteeism, absenteeism and job performance among surgeons: The mediating role of occupational fatigue

Introduction

Surgeons are one of the most significant jobs in the health care system that plays an important role in the patients' health promotion and their treatment. In the current study, the effect of mental workload on the work performance of surgeons was tested by considering the mediating effect of fatigue on this relationship.

Method

This study was done analytically on 165 surgeons working in the operating rooms of hospitals in Iran. To determine of mental workload, the SURG-TLX method was used. The job performance was measured using the short version of the job performance questionnaire provided by the World Health Organization (WHO-HPQ), and accordingly relative presenteeism, relative absenteeism and job performance variables were calculated. The Swedish Occupational Fatigue Inventory (SOFI) questionnaire was used to determine occupational fatigue. A conceptual model was built to determine the direct and indirect relationship between mental workload and job performance, and the mediating effect of occupational fatigue on the relationship between mental workload and job performance was tested using structural equation modeling (SEM).

Results

Out of 165 distributed questionnaires, 140 questionnaires were completed and delivered to the researchers (85% response rate). The mean ± standard deviations of mental workload, fatigue, and work performance were 16.57 ± 5.83, 6.32 ± 2.86, and 0.65 ± 0.28, respectively. The results of model fit indexes revealed that all indexes are within the acceptable range. Regarding this model, the direct effect of mental workload on job performance was not significant (β = -0.21; p = 0.072). A significant positive relationship was observed between mental workload and fatigue (β = 0.36; p < 0.001). The direct effect of fatigue on job performance was also the opposite and statistically significant (β = -0.39; p < 0.001). Finally, results indicated that the effect of mental workload on work performance mediated by occupational fatigue.

Conclusion

Surgeons suffer a high level of mental workload during their work, and this factor can have a negative effect on surgeons' job performance. The effect of mental workload on job performance in surgeons can be detected, directly and indirectly, through the mediating effect of occupational fatigue. Improving the mental and physical conditions of the work environment can reduce occupational fatigue and improve surgeons' job performance.

Fundamentals of Microsurgery: A Novel Simulation Curriculum Based on Validated Laparoscopic Education Approaches

BACKGROUND

 Microsurgical techniques have a steep learning curve. We adapted validated surgical approaches to develop a novel, competency-based microsurgical simulation curriculum called Fundamentals of Microsurgery (FMS). The purpose of this study is to present our experience with FMS and quantify the effect of the curriculum on resident performance in the operating room.

METHODS

 Trainees underwent the FMS curriculum requiring task progression: (1) rubber band transfer, (2) coupler tine grasping, (3) glove laceration repair, (4) synthetic vessel anastomosis, and (5) vessel anastomosis in a deep cavity. Resident anastomoses were also evaluated in the operative room with the Stanford Microsurgery and Resident Training (SMaRT) tool to evaluate technical performance. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) and Short-Form Spielberger State-Trait Anxiety Inventory (STAI-6) quantified learner anxiety and workload.

RESULTS

 A total of 62 anastomoses were performed by residents in the operating room during patient care. Higher FMS task completion showed an increased mean SMaRT score (p = 0.05), and a lower mean STAI-6 score (performance anxiety) (p = 0.03). Regression analysis demonstrated residents with higher SMaRT score had lower NASA-TLX score (mental workload) (p < 0.01) and STAI-6 scores (p < 0.01).

CONCLUSION

 A novel microsurgical simulation program FMS was implemented. We found progression of trainees through the program translated to better technique (higher SMaRT scores) in the operating room and lower performance anxiety on STAI-6 surveys. This suggests that the FMS curriculum improves proficiency in basic microsurgical skills, reduces trainee mental workload, anxiety, and improves intraoperative clinical proficiency.

Multimodal Approach to Assess a Virtual Reality-based Surgical Training Platform

Virtual reality (VR) can bring numerous benefits to the learning process. Combining a VR environment with physiological sensors can be beneficial in skill assessment. We aim to investigate trainees' physiological (ECG) and behavioral differences during the virtual reality-based surgical training environment. Our finding showed a significant association between the VR-Score and all participants' total NASA-TLX workload score. The extent of the NASA-TLX workload score was negatively correlated with VR-Score (R2 =0.15, P < 0.03). In time-domain ECG analysis, we found that RMSSD (R2 =0.16, P < 0.05) and pNN50 (R2 =0.15, P < 0.05) scores correlated with significantly higher VR-score of all participants. In this study, we used SVM (linear kernel) and Logistic Regression classification techniques to classify the participants as gamers and non-gamers using data from VR headsets. Both SVM and Logistic Regression accurately classified the participants as gamers and non-gamers with 83% accuracy. For both SVM and Linear Regression, precision was noted as 88%, recall as 83%, and f1-score as 83%. There is increasing interest in characterizing trainees' physiological and behavioral activity profiles in a VR environment, aiming to develop better training and assessment methodologies.

Video game experience affects performance, cognitive load, and brain activity in laparoscopic surgery training

Objectives

Video games can be a valuable tool for surgery training. Individuals who interact or play video games tend to have a better visuospatial ability when compared to non-gamers. Numerous studies suggest that video game experience is associated with faster acquisition, greater sharpening, and longer retention of laparoscopic skills. Given the neurocognitive complexity of surgery skill, multimodal approaches are required to understand how video game playing enhances laparoscopy skill.

Material and Methods

Twenty-seven students with no laparoscopy experience and varying levels of video game experience performed standard laparoscopic training tasks. Their performance, subjective cognitive loading, and prefrontal cortical activity were recorded and analyzed. As a reference point to use in comparing the two novice groups, we also included data from 13 surgeons with varying levels of laparoscopy experience and no video game experience.

Results

Results indicated that video game experience was correlated with higher performance (R2 = 0.22, p <0.01) and lower cognitive load (R2 = 0.21, p <0.001), and the prefrontal cortical activation of students with gaming experience was relatively lower than those without gaming experience. In terms of these variables, gaming experience in novices tended to produce effects similar to those of laparoscopy experience in surgeons.

Conclusion

Our results suggest that along the dimensions of performance, cognitive load, and brain activity, the effects of video gaming experience on novice laparoscopy trainees are similar to those of real-world laparoscopy experience on surgeons. We believe that the neural underpinnings of surgery skill and its links with gaming experience need to be investigated further using wearable functional brain imaging.

[Assessment method of cognitive load and stress inducer factors of surgeons and anesthetists in the operating room]

INTRODUCTION

For many years, surgeons and anesthetists have recognized that stress can be present in their daily professional practice. The goal of this study was to identify tools for assessing stress and cognitive load in the operating room.

MATERIAL AND METHODS

We conducted a literature review in the PubMed database of scientific articles published on the subject without date limit using the keywords anesthesia, surgery, surgeon, cognitive workload, definition, pathophysiology, physiological measurement, objective, subjective, stress.

RESULTS

Nineteen articles were selected, focusing on cardiac surgery, gastrointestinal surgery, vascular surgery and urology. No publications concerning ophthalmology were found through the literature search. The means of measurement found were either subjective, such as questionnaires, or objective, such as the study of heart rate variability (HRV), reaction time, eye movements, electrical conductivity of the skin, biological markers and electroencephalogram. Of all these measurement tools, the NASA-TLX questionnaire, used in four articles, and the HRV study, used in eight articles, appear to be the most widely used and are strongly correlated with stress.

CONCLUSION

The articles reviewed use only some of the available tools for assessment of stress and cognitive load. The main objective is to improve the quality of care and the quality of life of caregivers. It would be interesting to develop other methods to identify and better characterize the risk factors that increase stress and cognitive load.

Domain- and task-analytic workload (DTAW) method: a methodology for predicting mental workload during severe accidents in nuclear power plants

Excessive mental workload reduces operators' performance and threatens the safety of nuclear power plants (NPPs) in severe accident management (SAM). Given the lack of suitable mental workload measurement methods for SAM tasks, we proposed a Domain- and Task-Analytic Workload (DTAW) method to predict SAM workload. The DTAW method is developed in three stages: scenario construction based on work domain analysis, task analysis, and workload estimation with eight workload components scored through task-analytic and projective methods. To demonstrate its utility, we applied the method to construct two SAM scenarios and predict the mental workload demand of operators in these scenarios as compared to two design basis accident scenarios. With statistical analysis, the DTAW method can predict the overall subjective workload rated by NPP operators, be used to identify high-load tasks, cluster tasks with similar workload patterns, and provide direct implications for improving SAM strategies and supporting systems.Practitioner summary: To predict mental workload in severe accident management (SAM) scenarios in nuclear power plants, we proposed an analytic method and applied it to estimate mental workload in two SAM scenarios and two design basis accident (DBA) scenarios. We found that the workload pattern in SAM scenarios is different from that in DBA scenarios.

The neurophysiology of intraoperative error: An EEG study of trainee surgeons during robotic-assisted surgery simulations

Surgeons operate in mentally and physically demanding workspaces where the impact of error is highly consequential. Accurately characterizing the neurophysiology of surgeons during intraoperative error will help guide more accurate performance assessment and precision training for surgeons and other teleoperators. To better understand the neurophysiology of intraoperative error, we build and deploy a system for intraoperative error detection and electroencephalography (EEG) signal synchronization during robot-assisted surgery (RAS). We then examine the association between EEG data and detected errors. Our results suggest that there are significant EEG changes during intraoperative error that are detectable irrespective of surgical experience level.

Mental workload during endoscopic sinus surgery is associated with surgeons' skill levels

Introduction

Surgeons' mental workload during endoscopic sinus surgery (ESS) has not been fully evaluated. The assessment was challenging due to the great diversity of each patient's anatomy and the consequence variety of surgical difficulties. In this study, we examined the mental workload of surgeons with various surgical skill levels during ESS under the standardized condition provided by novel-designed 3D sinus models.

Materials and methods

Forty-seven participants performed a high-fidelity ESS simulation with 3D-printed sinus models. Surgeons' mental workload was assessed with the national aeronautics and space administration-task load index (NASA-TLX). Associations between the total and subscales score of NASA-TLX and surgical skill index, including the board certification status, the number of experienced ESS cases, and the objective structured assessment of technical skills (OSATS), were analyzed. In addition, 10 registrars repeated the simulation surgery, and their NASA-TLX score was compared before and after the repetitive training.

Results

The total NASA-TLX score was significantly associated with OSATS score (p = 0.0001). Primary component analysis classified the surgeons' mental burden into three different categories: (1) the skill-level-dependent factors (temporal demand, effort, and performance), (2) the skill-level-independent factors (mental and physical demand), and (3) frustration. After the repetitive training, the skill-level-dependent factors were alleviated (temporal demand; z = -2.3664, p = 0.0091, effort; z = -2.1704, p = 0.0346, and performance; z = -2.5992, p = 0.0017), the independent factors were increased (mental demand; z = -2.5992, p = 0.0023 and physical demand; z = -2.2509, p = 0.0213), and frustration did not change (p = 0.3625).

Conclusion

Some of the mental workload during ESS is associated with surgical skill level and alleviated with repetitive training. However, other aspects remain a burden or could worsen even when surgeons have gained surgical experience. Routine assessment of registrars' mental burdens would be necessary during surgical training to sustain their mental health.

Next in Surgical Data Science: Autonomous Non-Technical Skill Assessment in Minimally Invasive Surgery Training

Background: It is well understood that surgical skills largely define patient outcomes both in Minimally Invasive Surgery (MIS) and Robot-Assisted MIS (RAMIS). Non-technical surgical skills, including stress and distraction resilience, decision-making and situation awareness also contribute significantly. Autonomous, technologically supported objective skill assessment can be efficient tools to improve patient outcomes without the need to involve expert surgeon reviewers. However, autonomous non-technical skill assessments are unstandardized and open for more research. Recently, Surgical Data Science (SDS) has become able to improve the quality of interventional healthcare with big data and data processing techniques (capture, organization, analysis and modeling of data). SDS techniques can also help to achieve autonomous non-technical surgical skill assessments. Methods: An MIS training experiment is introduced to autonomously assess non-technical skills and to analyse the workload based on sensory data (video image and force) and a self-rating questionnaire (SURG-TLX). A sensorized surgical skill training phantom and adjacent training workflow were designed to simulate a complicated Laparoscopic Cholecystectomy task; the dissection of the cholecyst’s peritonial layer and the safe clip application on the cystic artery in an uncomfortable environment. A total of 20 training sessions were recorded from 7 subjects (3 non-medicals, 2 residents, 1 expert surgeon and 1 expert MIS surgeon). Workload and learning curves were studied via SURG-TLX. For autonomous non-technical skill assessment, video image data with tracked instruments based on Channel and Spatial Reliability Tracker (CSRT) and force data were utilized. An autonomous time series classification was achieved by a Fully Convolutional Neural Network (FCN), where the class labels were provided by SURG-TLX. Results: With unpaired t-tests, significant differences were found between the two groups (medical professionals and control) in certain workload components (mental demands, physical demands, and situational stress, p<0.0001, 95% confidence interval, p<0.05 for task complexity). With paired t-tests, the learning curves of the trials were also studied; the task complexity resulted in a significant difference between the first and the second trials. Autonomous non-technical skill classification was based on the FCN by applying the tool trajectories and force data as input. This resulted in a high accuracy (85%) on temporal demands classification based on the z component of the used forces and 75% accuracy for classifying mental demands/situational stress with the x component of the used forces validated with Leave One Out Cross-Validation. Conclusions: Non-technical skills and workload components can be classified autonomously based on measured training data. SDS can be effective via automated non-technical skill assessment.

Surgeons' workload assessment during indocyanine-assisted deep endometriosis surgery using the surgery task load index: The impact of the learning curve

Objective

Assess the surgeons' workload during deep endometriosis surgery after ureteral ICG

Design

Prospective, consecutive, comparative, single-center study

Population

41 patients enrolled to deep endometriosis surgery with ureteral ICG from January 2019 to July 2021 at La Paz University Hospital

Methods

Patients were divided into 2 groups: patients operated during the learning curve of ureteral ICG instillation and patients operated after the technique was implemented and routinely performed. After surgery, the SURG-TLX form was completed by the surgeons. We evaluated whether a workload reduction occurred.

Main outcomes measures

Surgeon's workload was measured using the SURG-TLX form, obtaining the total workload and 6 different dimensions (distractions, temporal demands, task complexity, mental demands, situational stress and physical demands)

Results

A significant positive correlation was found between surgical complexity and situational stress (p = 0.04). Mental demands (p = 0.021), physical demands (p = 0.03), and total workload (p = 0.025) were significantly lower when the technique was routinely performed. The mental demand, physical demands, and total workload perceived by the surgeons at the beginning of the implementation was higher (68 [39–72], 27 [11–46.5], 229 [163–240], respectively) than in the latter ones (40 [9–63], 11.5 [0–32.8], 152 [133.3–213.8], respectively). Distractions appeared to be higher in the latter surgeries (8.5 [0–27.8]) than in the first surgeries (0 [0–7]; p = 0.057).

Conclusions

Ureter ICG instillation prior to DE surgery significantly reduces the mental and physical demands and total workload of the surgeons in DE surgeries after overcoming the learning curve. Distractions appear to increase as surgical stress decreases.

Endoscopy Training in Small Animal Internal Medicine: A Survey of Residency Training Programs in North America

Competency in multiple endoscopic techniques is a major goal of small animal internal medicine (SAIM) residency programs. Training relies predominantly on mentored supervision of procedures performed on patients. Supplementation of this apprenticeship model with classroom sessions and hands-on laboratories can be advantageous to trainees and patients. Few veterinary resources describe supplemental training options, and no single source exists for mentors to consult for program development. The purpose of this study was to describe the supplemental training opportunities currently available to SAIM residents at academic hospitals in the US and Canada and to compare their timing during the residency, resident and faculty time commitment, and perceived helpfulness. Data were collected by an electronic survey distributed to one faculty member per institution. The response rate was 80% (24/30). Most programs (22/24; 92%) offered some form of supplemental training, including classroom sessions (9/24) and hands-on laboratories using physical models (7/24), virtual reality simulators (2/24), and cadaver (2/24) and anesthetized (2/24) dogs. Fifteen programs provided residents with the opportunity to attend external endoscopy workshops. Only three programs required any training prior to residents performing procedures on patients. There was considerable variability in training between programs, precluding statistical comparisons. The survey identified topics for classroom sessions and several inexpensive physical models, rated very or extremely helpful, that would be suitable for programs with limited budgets. A human-based virtual reality simulator was also rated highly by two programs. Comprehensive, external workshops evoked numerous positive comments with perceived value ranging from somewhat to extremely helpful.

Objective Measurement of Learners' Cognitive Load During Simulation-Based Trauma Team Training: A Pilot Study

INTRODUCTION

Literature has shown cognitive overload which can negatively impact learning and clinical performance in surgery. We investigated learners' cognitive load during simulation-based trauma team training using an objective digital biomarker.

METHODS

A cross-sectional study was carried out in a simulation center where a 3-h simulation-based interprofessional trauma team training program was conducted. A session included three scenarios each followed by a debriefing session. One scenario involved multiple patients. Learners wore a heart rate sensor that detects interbeat intervals in real-time. Low-frequency/high-frequency (LF/HF) ratio was used as a validated proxy for cognitive load. Learners' LF/HF ratio was tracked through different phases of simulation.

RESULTS

Ten subjects participated in 12 simulations. LF/HF ratios during scenario versus debriefing were compared for each simulation. These were 3.75 versus 2.40, P < 0.001 for scenario 1; 4.18 versus 2.77, P < 0.001 for scenario 2; and 4.79 versus 2.68, P < 0.001 for scenario 3. Compared to single-patient scenarios, multiple-patient scenarios posed a higher cognitive load, with LF/HF ratios of 3.88 and 4.79, P < 0.001, respectively.

CONCLUSIONS

LF/HF ratio, a proxy for cognitive load, was increased during all three scenarios compared to debriefings and reached the highest levels in a multiple-patient scenario. Using heart rate variability as an objective marker of cognitive load is feasible and this metric is able to detect cognitive load fluctuations during different simulation phases and varying scenario difficulties.

Human Mental Workload: A Survey and a Novel Inclusive Definition

Human mental workload is arguably the most invoked multidimensional construct in Human Factors and Ergonomics, getting momentum also in Neuroscience and Neuroergonomics. Uncertainties exist in its characterization, motivating the design and development of computational models, thus recently and actively receiving support from the discipline of Computer Science. However, its role in human performance prediction is assured. This work is aimed at providing a synthesis of the current state of the art in human mental workload assessment through considerations, definitions, measurement techniques as well as applications, Findings suggest that, despite an increasing number of associated research works, a single, reliable and generally applicable framework for mental workload research does not yet appear fully established. One reason for this gap is the existence of a wide swath of operational definitions, built upon different theoretical assumptions which are rarely examined collectively. A second reason is that the three main classes of measures, which are self-report, task performance, and physiological indices, have been used in isolation or in pairs, but more rarely in conjunction all together. Multiple definitions complement each another and we propose a novel inclusive definition of mental workload to support the next generation of empirical-based research. Similarly, by comprehensively employing physiological, task-performance, and self-report measures, more robust assessments of mental workload can be achieved.

Eye-Tracking Indicators of Workload in Surgery: A Systematic Review

BackgroundEye tracking is a powerful tool for unobtrusive and real time assessment of workload in clinical settings. Before the complex eye tracking derived surrogates can be proactively utilized to improve surgical safety, the indications, validity and reliability requires careful evaluation.MethodsWe conducted a systematic review of literature from 2010 to 2020 according to PRISMA guidelines. A search on PubMed, Cochrane, Scopus, Web of science, PsycInfo and Google scholar databases was conducted on July 2020. The following search query was used" ("eye tracking" OR "gaze tracking") AND (surgery OR surgical OR operative OR intraoperative) AND (workload OR stress)". Short papers, no peer reviewed or papers in which eye-tracking methodology was not used to investigate workload or stress factors in surgery, were omitted.ResultsA total of 17 (N = 17) studies were identified eligible to this review. Most of the studies (n = 15) measured workload in simulated setting. Task difficulty and expertise were the most studied factors. Studies consistently showed surgeon's eye movements such as pupil responses, gaze patterns, blinks were associated with the level of perceived workload. However, differences between measurements in operational room and simulated environments have been found.ConclusionPupil responses, blink rate and gaze indices are valid indicators of workload. However, the effect of distractions and non-technical factors on workload is underrepresented aspect in the literature even though recognized as underlying factors in successful surgery.

Using a 360° Virtual Reality or 2D Video to Learn History Taking and Physical Examination Skills for Undergraduate Medical Students: Pilot Randomized Controlled Trial

BACKGROUND

Learning through a 360° virtual reality (VR) or 2D video represents an alternative way to learn a complex medical education task. However, there is currently no consensus on how best to assess the effects of different learning materials on cognitive load estimates, heart rate variability (HRV), outcomes, and experience in learning history taking and physical examination (H&P) skills.

OBJECTIVE

The aim of this study was to investigate how learning materials (ie, VR or 2D video) impact learning outcomes and experience through changes in cognitive load estimates and HRV for learning H&P skills.

METHODS

This pilot system-design study included 32 undergraduate medical students at an academic teaching hospital. The students were randomly assigned, with a 1:1 allocation, to a 360° VR video group or a 2D video group, matched by age, sex, and cognitive style. The contents of both videos were different with regard to visual angle and self-determination. Learning outcomes were evaluated using the Milestone reporting form. Subjective and objective cognitive loads were estimated using the Paas Cognitive Load Scale, the National Aeronautics and Space Administration Task Load Index, and secondary-task reaction time. Cardiac autonomic function was assessed using HRV measurements. Learning experience was assessed using the AttrakDiff2 questionnaire and qualitative feedback. Statistical significance was accepted at a two-sided P value of <.01.

RESULTS

All 32 participants received the intended intervention. The sample consisted of 20 (63%) males and 12 (38%) females, with a median age of 24 (IQR 23-25) years. The 360° VR video group seemed to have a higher Milestone level than the 2D video group (P=.04). The reaction time at the 10th minute in the 360° VR video group was significantly higher than that in the 2D video group (P<.001). Multiple logistic regression models of the overall cohort showed that the 360° VR video module was independently and positively associated with a reaction time at the 10th minute of ≥3.6 seconds (exp B=18.8, 95% CI 3.2-110.8; P=.001) and a Milestone level of ≥3 (exp B=15.0, 95% CI 2.3-99.6; P=.005). However, a reaction time at the 10th minute of ≥3.6 seconds was not related to a Milestone level of ≥3. A low-frequency to high-frequency ratio between the 5th and 10th minute of ≥1.43 seemed to be inversely associated with a hedonic stimulation score of ≥2.0 (exp B=0.14, 95% CI 0.03-0.68; P=.015) after adjusting for video module. The main qualitative feedback indicated that the 360° VR video module was fun but caused mild dizziness, whereas the 2D video module was easy to follow but tedious.

CONCLUSIONS

Our preliminary results showed that 360° VR video learning may be associated with a better Milestone level than 2D video learning, and that this did not seem to be related to cognitive load estimates or HRV indexes in the novice learners. Of note, an increase in sympathovagal balance may have been associated with a lower hedonic stimulation score, which may have met the learners' needs and prompted learning through the different video modules.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03501641; https://clinicaltrials.gov/ct2/show/NCT03501641.

NASA-TLX assessment of workload in resident physicians and faculty surgeons covering trauma, surgical intensive care unit, and emergency general surgery services

BACKGROUND

Higher workload is associated with burnout and lower performance. Therefore, we aim to assess shift-related factors associated with higher workload on EGS, ICU, and trauma surgery services.

METHODS

In this prospective cohort study, faculty surgeons and surgery residents completed a survey after each EGS, ICU, or trauma shift, including shift details and a modified NASA-TLX.

RESULTS

Seventeen faculty and 12 residents completed 174 and 48 surveys after working scheduled 12-h and 24-h shifts, respectively (response rates: faculty - 62%, residents - 42%). NASA-TLX was significantly increased with a higher physician subjective fatigue level. Further, seeing more consults or performing more operations than average significantly increased workload. Finally, NASA-TLX was significantly higher for faculty when they felt their shift was more difficult than expected.

CONCLUSIONS

Higher volume clinical responsibilities and higher subjective fatigue levels are independently associated with higher workload. Designing shift coverage to expand on busier days may decrease workload, impacting burnout and shift performance.

Which Factors Affect the Stress of Intraoperative Orthopedic Surgeons by Using Electroencephalography Signals and Heart Rate Variability?

Can we recognize intraoperative real-time stress of orthopedic surgeons and which factors affect the stress of intraoperative orthopedic surgeons with EEG and HRV? From June 2018 to November 2018, 265 consecutive records of intraoperative stress measures for orthopedic surgeons were compared. Intraoperative EEG waves and HRV, comprising beats per minute (BPM) and low frequency (LF)/high frequency (HF) ratio were gathered for stress-associated parameters. Differences in stress parameters according to the experience of surgeons, intraoperative blood loss, and operation time depending on whether or not a tourniquet were investigated. Stress-associated EEG signals including beta 3 waves were significantly higher compared to EEG at rest for novice surgeons as the procedure progressed. Among senior surgeons, the LF/HF ratio reflecting the physical demands of stress was higher than that of novice surgeons at all stages. In surgeries including tourniquets, operation time was positively correlated with stress parameters including beta 1, beta 2, beta 3 waves and BPM. In non-tourniquet orthopedic surgeries, intraoperative blood loss was positively correlated with beta 1, beta 2, and beta 3 waves. Among orthopedic surgeons, those with less experience demonstrated relatively higher levels of stress during surgery. Prolonged operation time or excessive intraoperative blood loss appear to be contributing factors that increase stress.

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

BACKGROUND: Sensor technologies and data collection practices are changing and improving quality metrics across various domains. Surgical skill assessment in Robot-Assisted Minimally Invasive Surgery (RAMIS) is essential for training and quality assurance. The mental workload on the surgeon (such as time criticality, task complexity, distractions) and non-technical surgical skills (including situational awareness, decision making, stress resilience, communication, leadership) may directly influence the clinical outcome of the surgery. METHODS: A literature search in PubMed, Scopus and PsycNet databases was conducted for relevant scientific publications. The standard PRISMA method was followed to filter the search results, including non-technical skill assessment and mental/cognitive load and workload estimation in RAMIS. Publications related to traditional manual Minimally Invasive Surgery were excluded, and also the usability studies on the surgical tools were not assessed. RESULTS: 50 relevant publications were identified for non-technical skill assessment and mental load and workload estimation in the domain of RAMIS. The identified assessment techniques ranged from self-rating questionnaires and expert ratings to autonomous techniques, citing their most important benefits and disadvantages. CONCLUSIONS: Despite the systematic research, only a limited number of articles was found, indicating that non-technical skill and mental load assessment in RAMIS is not a well-studied area. Workload assessment and soft skill measurement do not constitute part of the regular clinical training and practice yet. Meanwhile, the importance of the research domain is clear based on the publicly available surgical error statistics. Questionnaires and expert-rating techniques are widely employed in traditional surgical skill assessment; nevertheless, recent technological development in sensors and Internet of Things-type devices show that skill assessment approaches in RAMIS can be much more profound employing automated solutions. Measurements and especially big data type analysis may introduce more objectivity and transparency to this critical domain as well. SIGNIFICANCE: Non-technical skill assessment and mental load evaluation in Robot-Assisted Minimally Invasive Surgery is not a well-studied area yet; while the importance of this domain from the clinical outcome's point of view is clearly indicated by the available surgical error statistics.

High density optical neuroimaging predicts surgeons's subjective experience and skill levels

Measuring cognitive load is important for surgical education and patient safety. Traditional approaches of measuring cognitive load of surgeons utilise behavioural metrics to measure performance and surveys and questionnaires to collect reports of subjective experience. These have disadvantages such as sporadic data, occasionally intrusive methodologies, subjective or misleading self-reporting. In addition, traditional approaches use subjective metrics that cannot distinguish between skill levels. Functional neuroimaging data was collected using a high density, wireless NIRS device from sixteen surgeons (11 attending surgeons and 5 surgery resident) and 17 students while they performed two laparoscopic tasks (Peg transfer and String pass). Participant’s subjective mental load was assessed using the NASA-TLX survey. Machine learning approaches were used for predicting the subjective experience and skill levels. The Prefrontal cortex (PFC) activations were greater in students who reported higher-than-median task load, as measured by the NASA-TLX survey. However in the case of attending surgeons the opposite tendency was observed, namely higher activations in the lower v higher task loaded subjects. We found that response was greater in the left PFC of students particularly near the dorso- and ventrolateral areas. We quantified the ability of PFC activation to predict the differences in skill and task load using machine learning while focussing on the effects of NIRS channel separation distance on the results. Our results showed that the classification of skill level and subjective task load could be predicted based on PFC activation with an accuracy of nearly 90%. Our finding shows that there is sufficient information available in the optical signals to make accurate predictions about the surgeons’ subjective experiences and skill levels. The high accuracy of results is encouraging and suggest the integration of the strategy developed in this study as a promising approach to design automated, more accurate and objective evaluation methods.

Sensor-based indicators of performance changes between sessions during robotic surgery training

Training of surgeons is essential for safe and effective use of robotic surgery, yet current assessment tools for learning progression are limited. The objective of this study was to measure changes in trainees' cognitive and behavioral states as they progressed in a robotic surgeon training curriculum at a medical institution. Seven surgical trainees in urology who had no formal robotic training experience participated in the simulation curriculum. They performed 12 robotic skills exercises with varying levels of difficulty repetitively in separate sessions. EEG (electroencephalogram) activity and eye movements were measured throughout to calculate three metrics: engagement index (indicator of task engagement), pupil diameter (indicator of mental workload) and gaze entropy (indicator of randomness in gaze pattern). Performance scores (completion of task goals) and mental workload ratings (NASA-Task Load Index) were collected after each exercise. Changes in performance scores between training sessions were calculated. Analysis of variance, repeated measures correlation, and machine learning classification were used to diagnose how cognitive and behavioral states associate with performance increases or decreases between sessions. The changes in performance were correlated with changes in engagement index (rrm=-.25,p<.001) and gaze entropy (rrm=-.37,p<.001). Changes in cognitive and behavioral states were able to predict training outcomes with 72.5% accuracy. Findings suggest that cognitive and behavioral metrics correlate with changes in performance between sessions. These measures can complement current feedback tools used by medical educators and learners for skills assessment in robotic surgery training.

Eye-Tracking Metrics Predict Perceived Workload in Robotic Surgical Skills Training

OBJECTIVE

The aim of this study is to assess the relationship between eye-tracking measures and perceived workload in robotic surgical tasks.

BACKGROUND

Robotic techniques provide improved dexterity, stereoscopic vision, and ergonomic control system over laparoscopic surgery, but the complexity of the interfaces and operations may pose new challenges to surgeons and compromise patient safety. Limited studies have objectively quantified workload and its impact on performance in robotic surgery. Although not yet implemented in robotic surgery, minimally intrusive and continuous eye-tracking metrics have been shown to be sensitive to changes in workload in other domains.

METHODS

Eight surgical trainees participated in 15 robotic skills simulation sessions. In each session, participants performed up to 12 simulated exercises. Correlation and mixed-effects analyses were conducted to explore the relationships between eye-tracking metrics and perceived workload. Machine learning classifiers were used to determine the sensitivity of differentiating between low and high workload with eye-tracking features.

RESULTS

Gaze entropy increased as perceived workload increased, with a correlation of .51. Pupil diameter and gaze entropy distinguished differences in workload between task difficulty levels, and both metrics increased as task level difficulty increased. The classification model using eye-tracking features achieved an accuracy of 84.7% in predicting workload levels.

CONCLUSION

Eye-tracking measures can detect perceived workload during robotic tasks. They can potentially be used to identify task contributors to high workload and provide measures for robotic surgery training.

APPLICATION

Workload assessment can be used for real-time monitoring of workload in robotic surgical training and provide assessments for performance and learning.

Comparison of KD-SR-01 robotic partial nephrectomy and 3D-laparoscopic partial nephrectomy from an operative and ergonomic perspective: A prospective randomized controlled study in porcine models

BACKGROUND

To investigate the feasibility, validity and security of a new robot platform called KD-SR-01 and compare relative merits of KD-SR-01 robotic partial nephrectomy (KD-RPN) and 3D-Laparoscopic Partial Nephrectomy (3D-LPN).

METHODS

Twelve porcine models were randomly and equally divided for KD-RPN and 3D-LPN. The perioperative outcomes, physical and mental workload of the surgeon were compared. Physical workload was evaluated with surface electromyography. Mental workload was evaluated with National Aeronautics and Space Administration Task Load Index (NASA-TLX).

RESULTS

All surgeries were performed successfully. The average docking time of KD-RPN was 6 min. The estimated blood loss was lower in KD-RPN (p < 0.05). There were no differences in all the other operative variables (p > 0.05). KD-RPN showed advantages in physical workload and was significantly superior in mental workload (p < 0.05).

CONCLUSIONS

KD-RPN is technically feasible, valid and safe in porcine models. It's comparable from operative perspective while KD-RPN had advantages over 3D-LPN from ergonomic perspective.

The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study

BACKGROUND

Worldwide, music is commonly played in the operation room. The effect of music on surgical performance reportedly has varying results, while its effect on mental workload and key surgical stressor domains has only sparingly been investigated. Therefore, the aim is to assess the effect of recorded preferred music versus operating room noise on laparoscopic task performance and mental workload in a simulated setting.

METHODS

A four-sequence, four-period, two-treatment, randomized controlled crossover study design was used. Medical students, novices to laparoscopy, were eligible for inclusion. Participants were randomly allocated to one of four sequences, which decided the exposure order to music and operation room noise during the four periods. Laparoscopic task performance was assessed through motion analysis with a laparoscopic box simulator. Each period consisted of ten alternating peg transfer tasks. To account for the learning curve, a preparation phase was employed. Mental workload was assessed using the Surgery Task Load Index. This study was registered with the Netherlands Trial Register (NL7961).

RESULTS

From October 29, 2019 until March 12, 2020, 107 participants completed the study, with 97 included for analyzation. Laparoscopic task performance increased significantly during the preparation phase. No significant beneficial effect of music versus operating room noise was observed on time to task completion, path length, speed, or motion smoothness. Music significantly decreased mental workload, reflected by a lower score of the total weighted Surgery Task Load Index in all but one of the six workload dimensions.

CONCLUSION

Music significantly reduced mental workload overall and of several previously identified key surgical stressor domains, and its use in the operating room is reportedly viewed favorably. Music did not significantly improve laparoscopic task performance of novice laparoscopists in a simulated setting. Although varying results have been reported previously, it seems that surgical experience and task demand are more determinative.

Physiological correlates of cognitive load in laparoscopic surgery

Laparoscopic surgery can be exhausting and frustrating, and the cognitive load experienced by surgeons may have a major impact on patient safety as well as healthcare economics. As cognitive load decreases with increasing proficiency, its robust assessment through physiological data can help to develop more effective training and certification procedures in this area. We measured data from 31 novices during laparoscopic exercises to extract features based on cardiac and ocular variables. These were compared with traditional behavioural and subjective measures in a dual-task setting. We found significant correlations between the features and the traditional measures. The subjective task difficulty, reaction time, and completion time were well predicted by the physiology features. Reaction times to randomly timed auditory stimuli were correlated with the mean of the heart rate (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = - 0.29$$\end{document}r=-0.29) and heart rate variability (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = 0.4$$\end{document}r=0.4). Completion times were correlated with the physiologically predicted values with a correlation coefficient of 0.84. We found that the multi-modal set of physiology features was a better predictor than any individual feature and artificial neural networks performed better than linear regression. The physiological correlates studied in this paper, translated into technological products, could help develop standardised and more easily regulated frameworks for training and certification.

Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams

Background. The most commonly used subjective assessment of perceived cognitive load, the NASA Task Load Index (TLX), has proven valuable in measuring individual load among general populations. The surgery task load index (SURG-TLX) was developed and validated to measure cognitive load specifically among individuals within a surgical team. Notably, the TLX lacks temporal sensitivity in its typical retrospective administration. Objective. This study sought to expand the utility of SURG-TLX by investigating individual measures of cognitive load over time during cardiac surgery, and the relationship between individual and team measures of cognitive load and proxies for surgical complexity. Materials & Methods. SURG-TLX was administered retrospectively in the operating room immediately following each case to approximate cognitive load before, during, and after cardiopulmonary bypass for cardiac surgery team members (surgeon, anesthesiologist, and perfusionist). Correlations were calculated to determine the relationship of individual and team measures of cognitive load over the entire procedure with bypass length and surgery length. Results. Results suggest that perceived cognitive load varies throughout the procedure such that cognitive load during bypass significantly differs compared to before or after bypass, across all 3 roles. While on bypass, results show that anesthesiologists experience significantly lower levels of perceived cognitive load than both surgeons and perfusionists. Correlational analyses reveal that perceived cognitive load of both the surgeon and the team had significant positive associations with bypass length and surgery length. Conclusion. Our findings support the utility of SURG-TLX in real cardiac cases as a measure of cognitive load over time, and on an individual and team-wide basis.

Visual behaviour in robotic surgery-Demonstrating the validity of the simulated environment

BACKGROUND

Eye metrics provide insight into surgical behaviour allowing differentiation of performance, however have not been used in robotic surgery. This study explores eye metrics of robotic surgeons in training in simulated and real tissue environments.

METHODS

Following the Fundamentals of Robotic Surgery (FRS), training curriculum novice robotic surgeons were trained to expert-derived benchmark proficiency using real tissue on the da Vinci Si and the da Vinci skills simulator (dVSS) simulator. Surgeons eye metrics were recorded using eye-tracking glasses when both "novice" and "proficient" in both environments. Performance was assessed using Global Evaluative Assessment of Robotic skills (GEARS) and numeric psychomotor test score (NPMTS) scores.

RESULTS

Significant (P ≤ .05) correlations were seen between pupil size, rate of change and entropy, and associated GEARS/NPMTS in "novice" and "proficient" surgeons. Only number of blinks per minute was significantly different between pupilometrics in the simulated and real tissue environments.

CONCLUSIONS

This study illustrates the value of eye tracking as an objective physiological tool in the robotic setting. Pupilometrics significantly correlate with established assessment methods and could be incorporated into robotic surgery assessments.

Impact of robotic assistance on mental workload and cognitive performance of surgical trainees performing a complex minimally invasive suturing task

BACKGROUND

Few studies have investigated the potential impact of robotic assistance on cognitive ergonomics during advanced minimally invasive surgery. The purpose of this study was to assess the impact of robotic assistance on mental workload and downstream cognitive performance in surgical trainees.

METHODS

Robot-naïve trainees from general surgery, urology and gynaecology, stratified by specialty and level of training, were randomised to either laparoscopic surgery (LS) or robotic-assisted laparoscopic surgery (RALS) and performed a time-limited, complex laparoscopic suturing task after watching a 5-min instructional video. The RALS group received an additional 5-min orientation to the robotic console. Subjective mental workload was measured using NASA Task Load Index. Concentration and executive cognitive function were assessed using Psychomotor Vigilance Task (PVT) and Wisconsin Card Sorting Test (WCST), respectively. A p value of 0.05 was considered significant.

RESULTS

Sixteen senior residents (SR; ≥ PGY3) and 14 junior residents (JR; PGY1-2) completed the study. There was no difference in mental workload between LS and RALS. Within JR there was no difference in task completion time comparing LS versus RALS; however, LS was associated with impaired concentration post-task versus pre-task (PVT reaction time 306 versus 324 ms, p = 0.03), which was not observed for RALS. In contrast, amongst SR, RALS took significantly longer than LS (10.3 vs. 14.5 min, p = 0.02) and was associated with significantly worse performance on WCST (p < 0.01).

CONCLUSIONS

Robotic assistance, in this setting, did not provide a technical performance advantage nor impact subjective mental workload with novice users regardless of level of surgery training. We observed a protective effect on cognitive performance offered by RALS to junior trainees with limited LS experience, yet a detrimental effect on senior trainees with greater LS ability and inadequate pre-study robotic training, suggesting that robotic consoles may be mentally taxing for robotic novices and consideration should be given to formal console training prior to initial clinical exposure.

Do surgeon non-technical skills correlate with teamwork-related outcomes during robot-assisted surgery?

Introduction

To evaluate the impact of non-technical skills (NTS) on team performance, workload and clinical outcomes.

Methods

The operating room (OR) environment of 20 robot-assisted radical prostatectomies performed by three different surgeons was recorded. Trained observers assessed NTS utilising the Non-Technical Skills for Surgeons (NOTSS) questionnaire. Associations between NOTSS scores, teamwork attributes (anticipation and inconveniences), workload (measured by National Aeronautics and Space Administration-Task Load Index (NASA-TLX)) and clinical outcomes (operative time, blood loss and surgical complexity) were determined using logistic regression and Pearson correlation.

Results

1780 requests were observed, 703 (39%) were non-verbal. Utilisation of non-verbal requests differed significantly among surgeons (26%, 36% and 44%, p<0.001). Anticipation was significantly associated with ‘Situational Awareness’ (OR 2.59, 95% CI 1.52 to 4.38, p<0.001), ‘Decision Making’ (OR 0.42, 95% CI 0.33 to 0.55, p<0.001) and ‘Communication and Teamwork’ (OR 0.43, 95% CI 0.25 to 0.74, p=0.002) domains. Inconveniences were significantly associated with ‘Situational Awareness’ (OR 0.21, 95% CI 0.08 to 0.59, p=0.003), ‘Decision Making’ (OR 2.73, 95% CI 1.53 to 4.86, p<0.001), and ‘Leadership’ (OR 0.62, 95% CI 0.41 to 0.94, p=0.03). There was a significant positive correlation between NOTSS scores and perceived physical and mental workload measures of NASA-TLX, as well as self-perceived performance. There was no significant association between NOTSS scores and any of the investigated clinical outcomes.

Conclusion

NTS in the OR were associated with team efficiency, fewer surgical flow disruptions and an improved self-perceived performance.

Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty

BACKGROUND

To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty.

MATERIALS AND METHODS

For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys.

RESULTS

Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases.

CONCLUSIONS

Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus.

Detecting Mental Workload in Surgical Teams Using a Wearable Single-Channel Electroencephalographic Device

OBJECTIVE

To assess the sensitivity of an electroencephalographic (EEG)-based index, the prefrontal beta power, to quantify the mental workload in surgeons in real scenarios. Such EEG-based index might offer unique and unbiased measures of overload, a crucial factor when designing learning and training surgical programs.

DESIGN

The experiment followed a 2 × 2 × 2 within subjects design with 3 factors: (1) Surgical Role during the surgery (primary surgeon vs. assistant surgeon), (2) the Surgical Procedure (laparo-endoscopic single-site [LESS] surgery vs. multiport laparoscopic surgery [MPS]), and (3) the Suturing Techniques (interrupted vs. continuous suture).

SETTING

The study was carried out at the Advanced Multi-Purpose Simulation and Technological Innovation Complex situated at IAVANTE (Granada, Spain).

METHODS

Four surgical teams (primary surgeon and assistant surgeon, experts in MPS) performed 8 surgical exercises on porcine models, under different task complexities. They performed 2 suturing techniques (continuous and interrupted), employing a low complex procedure (MPS) and a high complex procedure (LESS). Surgeons acted as the primary surgeon during half of the exercises, and, as the assistant surgeon, during the rest of them. Simultaneously, we monitored EEG prefrontal EEG beta power spectra of both surgeons, using 2 synchronized wearable EEG devices. We also collected performance and subjective data.

RESULTS

Surgical complexity modulated prefrontal beta power. LESS surgery caused significant higher prefrontal beta power for both suturing techniques for both surgical roles which indicates higher demands than MPS. Perceived task complexity, overall surgical evaluation, and laparoscopic execution time confirmed EEG-based results. Finally, subjective ratings of surgical complexity differentiated between surgical roles within the same exercise, even when prefrontal beta power did not.

CONCLUSIONS

To detect mental overload when surgeons are engaged with complex surgeries, real or simulated, is still guesswork. EEG-based indices have great potential as objective and nonintrusive measures to assess mental overload in surgeons. Furthermore, EEG-based indices might play a relevant role in monitoring surgeons and residents' cognitive state during their training.

Subjective and Objective Quantification of the Effect of Distraction on Physician's Workload and Performance During Simulated Laparoscopic Surgery

Background

Distracting interference cognitive tasks place undeniable pressure on the minds of people who need high precision and attention during the tasks, such as those tasks performed during surgery; these tasks might affect current surgical procedures. We measured the effect of additional cognitive tasks on the mental load of the physician by measuring the mean change in pupil size, blink rate, and subjective assessment during surgery.

Material/Methods

We recruited 24 participants with different levels of laparoscopic surgery to perform a complete appendectomy using a standardized virtual reality laparoscopic surgery simulator. The participants then performed the cognitive task (arithmetic problem), after that they performed an appendectomy surgery task while completing the cognitive task on the simulator. All participants wore trackers to monitor pupil size and blink rate during surgery and the cognitive task. The National Aeronautics and Space Administration (NASA) Task Load Index (TLX) score also recorded performance parameters during the surgical mission.

Results

The double-task pupil size and the blink rate were significantly increased compared to the single-task observation, and the associated increase in psychological load might have been affected by surgical performance, and the performance parameters were also statistically significant. However, for the aforementioned parameters, experienced surgeons had some differences compared with inexperienced surgeons, but these differences did not reach statistical significance.

Conclusions

Distracted cognitive task stimulation in the operating room can increase the surgeon’s psychological burden while also affecting their operational skills, thereby threatening patient safety; reduced cognitive costs might be obtained by improving or managing cognitive deficits.

Experience implication in subjective surgical ergonomics comparison between laparoscopic and robot-assisted surgeries

INTRODUCTION

Laparoscopic surgery (LS) may lead to musculoskeletal disorders (MSDs) and an increase in physical and mental workloads to the surgeon. Robot-assisted surgery (RAS) should improve the ergonomy of the surgeon. This study assesses the experience influence in surgical ergonomics between LS and RAS.

METHODS

LS and RAS lasting more than 60 min of effective operative time were compared. During the surgical procedure, the physical discomfort was evaluated using the Borg scale. At the end, the mental workload was evaluated using the NASA-TLX index. After global analysis, the experienced and young surgeons were assessed.

RESULTS

88 RAS and 82 LS were evaluated. During LS, the physical discomfort was significantly higher in all segments, and the pain increased significantly during the procedure in all segments compared to that evaluated in the RAS (p < 0.05). Forearms and the back were the most painful. The young surgeons did not display any improvement in the physical ergonomics of the RAS compared to the LS. Concerning the mental ergonomics, the overall workload and performance were significantly greater during the LS compared to the RAS (p < 0.05). For the young surgeons, the overall workload, the effort, the mental and the physical demands were greater during LS (p < 0.05). For the experienced surgeons, the physical demand was lower during the RAS compared to the LS (p < 0.05). However, the experienced surgeons expressed a feeling of greater performance after the LS (p < 0.01). RAS significantly reduces the onset of MSDs compared to LS, especially for the experienced surgeons.

CONCLUSION

RAS significantly reduces the onset of MSDs compared to LS, especially for the experienced surgeons.

Dynamic changes of brain functional states during surgical skill acquisition

There is lack of a standardized measure of technical proficiency and skill acquisition for robot-assisted surgery (RAS). Learning surgical skills, in addition to the interaction with the machine and the new surgical environment adds to the complexity of the learning process. Moreover, evaluation of surgeon performance in operating room is required to optimize patient safety. In this study, we investigated the dynamic changes of RAS trainee’s brain functional states by practice. We also developed brain functional state measurements to find the relationship between RAS skill acquisition (especially human-machine interaction skills) and reconfiguration of brain functional states. This relationship may help in providing trainees with helpful, structured feedback regarding skills requiring improvement and will help in tailoring training activities.

Implementing Cognitive Training Into a Surgical Skill Course: A Pilot Study on Laparoscopic Suturing and Knot Tying

Mini-invasive surgery-for example, laparoscopy-has challenged surgeons' skills by extending their usual haptic space and displaying indirect visual feedback through a screen. This may require new mental abilities, including spatial orientation and mental representation. This study aimed to test the effect of cognitive training based on motor imagery (MI) and action observation (AO) on surgical skills. A total of 28 postgraduate residents in surgery took part in our study and were randomly distributed into 1 of the 3 following groups: (1) the basic surgical skill, which is a short 2-day laparoscopic course + MI + AO group; (2) the basic surgical skill group; and (3) the control group. The MI + AO group underwent additional cognitive training, whereas the basic surgical skill group performed neutral activity during the same time. The laparoscopic suturing and knot tying performance as well as spatial ability and mental workload were assessed before and after the training period. We did not observe an effect of cognitive training on the laparoscopic performance. However, the basic surgical skill group significantly improved spatial orientation performance and rated lower mental workload, whereas the 2 others exhibited lower performance in a mental rotation test. Thus, actual and cognitive training pooled together during a short training period elicited too high a strain, thus limiting potential improvements. Because MI and AO already showed positive outcomes on surgical skills, this issue may, thus, be mitigated according to our specific learning conditions. Distributed learning may possibly better divide and share the strain associated with new surgical skills learning.

Physical and Mental Impact of Laparoscopic Sleeve Gastrectomy on the Surgeon: French vs. American Positions. A Randomized and Controlled Study

PURPOSE

To determine the physical and mental impact on the primary surgeon, by the patient's and surgical staff's dispositions at the operating table, during laparoscopic vertical sleeve gastrectomy.

MATERIALS AND METHODS

This is a randomized and controlled study that included 18 laparoscopic sleeve gastrectomy procedures performed by two surgeons in a private and academic hospital. The cases were randomized for the American or French position. After surgery, the National Aeronautics and Space Administration - Task Load Index (NASA-TLX) and the Body Part Discomfort (BPD) scales were applied to the primary surgeon.

RESULTS

An increased workload and more discomfort were reported when using the French position. The NASA-TLX was 28 ± 8 vs. 57 ± 18 (p = 0.001), and the BPD was 2 vs. 8 (p = 0.001).

CONCLUSIONS

The American position resulted in a lower physical and mental impact on the surgeon when performing a laparoscopic sleeve gastrectomy.

Experienced mental workload, perception of usability, their interaction and impact on task performance

Past research in HCI has generated a number of procedures for assessing the usability of interacting systems. In these procedures there is a tendency to omit characteristics of the users, aspects of the context and peculiarities of the tasks. Building a cohesive model that incorporates these features is not obvious. A construct greatly invoked in Human Factors is human Mental Workload. Its assessment is fundamental for predicting human performance. Despite the several uses of Usability and Mental Workload, not much has been done to explore their relationship. This empirical research focused on I) the investigation of such a relationship and II) the investigation of the impact of the two constructs on human performance. A user study was carried out with participants executing a set of information-seeking tasks over three popular web-sites. A deep correlation analysis of usability and mental workload, by task, by user and by classes of objective task performance was done (I). A number of Supervised Machine Learning techniques based upon different learning strategy were employed for building models aimed at predicting classes of task performance (II). Findings strongly suggests that usability and mental workload are two non overlapping constructs and they can be jointly employed to greatly improve the prediction of human performance.

Measuring mental workload and physiological reactions in marine pilots: Building bridges towards redlines of performance

This paper investigates the effects of shiphandling manoeuvres on mental workload and physiological reactions in ten marine pilots. Each pilot performed four berthings in a ship simulator. Those berthings were differentiated by two factors, level of difficulty and familiarity with the port. Each berthing could also be divided into five phases, three during the execution and two resting periods, one before and one after the execution (dedicated to baseline physiological data collection). Mental workload was measured through two self assessment scales: the NASA TLX and a Likert scale. Power spectral densities on Beta bands 1 and 2 were obtained from EEG. Heart rate and heart rate variability were obtained from ECG. Pupil dilation was obtained from eye tracking. Workload levels were higher as berthings increased in difficulty level and/or the pilots completed the berthings in unfamiliar ports. Responses differed across specific phases of the berthings. Physiological responses could indirectly monitor levels of mental workload, and could be adopted in future applications to evaluate training improvements and performance. This study provides an example of an applied methodology aiming to define an upper redline of task demands in the context of marine pilotage.

The effect of multitasking on the communication skill and clinical skills of medical students

BACKGROUND

Mental workload is an abstract concept that perceives cognition as the brain having a small and finite capacity to process information, with high levels of workload associated with poor performance and error. While an individual may be able to complete two different tasks individually, a combination of tasks may lead to cognitive overload and poor performance. In many high-risk industries, it is common to measure mental workload and then to redesign tasks until cognitive overload is avoided. This study aimed to measure the effect of multitasking on the mental workload and performance of medical students completing single and combined clinical tasks.

METHODS

Medical students who had completed basic clinical skills training in a single undergraduate Medical School completed four standardised tasks for a total of four minutes each, consisting of: inactivity, listening, venepuncture and a combination of listening and venepuncture. Task performance was measured using standard binary checklists and with mental workload measured using a secondary task method.

RESULTS

The tasks were successfully completed by 40 subjects and as expected, mental workload increased with task complexity. Combining the two tasks showed no difference in the associated mental workload and performance at venepuncture (p = 0.082) However, during the combined task, listening appeared to deteriorate (p < 0.001).

CONCLUSIONS

If staff are expected to simultaneously complete multiple tasks then they may preferentially shed communication tasks in order to maintain their performance of physical tasks, leading to the appearance of poor communication skills. Although this is a small-scale study in medical students it suggests that the active assessment and management of clinician workload in busy clinical settings may be an effective strategy to improve doctor-patient communication.

Developing a Basic Scale for Workers' Psychological Burden from the Perspective of Occupational Safety and Health

Background

Organizations are pursing complex and diverse aims to generate higher profits. Many workers experience high work intensity such as workload and work pressure in this organizational environment. Especially, psychological burden is a commonly used term in workplace of Republic of Korea. This study focused on defining the psychological burden from the perspective of occupational safety and health and tried to develop a scale for psychological burden.

Methods

The 48 preliminary questionnaire items for psychological burden were prepared by a focus group interview with 16 workers through the Copenhagen Psychosocial Questionnaire II and Mindful Awareness Attention Scale. The preliminary items were surveyed with 572 workers, and exploratory factor analysis, confirmatory factor analysis, and correlation analysis were conducted for a new scale.

Results

As a result of the exploratory factor analysis, five factors were extracted: organizational activity, human error, safety and health workload, work attitude, and negative self-management. These factors had significant correlations and reliability, and the stability of the model for validity was confirmed using confirmatory factor analysis.

Conclusion

The developed scale for psychological burden can measure workers' psychological burden in relation to safety and health. Despite some limitations, this study has applicability in the workplace, given the relatively small-sized questionnaire.